Test #4

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heatherrobinson444
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121756
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Test #4
Updated:
2011-12-08 00:05:38
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Fundamentals Nursing
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Skin integrity,Cultural & Spiritual,Teaching role,IV Therapy,Nursing Profession & Education
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  1. A patient is prescribed a low-sodium, low-fat diet. How can the nurse best ensure that the patient follows the prescribed diet during hospitalization?1) Make sure dietary services sends a low-sodium, low-fat meal tray.2) Arrange for meals that accommodate his cultural dietary practices and specified diet.3) Ask the patient's family to bring in foods from home he typically eats.4) Sit with the patient while he eats to make sure he consumes the prescribed diet.
    2) Arrange for meals that accommodate his cultural dietary practices and specified diet.

    Rationale:The nurse can help ensure that the patient consumes the prescribed diet by requesting a culturally appropriate meal tray for the patient.
  2. The nurse is caring for a patient whose primary language is Vietnamese. When working with the interpreter, the nurse should do which of the following? Select all that apply.
    1) Make eye contact with the interpreter.2) Speak a little more loudly than usual.3) Use an interpreter who is socially compatible with the patient.4) Try to find a family member to help interpret.
    • 1) Make eye contact with the interpreter.
    • 3) Use an interpreter who is socially compatible with the patient.

    Rationale:When choosing an interpreter, the nurse should use one who is socially compatible with the patient. The nurse should maintain eye contact with both the patient and interpreter. She should not speak loudly. It is best to not ask family members to interpret because of privacy issues.
  3. Which intervention by the nurse best indicates that she values a Native American patient's beliefs and indigenous healthcare system?
    1) Incorporating Native American practices into care based on consultation with a cultural resource book2) Explaining the values and beliefs of the traditional healthcare system to the patient so that the patient understands what is occurring3) Contacting a Native American resource group for information about the culture4) Planning how to incorporate traditional practices and beliefs through discussion with the patient
    • 4) Planning how to incorporate traditional practices and beliefs through discussion with the patient
    • Rationale:"Incorporating traditional practices and beliefs . . ." is the only answer that indicates that the nurse has assessed to determine what the patient's beliefs actually are. When consulting a cultural resource book or a Native American resource group for information, the nurse would be assuming that the patient's wishes will conform to her cultural group. By explaining the traditional healthcare system, the nurse would not even be attempting to deal with the patient's beliefs but would be trying to convince the patient that the mainstream way is preferred.
  4. A long-term care facility has started a program to increase the cultural competence of its employees. When notified of this, a nurse thinks to himself, "I don't have time for this nonsense. I already know all I need to about culture, and I don't really like taking care of so many different kinds of people anyway." This most clearly illustrates the nurse's lack of cultural:
    1) Awareness2) Desire3) Exposure4) Knowledge
    2) Desire

    Rationale:Cultural desire is the wish to be culturally competent. This nurse clearly does not want to improve in that area.
  5. While admitting a patient with a particular religious heritage, the nurse comments to another nurse, "This is going to be a pain. This kind of patient always has a million family members in and out, and they're always so noisy and demanding."
    This illustrates:1) Discrimination2) Sexism3) Ethnocentrism4) Prejudice
    4) Prejudice

    Rationale:Prejudice refers to negative attitudes toward other people, which are based on faulty and rigid stereotypes about race, gender, sexual orientation, and so on.
  6. When taking a cultural history, all of the following are important. Which one is most important in order to later plan for patient safety?
    1) Obtain data directly from the patient. 2) Show empathy and respect; build rapport.3) Ask about use of alternative medicine and folk remedies.4) Ask open-ended questions when beginning the assessment.
    • 3) Ask about use of alternative medicine and folk remedies.
    • Rationale:Always ask patients about their use of alternative medicine and folk remedies so that their effects on traditional biomedical medications and treatments can be evaluated. Some remedies may interfere with traditional treatments; others can be dangerous.
  7. Which nursing intervention is specific for promoting positive body image?
    1) Encourage the client to be active and focus on healthy eating.2) Discuss boundaries, expectations, and management defined by lifestyle and family networks.3) Monitor for and discourage self-doubt and self-criticism.4) Use positive and reaffirming language when speaking with the patient.
    • Answer:1) Encourage the client to be active and focus on healthy eating.
    • Rationale:Encouraging the client to be active and focus on healthy eating is a nursing intervention that promotes positive body image.
  8. __________________ is defined as a loss of interest or pleasure in previously enjoyed activities.
    1) Anhedonia
    2) Anxiety
    3) Depression
    4) Ambivalence
    • Answer:1 Anhedonia
    • Rationale:Anhedonia is defined as a loss of interest or pleasure in previously enjoyed activities. It is one of the symptoms of depression. Anxiety is defined as a nonspecific mental feeling of uneasiness or apprehension caused by perception of threat to self.
  9. Each patient develops unique patterns of coping with anxiety, called _____________________, which the patient uses both consciously and unconsciously to relieve anxiety.
    Answer:Defense mechanisms

    Rationale:Each person develops unique patterns of coping with anxiety, called defense mechanisms, which are used consciously or unconsciously to relieve the anxiety.
  10. Over which factor affecting self-concept does a school-age child have the most control?

    1) Peer relationships2) Family relationships3) Socioeconomic status4) Developmental level
    • Answer:1) Peer relationships
    • Rationale:Factors that affect self-concept but are out of the school-age child's control include family relationships, socioeconomic status, and developmental level. Peer relationships influence self-concept and are within the child's control because she can choose whether to remain in a relationship.
  11. Negative body image has been linked to an increased risk for which of the following?
    Select all that apply.
    1) Sexually transmitted infections2) Hypertension3) Depression4) Colon cancer
    • 1) Sexually transmitted infections
    • 3) Depression
    • Rationale:A negative body image has been linked to (and therefore places a patient at risk for) depression, smoking among adolescents, unintended pregnancy, sexually transmitted infections, and HIV infection.
  12. Which statement by the patient demonstrates that she is identifying too closely with her disease?
    1) "Because I have high blood pressure, I need to watch my salt intake."2) "Now that I have had chemotherapy, I can't go anywhere; too many germs."3) "I have to watch my fluid intake so my lungs don't fill up with fluid again."4) "I try to exercise at least 3 times a week to avoid further bone loss."
    • 2) "Now that I have had chemotherapy, I can't go anywhere; too many germs."
    • Rationale:The patient who states "Now that I have had chemotherapy, I can't go anywhere" is identifying too closely with her disease. Although she must avoid crowds, she can still venture out of the house. Her response shows that she is placing too many limitations on herself because of the disease.
  13. The nurse is evaluating a patient's responses to interventions to promote her self-esteem. The patient has a nursing diagnosis of Chronic Low Self-Esteem. The patient is moderately overweight. Which of the following statements by the patient provides the most direct evidence of positive self-esteem?
    1) "I've always been a little overweight, even as a child."2) "When I look in the mirror, I can see that I've lost a little weight."3) "My husband says he likes me at this weight."4) "I've done a good job sticking to my diet this week."
    • 4) "I've done a good job sticking to my diet this week."
    • Rationale:When talking about her diet, the patient uses an evaluative word ("good") to indicate a positive feeling about herself. "I've always been overweight" states a fact but gives no clue as to how the patient feels about it. A person who knows she has "lost a little weight" may or may not have good self-esteem and could be in a state of denial. Even though the patient's husband says he likes her weight, she may not believe him and might not have good self-esteem. Also, that statement describes how someone else evaluates the patient, not how she evaluates herself.
  14. Which of the following is a common, normal emotional response to a stressor?
    1) Depression
    2) Fear
    3) Anxiety
    4) Panic
    • 3) Anxiety
    • Rationale:Anxiety is a common emotional response to a stressor. Depression is a prolonged feeling of sadness. Fear is a specific, cognitive response to a known threat. Panic is an unreasonable and irrational response to a stressor.
  15. During the admission assessment, a patient tells the nurse that he does not believe there is a God. The nurse should document his religious affiliation as:
    1) Agnostic
    2) Atheist
    3) Sikhism
    4) Rastafarianism
    • 2) Atheist
    • Rationale:Those who actively deny the existence of God are known as atheists. Agnostics believe it is not possible to know whether or not God actually exists. Sikhism combines the teachings of Hinduism and Islamic Sufism (a mystical branch of Islam); they believe in the presence of one God, not multiple gods. Rastafarians follow the Old and New Testaments of the Bible and emphasize a deep love of God.
  16. Which core issue of spirituality includes a patient's basic human need for achievement?
    1) Hope
    2) Faith
    3) Love
    4) Forgiveness
    • 1) Hope
    • Rationale:Hope includes the basic human needs to achieve, create, and make something of one's life. Faith addresses our ongoing effort to make sense of our life and our purpose for being. With the aspect of love, we extend our love to others with hope of receiving love. Forgiveness is not a core issue of spirituality.
  17. A patient of Mormon faith is admitted to the hospital with new onset diabetes mellitus. Based on his religious affiliation, which item(s) should the nurse be sure is replaced on the patient's dinner tray? Select all that apply.
    1) Pork2) Tea3) Meat4) Coffee
    • 1) Pork3) Meat
    • Rationale:Mormons follow a strict health code, known as the Word of Wisdom, which prohibits the consumption of tea, coffee, and alcohol. Conservative Jews avoid pork products. Most Hindus are lacto-vegetarians, which means they consume milk but not eggs. Buddhists, Hindus, some Rastafarians, and some Christians (on Fridays during Lent) do not consume meat.
  18. A patient remarks to the nurse, "What's the point of going through all these medical treatments. They make me feel so bad, and I will never be well anyway." What is the most helpful action for the nurse to take?

    1) Explore with the patient what has triggered his emotions.2) Treat the patient with dignity and respect.3) Pray with the patient in a private setting.4) Assist the patient to identify areas of hope in life.
    • 4) Assist the patient to identify areas of hope in life.
    • Rationale:The patient is demonstrating Hopelessness. All of the responses would be appropriate under certain circumstances, but helping the patient identify areas of hope in life most directly addresses Hopelessness.
  19. An agnostic nurse is caring for a devoutly religious patient. The client says, "I am so frightened. Please say a prayer with me." The patient begins praying aloud. What should the nurse do?

    1) Remain quietly beside the bed until the client finishes the prayer.2) Walk quietly from the room while the client is praying. 3) Stop the client and say, "I am not comfortable with prayer. I will get someone to join you."4) Stay during the prayer and say "Amen" at pauses and when the prayer is finished.
    • 1) Remain quietly beside the bed until the client finishes the prayer.
    • Rationale:The nurse might choose to pray or not to; but the nurse must respect the client's dignity and provide spiritual support.
  20. Which of the following questions would provide information about "O" in a HOPE assessment and "S" in a SPIRIT assessment?

    1) Do you have any dietary restrictions or needs on religious holidays?2) What is your religion or what church do you go to? 3) How comfortable are you with discussing spirituality?4) Do you have an advance directive?
    • 2) What is your religion or what church do you go to?
    • Rationale:In the HOPE assessment "O" represents "organized religion." In the SPIRIT tool, "S" represents "spiritual/religious belief system." Dietary needs provide information about ritualized practices and restrictions ("R" in the SPIRIT tool; "E" in the HOPE approach). Asking about the patient's comfort with discussing spirituality addresses personal spirituality ("P" in the SPIRIT tool; "P" in the HOPE approach). Advance directives address terminal events planning ("T" in the SPIRIT tool; "E" in the HOPE approach).
  21. The nurse is teaching a patient newly diagnosed with type 1 diabetes mellitus about how to best manage his blood sugar. Which outcome in the patient's plan of care is associated with the cognitive domain of learning?

    The patient:1) identifies signs and symptoms of hypoglycemia.2) nods affirmatively with direct eye contact.3) demonstrates fingerstick glucose monitoring.4) independently self-administers insulin.
    • 1) identifies signs and symptoms of hypoglycemia.
    • Rationale:Cognitive behavior includes recall and comprehension, which is demonstrated by stating information, such as indicators of hypoglycemia. Nodding with eye contact is an action that exhibits the listener is dealing with the information with emotion (respect), which shows affective domain.
  22. When teaching nursing students about how to provide culturally sensitive care to a diverse group of patients, which teaching strategy is most likely to promote affective learning?
    1) Demonstration2) Computer-assisted instruction3) Concept mapping4) Role-modeling
    • 4) Role-modeling
    • Rationale:Affective learning involves changes in feelings, beliefs, attitudes, and values. It is considered the "feeling domain."
  23. A nurse strives to teach a spouse how to monitor a patient's blood pressure. Which teaching method is best?
    1) Provide the patient and spouse with written instruction about how to obtain blood pressure.2) Demonstrate the technique for taking blood pressure, and then request a return demonstration.3) Schedule the spouse for a class about high blood pressure, including monitoring technique.4) Provide the spouse with a patient education brochure about blood pressure monitoring.
    • 2) Demonstrate the technique for taking blood pressure, and then request a return demonstration.
    • Rationale:The best way to teach a psychomotor skill, such as obtaining blood pressure, is through demonstration and return demonstration. Cognitive learning, which includes storage and recall of information, is most often taught through lecture and print and audiovisual materials.
  24. How might the nurse improve health literacy between patients and healthcare providers?
    1) Ask patients simple yes or no questions.2) Speak with passive voice instead of active.3) Avoid medical jargon and technical terms.4) Provide information printed in English.
    • 2) Speak with passive voice instead of active.
    • Rationale:Health literacy is the ability to understand basic health information and services needed to make appropriate healthcare decisions. A gap in health literacy results when a healthcare provider uses terminology that is unfamiliar or misunderstood by the patient, thus resulting in an unintended message or lack of meaningful information.
  25. Why is patient education important in today's healthcare environment?
    1) Primarily it is offered to increase patient confidence for self-care.2) Nurses do patient teaching to transfer responsibility for care to patients.3) Patient education contributes to rising healthcare costs.4) More healthcare is delivered in the home and outpatient settings.
    • 4) More healthcare is delivered in the home and outpatient settings.
    • Rationale:With shorter hospital stays and complex care increasingly being given in homes and the community, teaching is essential to protect patient well-being and safety in the outpatient environment. The primary goal of patient education is to increase the knowledge and skills needed for quality self-care or for providers delivering care in the outpatient setting.
  26. The nurse working in a hospital with a diverse population strives to offer culturally sensitive care. What nursing action would be most appropriate?
    1) Act as if familiar with cultural practices or values even if uncertain.2) Allow patient to include cultural practices in plan of care unless harmful.3) Use common, slang phrases as they are familiar to many people.4) Incorporate humor into interactions with patients to put them at ease.
    • 2) Allow patient to include cultural practices in plan of care unless harmful.
    • Rationale:Find ways to incorporate the client's current healthcare practices and beliefs into the plan of care unless there is potential for harm.
  27. How do the Langerhans cells protect the skin from injury? Langerhans cells:
    1) contain protein that give the skin strength and elasticity.2) are able to filter out beta ultraviolet light waves.3) are mobile and phagocytize foreign material.4) are located in the dermal layer of the skin.
    • 3) are mobile and phagocytize foreign material.
    • Rationale:Langerhans cells are located in the epidermal layer of the skin. They are mobile and able to phagocytize foreign material and trigger an immune response. Keratinocytes are protein-containing cells that give the skin strength and elasticity. Melanocytes provide protection from ultraviolet light.
  28. When performing an assessment for a patient with a 2-week-old wound, the nurse notes the formation of granulation tissue in the wound bed and recognizes the wound is most likely in which stage of wound healing?
    1) Proliferative phase2) Maturation phase3) Aggregation phase4) Inflammatory phase
    • 1) Proliferative phase
    • Rationale:The proliferative phase occurs from days 5 to 21. It is characterized by cell development aimed at filling the wound defect and resurfacing the skin. Granulation tissue forms during this stage, as fibroblasts migrate to the wound to form collagen, and new blood and lymph vessels sprout from the existing capillaries at the edge of the wound.
  29. A postsurgical patient who is morbidly obese informs the nurse that as she was coughing, she felt a "pop" at her abdominal incision site. Upon inspection, the nurse notes the sutures to the incision are intact; however, there is an increase in the amount of serosanguineous drainage.
    The nurse would suspect wound:1) Evisceration2) Fistula3) Hemorrhage4) Dehiscence
    • 4) Dehiscence
    • Rationale:Wound dehiscence is a rupture of one or more layers of a wound and usually occurs in the inflammatory phase before large amounts of collagen have been deposited in the wound to strengthen it. Dehiscence is usually associated with abdominal wounds, and patients often report feeling a pop or tear, especially with sudden straining from coughing, vomiting, or changing positions in bed. Usually there is an immediate increase in serosanguineous drainage. Patients with obesity are more likely to experience wound dehiscence because fatty tissue does not heal readily, and the patient's body mass increases the strain on the suture line.
  30. n older adult had a colon resection 1 week ago. When assessing the abdominal incision, the nurse notes foul-smelling brown drainage seeping from the middle of the incision site.
    The nurse suspects he has:1) an infected wound.2) wound dehiscence.3) a hematoma.4) a fistula.
    • Answer:4) a fistula.
    • Rationale:A fistula is an abnormal passage connecting two body cavities or a cavity and the skin. Based on the type of surgery and drainage present, the nurse would suspect fistula formation.
  31. The most appropriate nursing diagnosis for a patient with a draining wound would be:
    1) Risk for Infection related to dehiscence of wound.2) Body Image Disturbance related to nonhealing surgical wound.3) Risk for Impaired Skin Integrity related to wound drainage.4) Pain related to surgical incision.
    • 3) Risk for Impaired Skin Integrity related to wound drainage.
    • Rationale:The drainage from a wound places the patient at an increased risk for skin breakdown because of the dampness and presence of enzymes in the drainage. The risk of infection is present, but the data provided do not indicate this is a problem. There are no data indicating the patient is having a problem with body image or that he is in pain.
  32. The nurse is assessing an ischial pressure ulcer on a client. She observes that the pressure ulcer is 3 cm × 2 cm × 1 cm and involves only subcutaneous tissue. The nurse also notes an area extending 3 cm from 12 o'clock to 3 o'clock under the wound edges.
    The nurse would document this as:1) Stage IV pressure ulcer with undermining of 3 cm from 12:00 to 3:00.2) Stage III pressure ulcer with undermining of 3 cm from 12:00 to 3:00.3) Stage IV pressure ulcer with sinus tract from 12:00 to 3:00.4) Stage III pressure ulcer with sinus tract from 12:00 to 3:00.
    • Answer:2) Stage III pressure ulcer with undermining of 3 cm from 12:00 to 3:00.
    • Rationale:A stage III pressure ulcer is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. Undermining is deeper-level damage of adjacent tissue. Sinus tracts are narrow, blind tracts underneath the epidermis.
  33. To obtain the most accurate culture information of a chronic wound, the nurse would recommend:

    1) tissue biopsy.2) swab culture.3) sterile culture.4) needle aspiration culture.
    • Answer:1) tissue biopsy.
    • Rationale:A tissue biopsy, in which a piece of tissue is removed from the wound bed and analyzed, provides the most definitive information about infection status of a chronic wound. Chronic wounds are frequently colonized with bacteria; therefore, surface culture (swab) would not be accurate.
  34. An older adult has a 3 cm × 2 cm eschar on the right heel.
    The initial treatment choice for this wound is:1) elevate the right heel off the surface of the bed.2) request a surgical consult for débridement of the area.3) apply a hydrocolloid to promote autolytic débridement of the wound.4) request an order for an enzymatic débridement medication.
    • 1) elevate the right heel off the surface of the bed.
    • Rationale:A black wound (eschar) requires débridement of the necrotic tissue except at the heel. The Agency for Healthcare Quality and Research (AHQR) does not recommend débridement of this site. Therefore, your best treatment choice would be elevation of the heel off of the bed. This will relieve pressure to the affected area.
  35. The patient with a new colostomy refuses to participate in the care of her colostomy or meet with a support member from the ostomy society. She will not look at the site and describes the colostomy as disgusting. Based on these data, the priority nursing diagnosis for Mrs. Lore is:1) Anxiety related to colostomy.2) Disturbed Body Image related to colostomy.3) Disturbed Body Image related to incontinence of stool.4) Impaired Skin Integrity related to fecal drainage.
    • 2) Disturbed Body Image related to colostomy.
    • Rationale:Mrs. Lore is having difficulty adjusting to her colostomy. The colostomy is covered by a collection device, so there is no incontinence. There is no evidence of either anxiety or actual skin impairment.
  36. The nurse will know ostomy care teaching is most likely successful when the patient with a new ostomy device:
    1) demonstrates the proper method of cleansing her skin.2) demonstrates proficiency when providing treatment to excoriated skin.3) states she will start caring for the colostomy after she gets home.4) proficiently performs colostomy care prior to discharge.
    • Answer:4) proficiently performs colostomy care prior to discharge.
    • Rationale:By performing colostomy care, Mrs. Lore's behavior reflects acceptance of her colostomy. There is no information to suggest that her skin is excoriated. Waiting until she gets home to start care is delaying acceptance and will not allow her to get assistance or further instruction. Demonstrating correct skin cleansing does not ensure that the client is actually performing colostomy care or has accepted her condition.
  37. A patient was brought to the emergency department with complaints of extreme fatigue, nausea, vomiting, and muscle weakness. Lab results reveal the following: Na+ = 140 mEq/L; K+ = 2.0 mEq/L; Ca2+ = 8.6 mg/dl; Mg2+ = 1.4 mg/dL; and Cl– = 96 mEq/L. The electrocardiogram (ECG) tracing has a flat T wave and frequent PVCs (premature ventricular contractions). The patient's prescribed daily oral medications include furosemide 20 mg, digoxin 0.25 mg, and aspirin 81 mg. The nurse recognizes that these symptoms and diagnostic information are consistent with which of the following?1) Hypocalcemia2) Hypernatremia3) Hypokalemia4) Hypermagnesemia
    • 3) Hypokalemia
    • Rationale:The serum potassium level is low (norm = 3.5 to 5.0 mEq/L). PVCs related to cardiac irritability and a flat T wave on an ECG are also indicative of hypokalemia. The patient takes furosemide (Lasix), a diuretic that can induce hypokalemia.
  38. A patient was brought to the emergency department with complaints of extreme fatigue, nausea, vomiting, and muscle weakness. Lab results reveal the following: Na+ = 140 mEq/L; K+ = 2.0 mEq/L; Ca2+ = 8.6 mg/dL; Mg2+ = 1.4 mg/dL; and Cl– = 96 mEq/L. The electrocardiogram (ECG) tracing has a flat T wave and frequent PVCs (premature ventricular contractions). The patient's prescribed daily oral medications include furosemide 20 mg, digoxin 0.25 mg, and aspirin 81 mg. Why might the nurse question the order for digoxin 0.25 mg orally daily?1) Based on the digoxin level, the dose may need to be increased.2) The patient is at risk for an elevated digoxin level at this time.3) Digoxin and furosemide should never be taken together.4) The nurse should not be concerned about the order as written.
    • 2) The patient is at risk for an elevated digoxin level at this time.
    • Rationale:The hypokalemic patient on digoxin is at high risk for digoxin toxicity. The patient's serum digoxin level will need to be assessed as she receives potassium supplementation. Digoxin and furosemide can be taken together.
  39. Which of the following is considered a first-line intravenous solution for a patient with hypovolemia?

    1) 0.9% NaCl (normal saline)2) 0.45% NaCl (1/2 normal saline)3) Dextran (a plasma expander)4) D5W (5% dextrose in water)
    • Answer:1) 0.9% NaCl (normal saline)
    • Rationale:Hypovolemia occurs when there is a proportional loss of water and electrolytes from the extracellular fluid. Normal saline is an isotonic fluid that remains inside the intravascular space, thus increasing volume. Solutions of 0.45% NaCl and D5W are hypotonic fluids and therefore would pull body water from the intravascular compartment into the interstitial fluid compartment, leading to cellular death. Dextran is a hypertonic fluid that pulls fluid and electrolytes from the intercellular and interstitial compartments into the intravascular compartment and can be used in cases of hypovolemia but is not considered as a first choice.
  40. A physician has prescribed 1,000 ml of 0.9% NaCl (normal saline) over 4 hours for a hypovolemic patient. The drop (gtt) factor is 60. What would the nurse set the drip rate at?
    1) 75 gtt/min2) 100 gtt/min3) 250 gtt/min4) 500 gtt/min
    • 3) 250 gtt/min
    • Rationale:Calculate the drip rate by multiplying the hourly rate by the drop factor in drops/mL divided by 60 min. An infusion of 1,000 mL over 4 hours yields an hourly rate of 250 mL.
  41. A patient is to receive two units of packed red blood cells. Her blood group is O+. The nurse knows that the patient may receive blood from which of the following donors?

    1) AB+, A–, B+, and O–2) A+ and O+3) AB– and O+4) O+ and O–
    • 4) O+ and O–
    • Rationale:Persons with O+ blood may receive O+ or O-. Blood group O persons are considered "universal donors." Rh+ persons may receive Rh+ and Rh– blood. Persons who are Rh– may receive only Rh– blood.
  42. A patient has been admitted to the hospital with medical diagnoses of hypervolemia, acute renal failure, and cardiac dysrhythmias. The patient's vital signs are the following: T = 98.4°F (36.9°C); P = 110; R = 32; BP = 162/102. On physical examination the nurse notes distended neck veins and 3+ pitting edema in both lower extremities. The patient reports he has been drinking and eating as usual but has been unable to urinate. Which is the most appropriate nursing diagnosis for this patient?1) Excess Fluid Volume related to excessive food and fluid intake2) Deficient Fluid Volume related to increased metabolic demands3) Imbalanced Electrolytes secondary to fluid shifts4) Excess Fluid Volume secondary to acute renal failure
    • 4) Excess Fluid Volume secondary to acute renal failure
    • Rationale:This patient is experiencing Excess Fluid Volume secondary to acute renal failure. There is no indication that he has engaged in excessive food or fluid intake. There is no laboratory result to indicate an electrolyte imbalance, although his test results will most likely demonstrate abnormalities because of the acute renal failure.
  43. A patient is in respiratory distress. The physician has ordered arterial blood gases (ABGs). The results are the following: pH = 7.50; PCO2 = 26; HCO3 = 24 mEq/L. How should the nurse interpret the ABGs?
    1) Respiratory acidosis2) Respiratory alkalosis3) Metabolic acidosis4) Metabolic alkalosis
    • 2) Respiratory alkalosis
    • Rationale:The ABGs are consistent with respiratory alkalosis. The pH is elevated, indicating alkalosis. The PCO2 is decreased, which is also consistent with alkalosis. The HCO3 is within normal range.
  44. For a patient in respiratory distress, the first arterial blood gases (ABGs) were the following: pH = 7.50; PCO2 = 26; HCO3 = 24 mEq/L. The ABGs were repeated the next morning. The new results are the following: pH = 7.47; PCO2 = 26 mmol/L; HCO3 = 28 mEq/L. The nurse recognizes that the values have changed and that the patient is now experiencing
    1) respiratory acidosis.2) metabolic alkalosis.3) partial compensation.4) complete compensation.
    • Answer:3) partial compensation.
    • Rationale:Although the pH remains alkalotic, the bicarbonate level has begun to rise to compensate for the low PCO2. Complete compensation occurs when the pH returns to normal.
  45. The nurse is discontinuing a central venous access device. When she removes the catheter, she notes that a portion of the tip is missing. What action must she take?

    1) Apply a tourniquet above the site.2) Start a new peripheral IV.3) Apply warm compresses to the site.4) Notify the physician and radiologist.
    • 4) Notify the physician and radiologist.
    • Rationale:Loss of the catheter tip places the patient at risk for an embolus. Because the catheter was in a central vein, it is not possible to place a tourniquet above the site. Warm compresses are appropriate follow-up care for IV extravasation or infiltration. A new peripheral IV may be needed, but this is not the priority. The nurse must notify the physician and radiologist.
  46. he student nurse is reviewing a patient's laboratory reports. Which of the following results should be reported to the primary care provider?

    1) Na+ = 126 mEq/L2) K+ = 3.8 mEq/L3) Ca2+ = 9.2 mg/dL4) Mg2+ = 1.8 mg/dL
    • 1) Na+ = 126 mEq/L
    • Rationale:Serum sodium of 126 mEq/L indicates significant hyponatremia. The student nurse should report the findings to the nurse with whom she is working (or the primary care provider, depending on agency policy) who will report the findings to the primary care provider. The other laboratory results are all within normal limits.

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