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1. The nurse is caring for a client following an appendectomy. The client reports nausea and complains of surgical site pain at a 6 on a 0 to 10 scale. The client's employer is present in the room and states he is paying for the insurance and wants to know what pain medication has been prescribed by the physician. Which of the following is the appropriate nurse response?
A. Answer any questions the employer may have as he pays for the insurance.
B. Tell the employer his question is inappropriate and that the information is none of his business.
C. Explain to the employer that you cannot release private information and ask the employer to step out while you conduct your assessment of the client.
D. Ask the employer to leave and wait until the client returns home to visit.
- C. Explaining to the employer that the nurse cannot release information and asking the employer to step out while conducting an assessment allows the client privacy while still being respectful of the employer.
- Although the employer is paying for the insurance, this does not given him a right to confidential information. Providing information to the client's employer without permission is a violation of the right to privacy under HIPAA.
- Speaking rudely to a visitor by saying something is "none of his business" is never appropriate.
- Asking the person to leave and to wait until the client returns home to visit wrongly assumes the nurse has the right to speak for the patient.
The nurse is caring for a client with a history of advanced chronic obstructive pulmonary disease (COPD). The client had conventional gallbladder surgery 2 days previously. Which intervention has priority for preventing respiratory complications?
A. Incentive spirometry every 4 hours.
B. Coughing and deep breathing four times daily.
C. Getting the client out of bed 4 times daily as ordered by the physician.
D. Giving oxygen at 4 L/minute according to the physician's order.
- C. Getting the client out of bed 4 times daily as ordered by the physician.
- Getting the client out of bed prevents pooling of secretions in the lungs and promotes better lung expansion. An incentive spirometer (a device that measures air movement into the lungs and encourages the client to breathe deeply), coughing, and deep breathing are important, but the client needs to perform these more frequently (every 1 to 2 hours) instead of every 4 hours or 4 times daily. Giving oxygen at 4 L/minute could decrease the client's respiratory drive.
A nurse is developing a care plan for a client with acute mania. Place the following behaviors in the order in which they occur as the client develops acute mania. Use all of the options.
A. Delusions of grandeur.
B. Relevant, calm speech patterns.
C. Highly productive and competitive in work and leisure activities.
D. Easily irritated.
E. Poor judgment and impulse control.
- Symptoms of acute mania occur in the following sequence:
- B. Relevant, calm speech patterns.
- C. Highly productive and competitive in work and leisure activities.
- D. Easily irritated.
- A. Delusions of grandeur.
- E. Poor judgment and impulse control.
- Relevant and calm speech patterns are indicative of normal behavior. Once mania begins, the client may become highly productive and competitive in all activities. Sleep is not a priority.
- As mania progresses, emotional manifestations heighten and the client is easily irritated, begins to have delusions of grandeur, and may require medication to reduce restlessness and agitation.
- Client safety is the primary goal due to poor judgment and impulse control
When educating a pregnant client about home safety, which of the following information is appropriate for the nurse to include in the teaching plan? Select all that apply.
A. When taking a shower, place a non-skid mat on the floor of the tub or shower.
B. Avoid climbing stairs.
C. Avoid wearing high heels.
D. Use non-slip rugs on the floors.
- A. When taking a shower, place a non-skid mat on the floor of the tub or shower.
- C. Avoid wearing high heels.
- D. Use non-slip rugs on the floors.
- A woman's center of gravity changes during pregnancy, increasing her risk of falls. She should use a non-skid mat in the tub or shower.
- Wearing high heels will increase unbalance and can contribute to falls.
- Non-slip rugs will prevent tripping and falling.
- There is no reason that a pregnant woman in good health should avoid climbing stairs; in fact, stair climbing is good exercise.
A client had a C5 spinal cord contusion that resulted in quadriplegia. Two days after the injury occurred, the nurse sees his mother crying in the waiting room. The mother asks the nurse whether her son will ever play football again. Which of the following is the best initial response?
A. "Given time and motivation, your son can return to normal function."
B. "I'm not sure, but I'll call the physician to talk to you right away."
C. "What do you know about your son's injury?"
D. "Getting upset isn't in you son's best interest."
- C. "What do you know about your son's injury?"
- Asking the mother what she knows about her son's injury is a good way to encourage the mother to express her feelings. It also allows the nurse to gather more data about the mother's understanding of the injury. Providing reassurance that the woman's son will return to normal function may be incorrect because, in many cases, spinal cord contusion results in permanent loss of function. A definitive prognosis isn't possible so soon after a spinal cord contusion, so referring the mother to the doctor would not be helpful. The mother needs to be allowed to voice her concerns without being made to feel guilty.
The nurse is caring for a client who will undergo surgical repair of a detached retina. Which of the following is the most likely preoperative nursing diagnosis for this client?
A. Anxiety related to loss of vision and potential failure to regain vision.
B. Deficient knowledge (preoperative and postoperative activities) related to lack of information.
C. Acute pain related to tissue injury and decreased circulation to the eye.
D. Risk for infection related to the eye injury.
- A. Anxiety related to loss of vision and potential failure to regain vision.
- A client who perceives a threat to vision, such as a sudden loss of sight, is likely to be anxious about the possibility of permanent blindness. Because severe anxiety impairs the client's ability to process new information, this anxiety must be addressed before teaching is possible. The nurse should encourage the client to talk about her understanding of the surgery and the expected outcomes. A detached retina is not characterized by acute pain and there is little preoperative risk of infection.
When assessing a client with glaucoma, a nurse expects which of the following findings?
A. Complaints of double vision.
B. Complaints of halos around lights.
C. Intraocular pressure of 15 mm Hg.
D. Soft globe on palpation.
- B. Complaints of halos around lights.
- A complaint of halos around lights is a common finding in a client with glaucoma.
- Symptoms of glaucoma don't include double vision but can include loss of peripheral vision or blind spots, reddened sclera, firm globe, decreased accommodation, and occasional eye pain, but clients may be asymptomatic until permanent damage to the optic nerve and retina has occurred. Normal intraocular pressure is 10 to 21 mm Hg.
A client had a Caesarean delivery and is postpartum day 1. She asks for pain medication when the nurse enters the room to do her shift assessment. The client states that her pain level is an 8 on a scale of 1 to 10. What should be the nurse's priority of care?
A. Give the pain medication and return in an hour for further assessment to allow time for the medication to work.
B. Complete the postpartum assessment and then give the client pain medication.
C. Give the pain medication first, do a quick assessment while administering the medication to ensure the pain is not caused by a complication, and return for the full assessment after the client's pain has subsided.
D. Instruct the patient to do relaxation exercises to relieve her discomfort.
- Pain management is a priority, so the nurse should immediately bring pain medication. However, the nurse should do a quick assessment while administering the medication to ensure that a complication, such a hemorrhage, hasn't caused the increased pain. A complete assessment can wait until the pain subsides. Control of pain will enable the client to move, eliminating other potential complications of delivery. Bonding with the infant will be facilitated as well if the client is without discomfort. Relaxation techniques can act as an adjunct therapy but by themselves are not usually useful for pain management during the early post-Caesarean period.
The nurse is preparing to teach a client about the effects of isoniazid (INH). Which information is important for the client to understand?
A. Isoniazid should be taken on an empty stomach.
B. Prolonged use of isoniazid produces poorly concentrated urine.
C. Taking aluminum hydroxide (Maalox)® with isoniazid minimizes gastrointestinal upset.
D. Drinking alcohol daily can increase the incidence of drug-induced hepatitis.
- Drinking alcohol can induce isoniazid-related hepatitis. If hepatic damage occurs, the client's urine may become dark and appear concentrated. GI upset frequently occurs when isoniazid is taken on an empty stomach, so taking this drug with meals decreases GI upset. The client should avoid taking aluminum-containing antacids, such as aluminum hydroxide, with isoniazid as it may decrease the drug's effects.
A one-month old infant in the neonatal intensive care unit is dying. The parents request that the nurse administer an opioid analgesic to their infant, who is crying weakly. The infant's heart rate is 68 beats per minute and the respiratory rate is 18 breaths per minute. The infant is on room air and the oxygen saturation is 92%. The nurse's response is based on which of the following principles?
A. Providing analgesia during the last days and hours is an ethically-appropriate nursing action.
B. Withholding the opioid analgesia during the last days and hours is an ethical duty because administering it would represent assisted suicide.
C. Administering analgesia during the last days and hours is the parent's ethical decision.
D. Withholding the opioid analgesia is clinically appropriate because it will hasten the infant's death.
- All clients, regardless of age, have the right to die with dignity and be free from pain. The parents have the right to request an opioid to relieve the child's distress. Assisted suicide requires some action on the part of the client, and this is not possible for a 1-month old infant. Both the nurse and the parents have an ethical duty to the child. Withholding the opioid analgesic from a dying child is not appropriate because of fear it may hasten death, as opioids can hasten death with dying patients at any age, and this is not considered a contraindication for administration of analgesia.
While undergoing hemodialysis, the client becomes restless and tells the nurse he has a headache and feels nauseous. Which of the following complications does the nurse suspect?
B. Disequilibrium syndrome.
C. Air embolus.
D. Acute hemolysis.
- Disequilibrium syndrome is caused by a rapid reduction in urea, sodium, and other solutes from the blood. This may lead to cerebral edema and increased intracranial pressure (ICP). Signs and symptoms of increased ICP include headache, nausea, and restlessness as well as vomiting, confusion, twitching, and seizures. Fever and an elevated white blood cell count may indicate infection. Popping or ringing in the ears, chest pain, dizziness, or coughing suggests an air embolus. Chest pain, dyspnea, burning at the access site, and cramping suggest acute hemolysis.
An elderly couple is speaking to the nurse about their ambivalence related to sending the client, their adult, dual-diagnosed (bipolar and drug addict) son, into residential placement. They tell the nurse that neither keeping their son at home nor sending him to a facility is a satisfactory solution for them. What information should the nurse keep in mind when discussing this dilemma with the family? Select all that apply.
A. Implement what is best for the couple.
B. Suggest another psychiatric evaluation for the son.
C. Look for all potential options for care.
D. Review the client's treatment history.
E. Consult legal authorities for information.
- C and D
- One of the steps in ethical decision-making is to consider all possible options of care, such as outpatient programs, along with the potential results of each option. A review of the client's treatment history is part of the first step in gathering the background information, as this helps to create a clear picture of the client's situation. The nurse would not tell the elderly couple to implement what is best for them since they are concerned about what action is in the best interests of their son, and the nurse's responsibility is to the client. Since the son is dual-diagnosed, he has had a psychiatric evaluation, and another evaluation will not address the couple's dilemma. There is no reason to consult legal authorities.
The nurse is caring for a 44-year-old client diagnosed with hypoparathyroidism. Which electrolyte imbalance is closely associated with hypoparathyroidism?
- The parathyroid glands are responsible for maintaining calcium levels at 8.8 to 10.2 mg/dL. In hypoparathyroidism, parathyroid hormone levels are insufficient to maintain adequate calcium levels. The nurse should monitor clients with hypoparathyroidism for signs and symptoms of hypocalcemia, including muscle spasms, anxiety, seizures, hypotension, and congestive heart failure. Hyponatremia and hyperkalemia aren't associated with hypoparathyroidism. Hyperphosphatemia, not hypophosphatemia, may be seen in the client with hypoparathyroidism as calcium levels decrease.
The nurse is caring for a client diagnosed with end-stage liver disease. The client has completed an advance directive and a do-not-resuscitate (DNR) document and wishes to receive palliative care. Which of the following would correspond to the client's wish for comfort care?
A. Positioning frequently to prevent skin breakdown and providing pain management and other comfort measures.
B. Carrying out vigorous resuscitation efforts if the client were to stop breathing, but no resuscitation if the heart stops beating.
C. Providing intravenous fluids when the client becomes dehydrated.
D. Providing total parenteral nutrition (TPN) if the client is not able to eat.
- Palliative care includes measures to prevent skin breakdown, pain management, management of other symptoms that cause discomfort, and encouraging contact with family and friends. A DNR request precludes all resuscitative efforts related to respiratory or cardiac arrest. Dehydration is a normal part of the dying process, so intravenous fluids are inappropriate. Total parenteral nutrition (TPN) is an invasive procedure meant to prolong life and is not part of palliative care.
The nurse is caring for a client receiving warfarin therapy (Coumadin®) following a stroke. The client's PT/INR was completed at 7:00 A.M. prior to the morning meal with an INR reading of 4.0. Which of the following is the nurse's first priority?
A. Call the physician to request an increase in the Coumadin® dose.
B. Administer a vitamin K injection IM and notify the physician of the results.
C. Assess the client for bleeding around the gums or in the stool and notify the physician of the lab results and latest dose of Coumadin®.
D. Notify the next shift to hold the daily dose of Coumadin® scheduled for 5:00 pm.
- For a client taking Coumadin® following a stroke, the INR should be between 2.0 and 3.0. The elevated INR level should be communicated to the physician along with assessment data regarding possible bleeding. An increased dose of Coumadin® would increase the risk of bleeding. Administration of medications, such as warfarin and vitamin K, requires a physician's order. The nurse should notify the physician and receive an order prior to holding the Coumadin® scheduled for another shift.
The nurse is checking laboratory values on a patient who has crackling rales in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which of the following laboratory values does the nurse expect to be abnormal?
B. B-type natriuretic peptide (BNP).
C. C-reactive protein (CRP).
- The client's symptoms suggest heart failure. BNP is a neurohormone that is released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/mL is often associated with mild heart failure; and, as the BNP level increases, the severity of heart failure increases. Potassium levels are not affected by heart failure. CRP is an indicator of inflammation. It is used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding or clotting abnormalities, such as those seen with an abnormal platelet count.
A 12-year-old boy has been receiving aggressive treatment for leukemia for the past year. His condition has continued to deteriorate, and the prognosis is poor. The parents would like to implement a "Do Not Resuscitate" plan but inform the nurse that they cannot bring themselves to discuss it with their child and ask the nurse to discuss it with the child instead. When approaching the subject with the child, the nurse must assess which of the following first?
A. What the child knows about the disease and his prognosis.
B. How the child would like to handle the plan of care. C. What interventions the child would like in the event of cardiac or respiratory arrest.
D. What the child believes about death.
- When discussing the child's wishes for future care, it is important for the nurse to first identify what the child knows about the disease and his prognosis. Factors such as the perceived severity of the illness will be significant in planing for end-of-life care. If the child does not understand the disease process or prognosis, the plan of care would not be effective or realistic. In addition, asking a child about desired interventions in the event of cardiac or respiratory arrest would not be an appropriate initial area of questioning. If the child does not understand the disease process, these questions may seem frightening or threatening. While exploring the child's belief about death would be important, it would not be the initial area of discussion and should be guided by the child rather than the nurse.
The nurse is advising a client with a colostomy. The client reports problems with flatus. Which of the following foods should the nurse recommend?
A. High fiber foods, such as bran.
B. Cruciferous vegetables, such as cabbage, broccoli, and kale.
C. Carbonated beverages.
- The client should include yogurt in her diet to reduce gas formation. Other helpful foods include crackers and toast. High-fiber foods, such as bran, stimulate peristalsis and increase flatulence. Cruciferous vegetables tend to increase gas formation, as do beans. The client should also be advised that smoking, chewing gum, and drinking carbonated fluids, and drinking fluids with a straw can increase gas formation.
The nurse is reviewing self-care measures for a client with peripheral vascular disease. Which of the following statements indicates proper self-care measures?
A. "I like to soak my feet in the hot tub everyday."
B. "I walk to the mailbox in my bare feet."
C. "I stopped smoking and only use chewing tobacco." D. "I have my wife examine the soles of my feet each day."
- A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If he isn't able to do this, then a caregiver or family member should help him. Hot tubs should be avoided since the client may have decreased sensation in his feet and may not feel when the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, either from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.
A nurse is taking the health history of an 85-year-old client. Which of the following physical findings is consistent with normal aging?
A. Increase in subcutaneous fat.
B. Diminished cough reflex.
C. Long-term memory loss.
- Diminished cough reflex is consistent with normal aging, putting older adults at increased risk for aspiration and atelectasis. A decrease in subcutaneous fat increases risk for pressure ulcers. Long-term memory is usually intact unless the client suffers from dementia, but short-term memory is often impaired. Presbyopia (far-sightedness) is common with aging. Those who have had myopia (near-sightedness) may find their vision improving with age.
Which type of evaluation occurs continuously throughout the teaching and learning process?
- Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. It includes assessing needs, process, implementation and potential outcomes. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Retrospective or summative evaluation occurs at the conclusion of teaching and learning sessions and often evaluates how a group has done. It includes outcomes assessment, cost-effectiveness, and impact. Informative isn't a type of evaluation.
A client with chest pain arrives in the emergency room and receives nitroglycerin, morphine, oxygen, and aspirin. The client is diagnosed with acute coronary syndrome and suspected myocardial infarction. The client arrives on the unit, and his vital signs are stable and he has no complaints of pain. The nurse is reviewing the physician's orders. In addition to the medications given, which other medication does the nurse expect the physician to order?
A. A -blocker, such as carvedilol (Coreg®).
B. Digoxin (Lanoxin®).
C. Furosemide (Lasix®).
- A patient who is admitted with suspected myocardial infarction should receive aspirin, nitroglycerin, morphine, and a -blocker, such as carvedilol. Digoxin in indicated for arrhythmia rather than acute coronary syndrome. Furosemide would be used if the client had signs of heart failure, such as peripheral or pulmonary edema, but this is not evident. Nitroprusside is used to increase blood pressure, but the client has stable vital signs and is not hypotensive
The nurse is caring for a client after a lung lobectomy. The nurse notes fluctuating water levels in the water-seal chamber of the client's chest tube. What action should the nurse take?
A. Do nothing, but continue to monitor the client.
B. Call the physician immediately.
C. Check the chest tube for a loose connection.
D. Add more water to the water-seal chamber.
- Fluctuation in the water-seal chamber is a normal finding that occurs as the client breathes. No action is required except for continued monitoring of the client. The nurse doesn't need to notify the physician. Continuous bubbling in the water-seal chamber indicates an air leak in the chest tube system, such as from a loose connection in the chest tube tubing. The water-seal chamber should be filled initially to the 2 cm line, and no more water should be added.
A hospice program director was examining various activities related to client care with the intent of improving quality. The director determined that many are clients were being admitted on service without an advanced directive. The director along with a team of individuals developed a plan including goals, objectives, and a timeline to address the issue. This is an example of which of the following approaches?
A. Risk management project.
B. Performance improvement project.
C. Client care initiative.
D. Palliative care project.
- Performance improvement projects are an approach to design, measure, assess, and improve organizational performance. Risk management differs in that it is a planned program of loss prevention and liability control. Although this is an initiative that involves client care, the span of the issue extends beyond direct care providers. Advanced directives are important in the context of palliative care, but assuring that all patients have them relates more closely to organizational performance.
The nurse is making a teaching plan for a client with Parkinson's disease to help him understand the implications of beginning treatment with levodopa. Which of the following instructions should the nurse include?
A. Change positions slowly.
B. Increase intake of foods with vitamin B6.
C. Increase the dose if twitching worsens.
D. Call the physician if symptoms don't improve in 1 week.
- Because levodopa can cause orthostatic hypotension, the client should be cautioned to change positions slowly to avoid dizziness, light-headedness, or fainting. The client should avoid foods high in vitamin B6 and vitamin B6 supplements because they can reverse the effects of levodopa. Increased twitching may be a sign of drug overdose and should be reported to the physician. Other signs of overdose include palpitations, eye spasms, arrhythmias, and hypertension. When a client is started on levodopa, it may take several weeks for symptoms to improve, so the client should not expect immediate improvement.
The nurse is preparing to administer an I.M. injection in a client with a spinal cord injury that has resulted in paraplegia. Which of the following muscles is best site for the injection in this case?
B. Dorsal gluteal.
C. Vastus lateralis.
D. Ventral gluteal.
- I.M. injections should be given in the deltoid muscle in the client with a spinal cord injury. Paraplegia involves paralysis and lack of sensation in the lower trunk and lower extremities. Clients with spinal cord injuries exhibit reduced use of and consequently reduced blood flow to muscles in the buttocks (dorsal gluteal and ventral gluteal) and legs (vastus lateralis). Decreased blood flow results in impaired drug absorption and increases the risk of local irritation and trauma, which could result in ulceration of the tissue.
The nurse is evaluating treatment effectiveness indicators for a client who is being discharged from the intensive outpatient drug and alcohol clinic. Which client behavior would the nurse evaluate as a positive treatment outcome?
A. The client is following a regular sleeping routine.
B. The client is participating in scheduled group meetings.
C. The client is planning to engage in social activities. D. The client is applying the clinic rules to others.
- A client with a drug and alcohol problem who is participating in the scheduled group sessions is making an effort to learn lifestyle changes, coping skills, and ways to maintain a clean and sober life. Although it is healthy to follow a regular sleep pattern, this behavior is not a specific indicator of drug and alcohol treatment effectiveness. Plans to engage in social activities may be repeating patterns of the people, places, and things that triggered drug use; therefore, this action could be a negative treatment outcome. Applying the clinic rules to others is a form of distraction that prevents the client from focusing on personal treatment goals.
The nurse is caring for a client with heart failure. Which of the following statements by the client suggests that the client has left-sided heart failure?
A. "I sleep on three pillows each night."
B. "My feet are bigger than normal."
C. "My pants don't fit around my waist."
D. "I have to get up three times during the night to urinate."
- Orthopnea is a classic sign of left-sided heart failure. The client often sleeps on several pillows at night to help facilitate breathing because of pulmonary edema. Peripheral edema is indicative or right-sided failure. Ascites is a late symptom of right-sided heart failure and can increase girth. Nocturia is common with right-sided failure as peripheral edema decreases when the feet are not dependent, increasing urinary output.
A client with type 2 diabetes has a hemoglobin A1C level of 8.8 after 6 months of oral therapy with metformin (Glucophage®). The client tells the nurse that she often forgets to take her medication and doesn't really follow her diet. Which of the following is the nurse's best first response?
A. "If you don't get control of your blood sugar, you'll need to take insulin."
B. "It can be hard to get used to having a disease like diabetes. What are some of the things you find challenging about it?"
C. "Uncontrolled diabetes can lead to eye problems and kidneys problems."
D. "Many people have diabetes."
- Acknowledging that the client is going through changes and allowing her to express her concerns will help the nurse assess her needs. Hemoglobin AIC shows the average blood glucose levels over a 3-month period. Diabetes should maintain the AIC <7%. Lecturing, threatening and comparing the clients to others belittles the client and discourages discussion, but the patient must be provided adequate information in order to make informed decisions about self-care.
The nurse is reviewing laboratory values of a client diagnosed with hyperlipidemia 6 months previously. Which results indicate that the client has been following his therapeutic regime?
A. Total cholesterol level increases from 250 mg/dL to 275 mg/dL.
B. Low-density lipoproteins (LDL) increase from 180 mg/dL to 190 mg/dL.
C. High-density lipoproteins (HDL) increase from 25 mg/dL to 40 mg/dL.
D. Triglycerides increase from 225 mg/dL to 250 mg/dL.
- HDL levels have an inverse relationship with coronary artery disease and should be greater than 35 mg/dL. The goal of treating hyperlipidemia is to decrease total cholesterol and LDL levels, while increasing HDL levels. Total cholesterol levels are recommended to be below 200 mg/dL. LDL levels should be less than 160 mg/dL. In clients with known coronary artery disease or diabetes, the LDL level should be less than 70 mg/dL. Triglyceride level has a direct relationship a LDL level and an inverse relationship with HDL level. Triglyceride levels should be between 100 and 200 mg/dL.
The nurse is assessing a client with aortic stenosis. Which of the following best describes the murmur associated with aortic stenosis?
A. High-pitched and blowing.
B. Loud and rough during systole.
C. Low-pitched, rumbling during diastole.
D. Low-pitched and blowing.
- An aortic murmur is loud and rough and is heard over the aortic area during systole. Aortic insufficiency has a high-pitched and blowing murmur and is heard at the third or fourth intercostal space at the left sternal border. Mitral stenosis has a low-pitched rumbling murmur heard at the apex. Mitral insufficiency has a high-pitched, blowing murmur at the apex. There is no specific condition associated with a low-pitched, blowing murmur.
The nurse is preparing to discharge an adolescent with sickle cell disease. Which of the following should the nurse stress during teaching? Select all that apply.
A. Infection prevention and management.
B. Pain management.
C. Fluid restriction.
D. Effective emotional coping skills.
- A, B, and D
- The goals of sickle cell management include preventing crisis and managing pain and issues of self-esteem. This requires teaching the client how to avoid infection and follow protocols for antibiotics as infections can trigger crisis. Pain management may include analgesics as well as relaxation techniques and other comfort measures, such as heat application. Sickle cell disease, as with all chronic diseases, can affect an adolescent's feelings of self esteem, so coping skills include allowing the client as much independence in care as possible. Dehydration poses the risk of sickle cell crisis and blood clots, so the client must stay well hydrated.
Which type of nursing intervention does the nurse perform when she administers oral care to a client?
- Oral care is an example of a maintenance nursing intervention. Other examples of maintenance nursing interventions include skin care and hygiene. Psychomotor interventions include positioning the client. Educational nursing interventions include the nurse demonstrating and teaching a skill to the client. Supervisory nursing interventions occur when the nurse supervises other health care providers performing a task.
The nurse is caring for a client with pulmonary edema. Which of the following orders should the nurse clarify?
A. Dobutamine 5 mcg/kg/minute I.V.
B. 0.9% normal saline solution I.V. at 150 mL/hour.
C. Morphine I.V. 2 mg every 2 hours P.R.N. dyspnea.
D. Furosemide I.V. 40 mg every 6 hours.
- An I.V. rate of 150 mL/hour would further increase the fluid overload and worsen the pulmonary edema. Pulmonary edema is due to an increased blood volume in the lungs. This blood volume causes an increased hydrostatic pressure, which forces fluid from the pulmonary capillaries into the interstitial space and alveoli. The fluid in the alveoli blocks the air exchange, causing impaired gas exchange. The priority treatment for these patients is to improve their gas exchange and decrease volume overload. Dobutamine is a positive inotrope, which helps the heart pump more effectively, reducing the amount of blood pooling in the lungs. Morphine helps decrease venous pressure, which helps decrease the pressure in the lungs and the movement of fluid into the lungs, relieving dyspnea. Furosemide is a diuretic and helps remove some of the extra fluid from the lungs.
The nurse is teaching a client newly diagnosed with type 1 diabetes how to self-administer subcutaneous insulin injections. How does the nurse best evaluate the effectiveness of her teaching?
A. Have the client repeat the steps back to the nurse.
B. Give the client a written test on self-administration of insulin.
C. Ask the client to write out the steps for self-administration of insulin injections.
D. Ask the client to give a return demonstration of self-administration of insulin.
- Asking the client to give a return demonstration of his injection technique is the best way to assess whether the client can perform the procedure. It also gives the nurse the opportunity to provide feedback. Asking the client to recite the steps, pass a written test, or write out the steps shows the nurse whether the client is able to recall the steps but doesn't show that he has the necessary motor skills or the ability to perform the procedure.
The nurse is assessing a female client who reports infrequent, irregular menstrual periods. Which of the following signs and symptoms suggests to the nurse that the client may have polycystic ovarian syndrome (POS)?A. Muscle wasting and nervousness.
C. Poor appetite and weight loss.
D. Obesity and hirsutism with excessive facial hair.
- Polycystic ovarian syndrome (POS) is a constellation of symptoms including amenorrhea, hirsutism on the face, chest and limbs but thinning hair on the scalp, and obesity. Additionally, clients often exhibit insulin resistance (Type 2 diabetes mellitus). Muscle wasting and nervousness are not characteristic of POS, but depression is common. Hypertension may occur in some women. Increased appetite leads to weight gain.
A nurse is caring for a client returning from an x-ray. The nursing assistant is helping transfer the client back to bed. Which transfer technique by the nurse uses appropriate ergonomic principles?
A. Lowering the bed for transfer and then raising the bed before leaving the room, making sure to place the call light is within reach.
B. Maintaining a narrow base of support during transfer and encouraging the client to hold onto her if afraid during transfer.
C. Raising the bed for transfer, maintaining a wide base of support during transfer, and lowering the bed before leaving the room.
D. Explaining the procedure to the client and grabbing the client underneath the arms to pull her over to the bed.
- Raising the bed during transfer and maintaining a wide base of support reduces the risk of back injury, and the bed should always be left in the low position to reduce danger from falls. Transferring the patient with the bed in low position strains the lower back. The client should not grab or hold onto staff members during transfers as this can interfere with the transfer and cause the nurse injury. The nurse should not grab the client under the arms, as this can cause the client shoulder injury or nerve damage. In addition, pulling a client during transfers places the client at risk for skin shear injuries.
The nurse in the Emergency Department is caring for a client who has acute heart failure. The physician is writing orders for pharmacological management, including diuretics. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure?
A. Platelet count.
D. White blood cell count.
- Diuretics, such as furosemide (Lasix®) are commonly used to treat acute heart failure. Most diuretics increase the renal excretion of potassium. The nurse should check the potassium level before administering diuretics and obtain an order to replace potassium if the level is low. Other medications commonly used to treat heart failure include angiotensin converting enzymes, digoxin, and -adrenergic blockers. While checking the platelet count, calcium level, and white blood cell count is important, these results would not affect the administration of medications to treat acute heart failure.
The nurse is writing the teaching plan for a client undergoing a radioactive iodine uptake test to study thyroid function. Which of the following instructions should the nurse include?
A. "You need to stay at least 4 feet (1.2 m) away from other people after the test because you'll be radioactive." B. "You need to lie very still on a stretcher that is placed in a long tube for the scan"
C. "Don't take any iodine or thyroid medication before the test."
D. "Schedule the bone scans before your radioactive iodine uptake test."
- Medications such as iodine, contrast media, and antithyroid and thyroid drugs can affect the test results and should be withheld by the client for a week or longer, as directed by the physician. During a radioactive iodine uptake test, the client receives radioactive iodine by mouth or I.V. in small doses and doesn't require isolation. During magnetic resonance imaging--not radioactive iodine uptake testing--a client needs to lie still inside a long tube. Any test, such as a bone scan, that requires iodine contrast media should be scheduled after the radioactive iodine uptake test because the iodinated contrast medium can decrease uptake.
The nurse is assessing a client hospitalized with type 2 diabetes mellitus. Which assessment finding leads the nurse to suspect hyperosmolar hyperglycemic nonketotic syndrome (HHNS) in this client?
A. Kussmaul's respirations.
B. Metabolic acidosis.
C. Serum glucose of 1,200 mg/dL.
D. Dependent edema
- Serum glucose levels in HHNS are greater than 800 mg/dL and may be as high as 2,000 mg/dL. By comparison, serum glucose levels in diabetic ketoacidosis are 300 to 800 mg/dL. In HHNS the body produces enough insulin to prevent diabetic ketoacidosis but not enough to prevent hyperglycemia, diuresis, and dehydration. Metabolic acidosis and Kussmaul's respirations (deep, rapid breathing) occur with diabetic ketoacidosis. In the client with HHNS, respirations may be normal or rapid and shallow, without any fruity odor. The osmotic diuresis that occurs in HHNS leads to profound dehydration, so dependent edema doesn't occur.
The nurse is caring for a client with cirrhosis of the liver. The client has developed ascites and requires a paracentesis. Which of the following symptoms is associated with ascites and should be relieved by the paracentesis?
D. Peripheral neuropathy.
- Ascites (fluid buildup in the abdomen) puts pressure on the diaphragm, resulting in difficulty breathing and dyspnea. Paracentesis (surgical puncture of the abdominal cavity to aspirate fluid) is done to remove fluid from the abdominal cavity and thus reduce pressure on the diaphragm in order to relieve the dyspnea. Pruritus, jaundice, and peripheral neuropathy are signs of cirrhosis that aren't relieved or treated by paracentesis
The nurse is doing a physical assessment and electrocardiogram on an elderly client. Which finding during the nurse's assessment of the cardiac system is of most concern and warrants prompt further investigation?A. S4 heart sound.
B. Increased PR interval.
C. Orthostatic hypotension.
D. Irregularly irregular heart rate.
- An irregularly irregular heart rate is indicative of atrial fibrillation and should be investigated further. Older adults may have a prolonged systole, causing an S4 heart sound. Older adults also often have slowed conduction, causing an increased PR interval. As a person ages, it is normal for the baroreceptors in the body to decrease their response to changes in body position, so the client may experience orthostatic hypotension and dizziness when standing.
A client is admitted to the medical-surgical floor with a diagnosis of acute pancreatitis. His blood pressure is 136/76 mm Hg, pulse 96 beats/minute, respirations 22 breaths/minute, temperature 99°F (38.3°C), and he has been experiencing severe vomiting for 24 hours. His past medical history reveals hyperlipidemia and alcohol abuse. The physician prescribes a nasogastric (NG) tube for the client. Which of the following is the primary purpose for insertion of the NG tube?
A. Empty the stomach of fluids and gas to relieve vomiting.
B. Prevent spasms at the sphincter of Oddi.
C. Prevent air from forming in the small and large intestines.
D. Remove bile from the gallbladder.
- An NG tube is no longer routinely inserted to treat pancreatitis, but if the client has protracted vomiting, the NG tube is inserted to drain fluids and gas and relieve vomiting. An NG tube doesn't prevent spasms at the sphincter of Oddi (a valve in the duodenum that controls the flow of digestive enzymes) or prevent air from forming in the small and large intestine. The common bile duct connects to the pancreas and the gall bladder, and a T tube rather than an NG tube would be used to collect bile drainage from the common bile duct.
The nurse is caring for a client who requires a nasogastric (NG) tube for feeding. What should the nurse do immediately after inserting an NG tube for enteral feedings?
A. Aspirate for gastric secretions with a syringe.
B. Begin feeding slowly to prevent cramping.
C. Get an X-ray of the tip of the tube within 24 hours.
D. Clamp off the tube until the feedings begin.
- Before starting a feeding, it's essential to ensure that the tube is in the proper location. Aspirating for stomach contents confirms correct placement. While initial feedings should be given slowly, giving the feeding without confirming proper placement puts the client at risk for aspiration. Clamping the tube provides no information about tube placement. If an X-ray is ordered, it should be done immediately, not in 24 hours.
The nurse is caring for a client with a history of cardiac disease and type 2 diabetes. The nurse is closely monitoring the client's blood glucose level because of his other medication. Which other medication is the client most likely taking?
A. Procainamide (Procan®).
B. Carvedilol (Coreg®).
C. Amiodarone (Cordarone®).
D. Diltiazem (Cardizem®).
- Blood glucose levels need to be monitored closely in type 2 diabetics when the client is taking -adrenergic blockers, such as carvedilol. -adrenergic blockers may mask the signs of hypoglycemia, such as tachycardia and sweating. The QRS duration should be monitored in clients taking procainamide. Amiodarone may cause pulmonary fibrosis, and pulmonary function should be closely monitored in clients taking that drug. Diltiazem may cause increased PR interval or bradycardia.
A client is experiencing an acute episode of ulcerative colitis. Which of the following is the most important nursing action for this client?
A. Replace lost fluid and sodium.
B. Monitor for increased serum glucose level from steroid therapy.
C. Restrict the dietary intake of foods high in potassium. D. Note any change in the color and consistency of stools.
- Diarrhea due to an acute episode of ulcerative colitis leads to fluid and electrolyte losses, so fluid and sodium replacement is necessary. There is no need to restrict foods high in potassium, but potassium may need to be replaced. If the client is taking steroid medications, the nurse should monitor his glucose levels, but this isn't the highest priority. Noting changes in stool consistency is important, but fluid replacement takes priority.
A client with a history of long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) has dark, tarry and sometimes foul-smelling stools. The nurse knows that this may indicate bleeding in which part of the gastrointestinal tract?
A. Upper colon (ascending and transverse).
B. Lower colon (descending).
C. Stomach or proximal part of small intestine.
D. Distal part of small intestine.
- Melena is the passage of dark, tarry stools that contain a large amount of digested blood. It occurs with bleeding from the upper GI tract (stomach or proximal part of the small intestine). Passage of dark red blood from the rectum indicates lower GI (distal small intestine, colon, and rectum) bleeding. Bleeding in the lower colon or rectum would cause bright red blood in the stool.
A client admitted with peritonitis is under a nothing-by-mouth order. The client is complaining of dry mouth and thirst. Which of the following actions by the nurse is most appropriate?
A. Increase the I.V. infusion rate.
B. Use diversion activities.
C. Provide frequent mouth care.
D. Give ice chips every 15 minutes.
- Frequent mouth care, such as swabbing the mouth with moist sponge swabs and rinsing the mouth, helps relieve dry mouth and the sensation of thirst. Increasing the I.V. infusion rate isn't appropriate to relieve dry mouth and may cause fluid overload. Diversion activities aren't specific and are not likely to distract a person from feeling thirst. Because the client has a nothing-by-mouth order, she can't have ice chips, which are a form of liquid.
A client who is 24 hours post-partum is assessed by the nurse. Which client behavior warrants further investigation?
A. The client is quiet and spends time gazing at her infant in wonderment.
B. The client does not hold her child and allows the nurse to perform all of the infant care.
C. The client is nervous and voices concerns with her abilities to "handle everything."
D. The client frequently contacts the nursery to ask for assistance and supervision when performing infant care.
- The client who does not interact with her child and allows the nurse to provide all care will require further observation to evaluate bonding. Mothers who spend time gazing at their babies are normal. It is not unusual for a new mother to have numerous questions and experience feelings of uncertainty, especially if this is her first child. This gives the nurse the opportunity for teaching.
A client with a history of a seizure disorder is attempting to conceive a baby. The client asks the nurse for information concerning preconception care to increase her chances of having a healthy baby. What information should be provided to the client?
A. The client should reduce the amount of anticonvulsant medication being taken to promote her ability to conceive.
B. The client should increase intake of folic acid.
C. The client should discontinue anticonvulsant therapy until pregnancy is confirmed.
D. The client should increase the amount of exercise.
- Many anticonvulsants reduce absorption of folic acid. A reduction of folic acid is associated with neural tube defects, so the client should increase intake. Making changes in the prescribed dosages of any anticonvulsant is dangerous without close physician supervision; however, some anticonvulsant medications are teratogenic, so the prescribing physician should be consulted before the client becomes pregnant, as her medication may need to be changed. Increasing exercise is not a factor in the client's preconception care.
The nurse is caring for a client who is newly diagnosed with asthma. When teaching the client how to reduce exposure to allergens, which of the following actions should the nurse suggest?
A. Maintaining indoor humidity around 80%.
B. Working outdoors in the early morning.
C. Washing sheets and pillowcases in cold water.
D. Covering pillows and mattresses in plastic cases.
- Because dust and dust mites found in pillows and mattresses can trigger acute asthma attacks, the nurse should teach the client to cover them with plastic cases. Maintaining indoor humidity between 40% and 50% helps reduce the client's exposure to mold and pollen. Allergen levels are highest outdoors in the early morning, so the client should avoid working outdoors during this time. Sheets and pillowcases should be washed in hot water to reduce the client's exposure to allergens.
12. A client underwent a colostomy for a ruptured diverticulum. He did well throughout the surgery and returned to the medical-surgical floor in stable condition. The nurse assesses the client's colostomy stoma 2 days after surgery. Which assessment finding should the nurse report immediately to the physician?
A. Blanched stoma.
B. Edematous stoma.
C. Reddish-pink stoma.
D. Brownish-black stoma.
- A brownish-black stoma indicates a lack of blood flow to the stoma, and necrosis is likely. Two days postoperatively, the stoma should still be edematous and reddish-pink in color. A blanched or pale stoma indicates possible decreased blood flow and should be assessed regularly. Stomas should be assessed for color, size, characteristics (mucosa should be moist), shape, and protrusion (should be slightly above skin level).
A 37-year-old forklift operator presents with shakiness, sweating, anxiety, and palpitations and tells the nurse he has type 1 diabetes mellitus. Which of the follow actions should the nurse do first?
A. Inject 1 mg of glucagon subcutaneously.
B. Administer 50 mL of 50% glucose I.V.
C. Give 4 to 6 oz (118 to 177 mL) of orange juice.
D. Give the client four to six glucose tablets.
- Because the client is awake and complaining of symptoms, the nurse should first give him 15 grams of carbohydrate to treat hypoglycemia. This could be 4 to 6 oz of fruit juice, five to six hard candies such as Lifesavers, or 1 tablespoon of sugar. When a client has worsening symptoms of hypoglycemia or is unconscious, treatment includes 1 mg of glucagon subcutaneously or intramuscularly, or 50 mL of 50% glucose I.V. The nurse may also give two to three glucose tablets for a hypoglycemic reaction.
A client with cirrhosis of the liver develops ascites. Which of the following orders would the nurse expect?A. Restrict fluid to 1000 mL per day.
B. Ambulate 100 ft. three times per day.
C. High-sodium diet.
D. Maalox 30 ml P.O. BID.
- Fluid restriction is a primary treatment for ascites. Restricting fluids decreases the amount of fluid present in the body, thereby decreasing the fluid that accumulates in the peritoneal space. A high sodium diet would increase fluid retention. Physical activities are usually restricted until ascites is relieved. Loop diuretics (such as furosemide) are usually ordered, and Maalox® (a bismuth subsalicylate) may interfere with the action of the diuretics.
A client who recently underwent cranial surgery develops syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following symptoms should the nurse anticipate?
A. Edema and weight gain.
B. Excessive urinary output.
C. Fluid loss and dehydration.
D. Low urine specific gravity.
- Syndrome of inappropriate antidiuretic hormone (SIADH) results in an abnormally high release of antidiuretic hormone, which causes water retention as serum sodium levels fall, leading to edema and weight gain. Because of fluid retention, urine output is low. Fluid is restricted to prevent fluid overload rather than replaced. As the urine becomes more concentrated, the specific gravity increases. Other symptoms include nausea, vomiting, seizures, altered mentation, and coma. SIADH is most common with diseases of the hypothalamus but can also occur with heart failure, Guillain-Barré syndrome, meningitis, encephalitis, head trauma, or brain tumors. It may also be triggered by medications.
A client who underwent abdominal surgery now has a gaping open incision due to delayed wound healing. The nurse must irrigate the wound with a piston syringe and sterile normal saline and provide wound care. Which of the following procedures is correct?
A. Rapidly instill a stream of irrigating solution into the wound to flush out debris.
B. Apply a wet-to-dry dressing to the wound after the irrigation.
C. Moisten the area around the wound with normal saline solution after the irrigation.
D. Irrigate slowly and continuously until the solution becomes clear or all of the solution is used.
- To wash away tissue debris and drainage effectively, the nurse should slowly irrigate the wound until the solution becomes clear or all the solution is used. Irrigating solution should always be instilled slowly and gently, as rapid or forceful instillation can damage tissues. After the irrigation, the area around the wound should be dried, as moistening it promotes microorganism growth and skin irritation. When the area is dry, sterile dressing rather than a wet-to-dry dressing should be applied.
The nurse is doing teaching with the family of a client with liver failure. Which of the following foods should the nurse advise them to limit in the client's diet?
A. Meats and beans.
B. Butter and gravies.
C. Potatoes and pasta.
D. Cakes and pastries.
- Meats and beans are high-protein foods and are restricted with liver failure. In liver failure, the liver is unable to metabolize protein adequately, causing protein by-products to build up in the body rather than be excreted. This causes problems such as hepatic encephalopathy (neurologic syndrome that develops as a result of rising blood ammonia levels). Although other nutrients, such as fat and carbohydrates, may be regulated, it's most important to limit protein in the diet of the client with liver failure.
The nurse is evaluating a client's knowledge of miotic eye drop self-administration for the treatment of glaucoma. Which statement best demonstrates the client's understanding of miotic eye drop use?
A. "The drops should go directly in the middle of the eye so they'll go into the pupil."
B. "The eyedrops must be stored in the refrigerator so they don't grow germs."
C. "I need to use the drops daily for the rest of my life." D. "As soon as I recover from this glaucoma, I can stop using the drops."
- Glaucoma is a chronic condition of the eye, so therapy for glaucoma must continue for life to prevent damage to the optic nerve and retinal cells. Miotic eye drops increase drainage of the aqueous humor by constricting the pupil and contracting the ciliary muscle. The client needs to use the eyedrops daily to control intraocular pressure. Eyedrops are best put in the lower part of the eyelid, instilled into the conjunctival sac as this prevents leakage or misapplication. Miotic eye drops do not require refrigeration.
A client comes into the clinic during a spring break beach trip complaining of right ear pain. The nurse suspects acute otitis externa. Which other assessment findings by the nurse supports this diagnosis?
A. Cultures taken from the ear canal are positive for Pseudomonas aeruginosa.
B. The tympanic membrane has perforated.
C. The client is experiencing fever and chills.
D. The right external auditory canal is narrowed and erythematous.
- Acute otitis externa is characterized by inflammation or infection of the external auditory canal. It has a variety of possible causes, including bacterial infection caused by water retention after swimming. Though Pseudomonas aeruginosa and Staphylococcus aureus are the most common pathogens, cultures are usually unnecessary unless the client is refractory to treatment. The client's tympanic membrane would remain intact. Fever and chills are unlikely findings with acute otitis externa.
A client returns from the operating room after extensive abdominal surgery. He has 1,000 mL of lactated Ringer's solution infusing via a central venous catheter. The physician orders the I.V. fluid to be infused at 125 mL/hour plus the total output of the previous hour. The drip factor of the tubing is 15 gtt/mL and the output for the previous hour was 75 mL via Foley catheter, 50 mL via nasogastric tube, and approximately 10 mL via Jackson Pratt tube Which of the following I.V. flow rates is needed to deliver the correct amount of fluid?
A. 100 gtt/minute.
B. 65 gtt/minute.
C. 45 gtt/minute.
D. 80 gtt/minute.
- First, the volume to be infused (in milliliters) is calculated: 75 mL + 50 mL + 10 mL = 135 mL total output for the previous hour. 135 mL + 125 mL ordered as a constant flow = 260 mL to be infused over the next hour Next, the formula is applied: Volume to be infused X drip factor/Total minutes to be infused = Drops per minute. In this case, 260 mL (hourly volume) X 15 gtt/mL (drip factor) divided by 60 minutes = 65 gtt/minute
A gravida 2, para 0 client at 39 weeks gestation presents to the labor room with complaints of abdominal cramping. The nurse performs an assessment and data collection. Which of the following findings most supports the onset of true labor?
A. The client is experiencing nausea and centrally-located abdominal pains with varying frequency.
B. The client is experiencing abdominal cramps that radiate from the back around to the abdomen.
C. The client reports fatigue and mild abdominal cramping.
D. The client reports abdominal pain that is only relieved with rest.
- Abdominal cramping that radiates from the back to the abdomen is most indicative of true labor. Fatigue is associated with the discomforts of later pregnancy but does not signal labor. Nausea may be present during the later weeks of pregnancy but is not a sign of true labor. Centrally located abdominal pain is not a clear sign of labor, and true labor is not relieved by rest.
The nurse is caring for a client following gastric bypass surgery. The physician has encouraged the client to increase mobility as soon as possible. The nurse notes edema of the right leg with skin color changes (pallor) to the right lower extremity. The client reports pain at 3 on a 0 to 10 scale to the incision site and pain in the right calf at 7 on a 0 to 10 scale. Which of the following is the most likely cause of the leg pain?
A. Compression of the sciatic nerve.
B. Deep vein thrombosis.
C. Surgical infection and referred pain.
D. Postoperative dehiscence.
- Unilateral edema, skin color changes, and calf pain are all possible signs of a deep vein thrombosis, a possible complication of postoperative immobility. Compression of the sciatic nerve would cause pain to radiate down the hip. Surgical infection would not cause referred pain to the calf, and dehiscence would occur at the incision site (abdominal area).
The nurse is preparing to administer medications to two clients with the same last name. The nurse checks the medication three times before entering the room to administer medications to the first client. While leaving the room following administration, the nurse realizes she did not check the identification of the client prior to administering medication. Which of the following actions should the nurse complete first?
A. Return to the room to check the client identification and complete a variance report if an error was made.
B. Administer the remaining medication to the other client and check the client identification.
C. Alert the charge nurse that a medication error has been committed.
D. Document completion of the variance report and the medication error in the client's chart and notify the physician
- The nurse should immediately return to the room to compare the client's identification and the medication administration record to ensure the correct client received the medication. If an error was made, the nurse must complete a variance report per the facility policy. The variance report is used to report injury or high-risk events. In this case, failure to follow correct procedure put the client at risk. The nurse should check the remaining medication for the second client prior to administration. The charge nurse should be notified of any variance or medical error. Completion of a variance report for a medical error is not documented on the client's medical record.
A nurse is providing education regarding injury prevention to the parents of an 8-year-old child. The parents admit that they keep a gun in their home. Which statement made by the nurse would be most important?A. "The gun should be kept in a discreet location out of the child's sight."
B. "Your child should attend a gun safety program in the community."
C. "It is a good idea to keep the gun on hand, reminding the child that only a parent can touch the gun."
D. "The gun should be stored in a locked cabinet with the ammunition secured in a separate location."
- The gun must be kept in a locked cabinet, and it's safest to store the ammunition separately. Keeping the gun out of the child's sight would not be sufficient as the child may be able to locate the gun. A school-aged child should not be referred to a gun safety program. Even if taught gun safety, young children lack an adequate concept of cause and effect and often act impetuously, so the gun should not be kept on hand with the understanding that the child can be trusted not to touch it.
The nurse is assessing a client with chronic bronchospasm, which is treated with oral theophylline. Which of the following serum theophylline levels requires immediate nursing action?
A. 8 µg/mL.
B. 12 µg/mL.
C. 20 µg/mL.
D. 25 µg/mL.
- Serum theophylline levels are therapeutic when they fall between 10 to 20 µg/mL. A serum theophylline level of 25 µg/ml is in the toxic range and can lead to severe adverse reactions, which may be life threatening. The nurse should withhold the next dose of theophylline and notify the physician immediately. A theophylline level of 8 µg/ml is below the therapeutic range; the physician should be notified, but this level doesn't require immediate nursing action. Theophylline levels of 12 µg/ml and 20 µg/ml are within the therapeutic range.
After an abdominal resection for colon cancer, the client returns to her room with a Jackson-Pratt drain in place. The client's spouse asks the nurse what the purpose of the drain is. Which of the following is the nurse's best response?
A. "To irrigate the incision with a saline solution."
B. "To prevent bacterial infection of the incision."
C. "To measure the amount of fluid lost after surgery." D. "To prevent accumulation of drainage in the wound."
- The accumulation of fluid in a surgical wound interferes with the healing process. A Jackson-Pratt drain promotes wound healing by allowing fluid to escape from the wound. The drain may be placed in the client's incision, or it may be placed in the wound and brought out to the skin surface through a stab wound near the incision. The drain doesn't need to be irrigated. A Jackson-Pratt drain doesn't prevent infection. Fluid from the drain is absorbed into the dressings and can't be measured accurately.
The nurse is teaching a client with asthma about the proper use of a metered-dose inhaler. Which statement by the client indicates that the teaching was effective?
A. "I'll flex my head forward and breathe out forcefully before inhaling the drug."
B. "As I press down on the canister, I'll inhale slowly over 10 seconds."
C. "I'll hold my breath for 5 seconds after inhaling the drug to allow the drug to reach my lungs."
D. "I'll wait one minute between puffs."
- Waiting a full minute after taking the first puff allows the second puff to reach deeper into the client's lungs. Teach the client to tilt her head back slightly when using an inhaler and to breathe out normally. Breathing out forcefully can cause coughing, close the small airways, and trap air. After pressing down on the canister the client should breathe in slowly over 3 to 5 seconds and then hold her breath for 10 seconds to let the medication reach deep into the lungs.
A client returns to the clinic 48 hours after receiving a Mantoux skin test. The area of induration at the injection site measures 18 mm. The client has not previously had a reaction to this test. Which of the following actions should the nurse do next?
A. Move the client to a negative pressure room.
B. Have the client put on a facemask.
C. Prepare the client to have a chest x-ray.
D. Draw a blood sample to check his CBC for an elevated white blood cell count.
- A client with an initial positive reaction to a Mantoux test is at higher risk for active tuberculosis. Before taking him to another room or for a procedure such as a chest x-ray, he should be fitted with a mask to decrease the risk of disease transmission to others. It is not necessary to place him in a negative pressure room before further testing indicates the need. Drawing a CBC is not necessary at this point.
A client is admitted with acute pancreatitis. Which of the following laboratory results is expected for this client?
A. Serum creatinine of 4.3 mg/dL
B. Alanine aminotransferase (ALT) of 125 IU/L.
C. Serum amylase of 306 IU/L.
D. Troponin T level of 3.5 g/L.
- The normal value for serum amylase is 30 to 100 IU/L, so a level of 306 IU/L is indicative of pancreatitis. Pancreatitis involves activation of pancreatic enzymes, such as amylase and lipase. Therefore, serum amylase is often at least twice the normal level and lipase levels can be 5 times the normal level in a client with acute pancreatitis. Serum creatinine level (normal value 0.5 to 1.2 mg/dL) is elevated with kidney dysfunction. Injury or disease of the liver causes elevated ALT level (normal value 7 to 40 IU/L). Troponin T level (normal value <0.2 g/L) is elevated with heart damage, such as a myocardial infarction.
The nurse is caring for a client who fell from a scaffold 20 feet (6 m) to the ground. He was admitted to the emergency department with multiple abrasions and complaints of shortness of breath. The client's chest X-ray reveals a right pneumothorax. Which of the following actions should the nurse complete first?
A. Help the client turn, cough, and deep breathe.
B. Prepare a chest drainage system.
C. Prepare the client for a computed tomography (CT) scan.
D. Administer a sedative.
- When a pneumothorax is diagnosed, a chest tube must be inserted to evacuate air from the pleural space. The nurse should prepare the chest drainage system so that it can be attached to the chest tube immediately after insertion. A CT scan of the chest isn't used to diagnose a pneumothorax. Turning, coughing, and deep breathing can be encouraged after the chest tube is inserted. Sedation may be administered right before the chest tube is inserted but after the nurse prepares the chest drainage system.
The nurse is caring for a client diagnosed with respiratory failure. Which of the following orders should the nurse question for this client because of the possibility of adverse effects?
D. Oxygen therapy.
- In this case, an order for sedatives is questionable. Sedatives could cause decreased respirations and shallow breathing. Giving sedatives to a client with respiratory failure may worsen his already altered respiratory status. Antibiotics may be used to treat respiratory infection, such as pneumonia, a possible cause of the client's respiratory failure. Bronchodilators may be used to open the client's bronchioles to aid breathing. Oxygen therapy is a standard treatment for respiratory failure to relieve dyspnea.
A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). His serum glucose level is 926 mg/dL. The nurse observes the client for which complication of HHNS?
- Hyperglycemia (excess glucose in the blood) of 926 mg/dL causes an increase in serum osmolality. This causes fluid to shift from the interstitial to the intravascular space, causing osmotic diuresis and dehydration. Hemorrhage isn't a complication of HHNS. While pneumonia and infection may occur in clients with HHNS, these conditions aren't direct complications of HHNS.
An elderly client is recently diagnosed with hypothyroidism. He lives in his own apartment in a community development designed for the elderly. He asks the nurse for advice about his condition. What is the best advice for the nurse to give the client?
A. "Stop attending group activities."
B. "Increase fiber and fluids in your diet."
C. "Stop taking your self-prescribed daily aspirin."
D. "Keep the temperature in your apartment cooler than usual."
- Clients with hypothyroidism typically have constipation. A diet high in fiber and fluids can help prevent this. The client doesn't need to stop all group activities, although he may need to limit them until his condition improves. Taking aspirin isn't related to hypothyroidism management and does not interfere with treatment. Clients with hypothyroidism have an intolerance to cold and need an environment warmer than average.
The nurse is caring for a client with bacterial pneumonia. Of the following, which nursing diagnosis takes top priority?
A. Activity intolerance related to altered respiratory function.
B. Risk for fluid volume deficit related to fever and dyspnea.
C. Ineffective airway clearance related to copious tracheobronchial secretions.
D. Altered nutrition with less than body requirements related to anorexia and dyspnea.
- With bacterial pneumonia, inflammation of the respiratory system causes swelling of the bronchioles and bronchi with increased secretions and production of thick yellow, brown sputum. A client with bacterial pneumonia may have difficulty clearing secretions. Airway clearance always takes the highest priority because the client must breathe to live. Activity intolerance is expected with severe pneumonia because of dyspnea. Fluids and nutrition should be monitored to ensure adequate intake, but this is not the highest priority.
The nurse is faxing client information to a nursing home. Which is the appropriate action for the nurse to take before faxing the record?
A. Determine that the client has signed a record release. B. Make sure the client's name and birth date are displayed on the fax cover sheet.
C. Read all information to the client before faxing.
D. Obtain a written order to fax the information from the client's primary physician.
- Client authorization is required before any confidential information may be sent to a nursing home or other facility. The client's name, and other protected information should never be displayed on a fax cover sheet. It is not necessary to read the information to the client before sending it. A physician's order does not give the nurse the right to send a client's confidential information.
A nurse is having difficulty setting up humidified oxygen at 40% per Venturi mask and does not know how many liters of flow she should use. Which of the following actions is most appropriate to ensure safe oxygen administration?
A. Consult with a respiratory therapist.
B. Look at the package directions and try to figure it out. C. Ask the nursing assistant how to set it up.
D. Use a regular oxygen mask.
- When a problem falls outside a nurse's experience or knowledge, it is appropriate to consult with a specialist in that area. The respiratory therapist is an expert at setting up oxygen delivery systems. Using package directions is not reliable and may cause harm to the client if the nurse sets up the oxygen improperly. A nursing assistant is not considered an expert in oxygen delivery. Using a regular mask would not deliver the correct rate of flow to the client and would be unacceptable.
An 8-year old girl presents to the office for a routine examination. Considering the child's developmental level, which of the following actions is most appropriate?
A. Allowing the child to change into a gown while you are not in the room.
B. Allowing the child to play with the medical equipment prior to the examination.
C. Asking the parents to leave the room during the examination.
D. Encouraging the child to hold a stuffed animal during the examination.
- School-aged children tend to be very modest, so the child should be allowed to change into a gown while the health care provider is not in the room. Additionally, the child should be allowed to leave her underwear in place. Playing with medical equipment is characteristic of younger children. Parents should not be asked to leave the room unless the child requests that they not be present. The child may feel too old to hold a stuffed animal during the examination and may feel she is being treated "like a baby."
The nurse is providing care needed to support the respiratory function of a client with thick secretions. Which measure is most effective in helping a client with thick secretions mobilize and expectorate them?
A. Drinking salty fluids such as broth and bouillon.
B. Drinking 3 to 4 L of water per day.
C. Inhaling cool mist from a vaporizer daily.
D. Sitting in a tub of warm water three times a day.
- Adequate fluid intake decreases the viscosity of secretions. The nurse should encourage the client to drink 3 to 4 L of water or other fluids per day. Consuming salty fluids can cause secretions to thicken even further. Inhaling cool mist may help but only if done more than once a day. Sitting in a tub of warm water may be relaxing, but it doesn't loosen secretions.
19. A client is obtaining a psychiatric evaluation and counseling as a requirement for care while on a mental health, short-term disability leave. The client signs an information release form and requests that the evaluation and counseling records be emailed to the human resource representative at her company. Which of the following is an appropriate response by the nurse?
A. "The administrative policy must be reviewed with the agency director before records can be released."
B. "It is best not to send your records via the Internet, as this may jeopardize your right to privacy."
C. "Think about if you want your entire counseling record to be released to the company where you work." D. "Before disability related records are released, they must be reviewed by the treatment team."
- The client has a right to ask that her records be released, but there is an increased risk for breach of confidentiality if personal health care records are emailed to a place of employment. Although every health care agency has a policy and procedure related to release of client records, the staff is required to be informed about the policy upon employment. There is no need to review the policy with the agency director when a client requests that records be released. Asking the client to think about her statement is inappropriate and could create apprehension in the client. The review of a client's treatment goals and progress is an ongoing process; it is not initiated when client records are requested for release to a third party.
20. A client suddenly becomes short of breath. Which position is most beneficial for a client experiencing respiratory difficulty?
A. Dorsal recumbent.
- Semi-Fowler's position, or sitting at about 45 degrees, facilitates lung expansion. The dorsal recumbent (supine) position doesn't ease the work of breathing. The lithotomy (legs up in stirrups) position is normally used for gynecologic examination but might worsen dyspnea. Sims' position is a lateral position with the top leg flexed toward the chest. This position inhibits lung expansion.
A client is admitted with a possible bowel obstruction. Which of the following nursing actions is most important for the nurse to perform for a client with a bowel obstruction?
A. Obtain daily weights.
B. Measure abdominal girth.
C. Keep strict intake and output.
D. Encourage the client to increase fluids.
- With a bowel obstruction, abdominal distention occurs. Measuring abdominal girth provides quantitative information about increases or decreases in the amount of distention. Monitoring daily weights provides information about fluid status. An increase in daily weight usually indicates fluid retention. Measuring intake and output provides no information about abdominal distention or the obstruction although it is to monitor output. A client with a bowel obstruction will have a nothing-by-mouth order.
An infant is brought to the Emergency Department by the child's parents. The infant is limp and has central cyanosis, heart rate of 60 beats per minute, respiratory rate of 12 breaths per minute. The parents state that they have an advance directive for their infant because he has a terminal illness. Which of the following is the most appropriate action for the nurse?
A. Ask to see a copy of the advanced directive.
B. Provide oxygen while awaiting further physician's orders.
C. Provide palliative care for the infant and family.
D. Contact the nursing supervisor for assistance.
- The nurse should ask to see a copy of the advance directive for guidance in providing care. Advance directives for infants and children are often prepared by the parents with the assistance of their physicians as part of planning for end-of-life. These advance directives outline the type of care the parents want provided for their child and are especially important to guide care if the parents are not available when questions arise. The advance directive may specify whether oxygen should be used as part of palliative care. Waiting for the supervisor is not necessary since the parents are present, have an advance directive, and can indicate their wishes.
The nurse is caring for a client newly diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following exercises is most appropriate for this client?
A. Intercostal muscle expansion exercises.
B. Isometric leg exercises.
C. Diaphragmatic and pursed-lip breathing exercises.
D. Lumbar sacral strengthening exercises.
- Clients with COPD are taught to use their diaphragmatic muscles, not their intercostal muscles, to breathe. Because of air trapping due to COPD, pursed-lip breathing exercises are indicated to help expel carbon dioxide. These exercises increase expiratory time, decrease expiratory rate, and increase tidal volume. Isometric leg exercises and lumbar sacral strengthening exercises don't improve breathing but may be important for general health.
Parents tell the nurse that they have not been successful in meeting their goal for home management of their 20-year old son with a schizoaffective disorder. They report that the client is posing a threat to their safety. Which of the following is the best initial recommendation?
A. Have the client be evaluated for a voluntary admission to a mental health facility.
B. Discuss what the family can do to chemically restrain the client at home.
C. Tell the family that the client's behavior releases them from the duty of care.
D. Arrange for respite care as the family could be aggravating the client's condition.
- A voluntary admission is the preferred approach because it involves having the client recognize the problems the family is experiencing and facilitates the client's involvement in treatment. The client's rights would be violated by the use of chemical restraints since the client has the right to freedom from the use of restraints and seclusion. The duty of care is a legal relationship that applies only to the nurse-client relationship, not to the family relationship. In this case, the son is legally an adult, so the parents do not have a legal obligation to care for him. Respite care is not an appropriate recommendation at this time. The safety issue must be addressed and effective treatment and care instituted. At a later time, it would be prudent to talk to the family about caregiver burden and the option of using respite care.
A client comes to the clinic because of low-grade afternoon fevers, night sweats, and a productive cough. The client's wife was recently diagnosed with pulmonary tuberculosis, and the physician suspects that the client has now contracted the disease. A positive acid-fast bacillus sputum culture confirms the diagnosis. While obtaining the client's history, the nurse notes that he refers to his diagnosis as "it," never as tuberculosis, and avoids discussing the disease. What is the nurse's best response?
A. "It won't kill you if you take your medications."
B. "Tell me how you feel about the diagnosis of tuberculosis."
C. "You shouldn't be embarrassed that you have tuberculosis."
D. "Let's not talk about the tuberculosis. How long have you been having night sweats?"
- Asking the client how he feels about the diagnosis allows the client to express his feelings about the diagnosis. Saying "it" won't kill the client if he takes his medications belittles the client and reinforces the idea that he may be at fault. Telling the client he shouldn't be embarrassed is presumptive and judgmental. Responding with "Let's not talk about it" ignores the client's feelings, reinforces the idea that there is something shameful about tuberculosis, and does not help him to accept and deal with his disease.
The nurse is giving instructions to a parent of a 13-month-old who weighs 18 lbs. The child is being discharged from the pediatric unit after hospitalization for gastroenteritis. When talking to the parent about car seat safety, the nurse knows the parent understands the teaching when the mother states:
A. "My child can be in a front-facing car seat because he is 1 year old."
B. "My child can be in a front facing car seat as soon as he weighs 21 pounds."
C. "As long as I drive a sports utility vehicle, I can have my child rear or front facing."
D. "My child will need to be in a rear facing care seat until her is three years old."
- Any child under one year of age and/or 20 pounds must be in a rear facing car seat. The make or model of the car does not relate to child safety laws. The general rule for car seat application is that the child must be over one year of age and 20 pounds to move from a rear facing to front facing car seat but must be in the back seat of the car. Older children must use a booster seat until they are 7 to 8 years old, depending upon the state law.
A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis jiroveci pneumonia. Which nursing diagnosis has the highest priority for the client?
A. Impaired gas exchange.
B. Impaired oral mucous membrane.
C. Imbalanced nutrition: Less than body requirements. D. Activity intolerance.
- Pneumocystis jiroveci is a fungus infection that can cause severe pneumonia in those who are immunocompromised. While all these nursing diagnoses are appropriate for the client with AIDS and P jiroveci pneumonia, impaired gas exchange is the priority nursing diagnosis for the client as ensuring a patent airway, breathing, and circulation are critical for life. Patients who are severely ill often have impaired nutrition, oral mucous membranes, and activity intolerance, but these should resolve if the causative condition is adequately treated.
The nurse is caring for a 2-year-old child admitted for long-term treatment of a chronic illness. The nurse understands the normal growth and development of children. Which of the following is an important nursing action for the child?
A. Allow the child to sleep for at least 12 hours per night.
B. Speak with a play therapist regarding activities the child can participate in.
C. Be sure the child is continuously isolated due to the chronic illness and risk of infection.
D. Maintain a diet that is high in carbohydrates and low in fats.
- An important part of growth and development for a child is play. Even when a child has a chronic illness, play should be facilitated. Consulting a play therapist is appropriate for children with special needs. Although it is important for children to maintain adequate sleep, it is not required that toddlers receive 12 hours of sleep per night. Children with chronic illnesses do not need to be continuously isolated. The child might need to be isolated for a period of time; however, she should still have interaction with family. A diet high in carbohydrates and low in fat is not indicated for all toddlers with chronic illness, and the American Heart Association recommends that fat intake should be 30 to 35% of the diet for a 2-year old.
During the assessment interview, a depressed 15-year-old client states that she "can't ever sleep at night." When the nurse begins to explore the possible contributing factors by asking the client questions, the client changes the subject and avoids eye contact. The client tenses noticeably when the nurse touches her as part of the exam. Which of the following does the client's behavior suggest?
A. Sexual abuse.
B. Age-appropriate behavior.
C. Sleep apnea.
- Often a girl who is being sexually abused refuses to talk about it and changes the subject when questioned. Avoiding eye contact can indicate feelings of shame. While 15 year-old girls may be shy regarding their bodies, this behavior and her reaction when touched coupled with depression suggests abuse. Sleep apnea results in chronic fatigue although the person usually does not have difficulty falling asleep and is often unaware of the apneic periods. A client with narcolepsy has periods of deep sleep at night and falls asleep even during activities in the daytime.
A client with bipolar disorder who is taking lithium carbonate is instructed by the nurse on proper use of the drug, side effects, and symptoms of lithium toxicity. What statement by the client indicates that additional client teaching is required?
A. "I can still eat my favorite salty foods."
B. "When my moods fluctuate, I will increase my lithium."
C. "A good blood level means the drug is working."
D. "Eating too much watermelon will effect by lithium level."
- Increasing the dose of lithium without monitoring dosage through lab values can result in lithium toxicity, overdose, and renal failure. The client must take the medication as prescribed and discuss mood fluctuations with the physician to determine if the dosage should be increased. Clients on lithium must include adequate intake of both sodium and fluids. A low sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. Clients are cautioned against eating large amounts of foods that have a diuretic effect. Some examples of these foods are watermelon, cantaloupe, grapefruit juice, and cranberry juice.
The nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following treatments should the nurse include?
A. Administering a lactulose enema as ordered.
B. Encouraging a protein-rich diet.
C. Administering sedatives as necessary.
D. Encouraging ambulation at least four times a day.
- Hepatic encephalopathy is a degenerative disease of the brain that is a complication of cirrhosis. For the client with hepatic encephalopathy, the nurse may administer the laxative lactulose (Chronulac®) to reduce ammonia levels in the colon. Protein intake is usually restricted to reduce serum ammonia levels until the client's mental status begins to improve. Sedatives are avoided because they can cause respiratory or circulatory failure. Bed rest is encouraged because physical activity increases metabolism, leading to an increased production of ammonia.
A client is admitted to the medical-surgical floor with an exacerbation of myasthenia gravis. Which intervention is important for the nurse to include in the plan of care for this client?
A. Encouraging independent activities of daily living.
B. Helping the client cope with mood swings.
C. Scheduling the client's care around periods of rest.
D. Encouraging warm baths before exercise.
- Classic symptoms of myasthenia gravis are weakness and fatigue, so it's important to schedule care around periods of rest. Drastic mood changes are a symptom of other conditions, such as Cushing's syndrome, not myasthenia gravis. Encouraging independent activities of daily living is also important but these must be done around periods of rest as well. Warm baths, which relax the muscles, might increase the client's feeling of weakness and fatigue.
A client is admitted to the Emergency Department after a three-car accident. He's exhibiting early signs of increased intracranial pressure. Which of the following groups of symptoms is the nurse most likely to observe?A. Decreasing pulse, increasing respiratory rate, and decreasing blood pressure.
B. Decreasing pulse, decreasing respiratory rate, and increasing systolic pressure.
C. Increasing pulse, decreasing respiratory rate, and increasing pulse pressure.
D. Decreasing pulse, increasing respiratory rate, and increasing pulse pressure.
- In the early stages of increased intracranial pressure, the client's heart and respiratory rates slow down. The result is an increase in systolic pressure with further decrease in heart rate and respiratory rate, and a widening pulse pressure. With head trauma, there may be significant swelling that decreases perfusion, causing hypoxia and hypercapnia, triggering increased blood flow. The increase volume when injury has impaired auto-regulation increases the edema, which in turn increases intracranial pressure, causing further ischemia. If the intracranial pressure is not controlled, the brain may herniate..
The nurse is caring for a child who was in a house fire that killed 7 people, including his parents. He is the only survivor. The local newspapers and television stations are at the hospital and are trying to receive information regarding his condition. Which of the following is the correct action for the nurse?
A. The nurse does not give out any information regarding the child's condition.
B. The nurse does not give the name, only the condition of the patient.
C. The nurse gives a statement about how sad she is for the family and friends of the little boy.
D. The nurse contacts an attorney because of the legal issues regarding caring for the child.
- According to HIPAA standards, one cannot give information regarding a child's care unless permission is granted by the parents/guardian of the child to divulge information. In this case, the guardians may not yet have been identified. It would be inappropriate to give the name of the child, and there is no need for the nurse to contact an attorney. Although not illegal, giving a statement of feelings regarding the situation is not professional. In most hospitals, a public relations officer may be directed to make a public statement.
The nurse is leading a discussion on home safety to a group of parents with toddler-age children. Which of the following is important to emphasize?
A. Most deaths that occur regarding toddlers are accidental.
B. Overdose of medications is the leading cause of death in toddlers.
C. All children over the age of one can be in a front facing car seat.
D. The risk of injury for toddlers is the same as for adults.
- Most deaths in children are accidental. Many children are injured or killed each year from accidents related to fire, drowning, motor vehicles, and firearms. Generally, children of this age do not overdose on medications unless they are accidentally given too much medication. Most state laws require that infants remain rear-facing in a car seat until they are at least one year old and weigh 20 pounds, but studies indicate that it is safer to remain rear-facing for the first two years. Children are at a higher risk for injury then adults due to the developmental level of children and their lack of knowing right from wrong and recognizing danger signs.
The nurse is caring for a client diagnosed with a stroke. Because of the stroke, the client has dysphagia (difficulty swallowing). Which intervention by the nurse is best for preventing aspiration?
A. Placing the client in high Fowler's position to eat.
B. Offering liquids and solids together.
C. Keeping liquids thinned.
D. Placing food on the affected side of the mouth.
- Placing the client in high Fowler's position, such as in a chair, uses gravity to reduce the risk of aspiration. Solids and liquids shouldn't be offered together because when they're in the mouth together, the liquids can cause the solids to be swallowed before they're properly chewed. However, water or other fluid should be sipped after swallowing to clear the throat. Thin liquids should be thickened. Food should be placed on the unaffected side to prevent it from being trapped in the cheek on the affected side. Using smaller utensils to limit bite size and doing muscle-strengthening exercises may reduce dysphagia.
The nurse is explaining medication benefits and side effects to a client with a history of psychosis. The client's brother states to the nurse, "You are wasting your time explaining things to him." Based on the nurse's understanding of informed consent, which of the following statements serves as the best guide for the nurse's response?
A. Informed consent does not apply to clients who experience psychosis.
B. The nurse can assume that the client understands at least some of the information.
C. A third party is necessary when informing clients about treatment options.
D. The use of informed consent is an important part of effective client care for all clients, regardless of age or condition.
- The use of informed consent allows the client and the nurse to work as partners in the development and accomplishment of treatment goals. Even clients with a history of psychosis have the right to be informed about their treatment risks and benefits. It is not appropriate for the nurse to assume that the client understands information given without obtaining some feedback from the client. A third party is not required to be present unless the client cannot give informed consent. In the case of a minor or legally incompetent client, a legally appointed guardian or parent must give informed consent for treatment.
The nurse is caring for a client who suddenly develops a tonic-clonic seizure. Which nursing action is most appropriate during a seizure?
A. Forcing a padded tongue blade into the client's mouth.
B. Restraining the client's limbs.
C. Placing the client in a supine position.
D. Loosening constrictive clothing.
- Constrictive clothing, especially around the client's neck, can interfere with oxygenation, so it should be loosened. One should never force anything such as a padded tongue blade into the mouth because it could break teeth or induce vomiting. A client who is having seizures should not be restrained, as it can cause soft-tissue injury and musculoskeletal damage. Instead, any dangerous objects should be removed from around the client. Because a supine position increases the risk of aspiration, the client should be helped into a side-lying position.
1The nurse is caring for a 19-month-old with mild dehydration and weight loss. The parent states: "My son doesn't like to eat, and I hate to make him." Which of the following nursing actions is appropriate?
A. Contact the social worker on duty and give her information on the situation.
B. Contact the physician to have the child referred to a gastroenterologist.
C. Contact the dietitian and have him come to talk to the parent about toddlers and nutrition.
D. Contact the local police for suspected child abuse.
- The parent needs assistance in maintaining her child's diet. The dietitian is a healthcare professional that could speak to the parent regarding the diet of the child. This is within the scope of practice for a nurse. The nurse would not call the local police or social worker on duty. This is not a case of child abuse or neglect. Many toddlers are picky eaters and resist eating and drinking, and small children are less sensitive to feelings of thirst. The nurse would not call the physician to have the child referred to a gastroenterologist, as there is no indication that this is necessary.
An obese client has returned to the unit after receiving sedation and electroconvulsive therapy. The nurse requests assistance moving the client from the stretcher to the bed. There are 2 people available to assist. Which of the following is the best method of transfer for this patient?
A. Carry lift.
B. Sliding board.
C. Lift sheet transfer.
D. Hydraulic lift.
- Because this patient is obese and sedated, she is unable to assist with the transfer, so the sliding board transfer is the best method of transfer as it can be done with two to three people. The patient is turned to her side and the sliding board placed to bridge the stretcher and the bed. The nurse can stabilize the side opposite the bed while the other two pull the patient across to the bed with a pull sheet. A carry lift requires 4 people but is not safe for an obese patient. A lift sheet transfer requires at least 4 people, but if the patient is obese up to 7 or 8 people may be needed. The hydraulic lift is not the appropriate equipment to use with a sedated patient because the patient cannot cooperate
A nurse has admitted a client to the ER with complaints of chest pain over the previous 2 hours. There are no clear changes on the 12 lead ECG. The nurse would expect which lab test to provide confirmation of a myocardial infarction?
a. Potassium of 5.2
b. Creatine kinase (CK) of 545 with MB of 4%
c. CK of 320 with MB of 12%
d. WBC of 11,400
Rationale: a CK level above 150 with over 5% MB isoenzyme indicates myocardial damage from acute myocardial infarction. Elevated potassium is not indicative of MI and an elevated WBC is an indicator of many conditions including MI.
The nurse is planning to discharge a patient after a CABG. This patient is taking several new medications including: Digoxin, Metoprolol and Lasix. The patient is complaining of nausea and anorexia. The nurse is preparing to report this finding to the DR. before discharging this patient but what lab result will the nurse check before calling the DR.?
a. potassium level
b. sodium level
d. Digoxin level
- Rationale: nausea and anorexia are signs of digoxin toxicity. The other lab values would not explain the clients symptoms and therefore are not priorities to assess before telephoning the physicians.
The nurse is caring for a client with CHF taking Digoxin and Lasix. What electrolyte needs to be monitored closely?
- Rationale: Lasix increases potassium loss and low potassium levels potentiate (make more powerful) digoxin. As a result, monitoring potassium levels is important care of this client.
The nurse is caring for a client with a history of hypertension. The client is being treated with metoprolol, hydrochlorothiazide, and captopril. The client has a BP of 120/80 and pulse of 48 which of the following is the best action of the nurse?
a. Administer the metoprolol and the drochlorothiazide, hold the captopril and notify the MD
b. Administer the captopril and the hydrochlorothiazide, hold the metoprolol and notify the MD
c. Administer all the meds and notify the MD
d. Hold all the meds and notify the MD
- Rationale: the clients heart rate is bradycardic, and the metoprolol which is a beta blocker decreases the heart rate. Neither the captopril or the hydrochlorothiazide lower the heart rate and may be safely administered to control hypertension. When a dose of medication is held it is the nurses responsibility to notify the physician of the action and rationale.
The nurse has finished getting shift report on the cardiac unit. The nurse should plan on seeing which of the following patients first?
a. A client with hypertrophic cardiomyopathy who is reporting dyspnea
b. A client who had a cardiac catheterization and will be ambulating for the first time
c. A client receiving antibiotics for bacterial endocarditis who is reporting anxiety and chest pain
d. A client who is recovering from a CABG and has a temp of 101 degrees F
- Rationale: a client with endocarditis is at risk for thrombus formation the chest pain and anxiety are signs of pulmonary embolism which is a life threatening complication requiring immediate attention. Dyspnea is a chronic symptom with hypertrophic cardiomyopathy, which requires monitoring, a temp of 101 requires additional evaluation, and a client who is ambulating for the first time would be monitored by the nurse. However the client who needs to be assessed for PE is the most emergent.
The nurse is caring for a client with a history of renal failure and a new myocardial infarction. The nurse who is reviewing lab results would call the DR to report which of the following:
a. Potassium level 5.0
b. Sodium level 145
c. Calcium level 7.0
d. Digoxin level 0.8
- Rationale: renal failure is a common cause of hypocalcemia, and a value of 7.0 is below the normal range of calcium. Options A and B are within the upper limits for potassium and sodium and option D is within the therapeutic range for Digoxin.
The nurse is caring for a client who had a permanent pacemaker placed because of a complete heart block. The nurse determines that which of the following client outcomes indicates a successful procedures
a. Client ambulating in the hall within 4 hrs post op with no chest pain or dyspnea
b. Client's ECG monitor demonstrates normal sinus rhythm
c. HR 80 BPM, BP 120/80
d. Client's ECG monitor shows paced beats at the rate of 68 per min
- Rationale: the client is not allowed to ambulate for 24 hours to prevent dislodging the electrodes. Normal sinus rhythm, heart rate of 80 and BP of 120/80 does not reflect pacemaker function. Paced beats indicate the pacemaker is functioning.
Which of the following suggestions should the nurse include when reinforcing health teaching for clients with arterial insufficiency?
a. avoid long periods of sitting and standing
b. keep the legs and feet in a raised position
c. decrease ambulation to decrease pain
d. apply moist heat 2x/day
- Rationale: the client should avoid long periods of standing or sitting to promote adequate blood flow. The legs and feet should be below the heart level to increase peripheral circulation. Regular exercise enhances development of collateral circulation. Increases vascular return and is recommended for clients with arterial or venous insufficiency. Moist heat is helpful for venous problems
Which of the following clients is most at risk for DVT? a. A 30 Y.O client who is 1 week post-partum
b. A 63 Y.O client post CVA on anticoagulants
c. A 40 Y.O woman who smokes and uses oral contraceptives
d. A 41 Y.O client who just had a laparoscopic cholecystectomy
- Rationale: a major risk factor for formation of thrombophlebitis is oral contraceptive use in women who smoke. Being 1 week Postpartum does not place the client at risk since mobility is usually restored. Anticoagulant therapy is used to prevent the development of thrombi. Laparoscopic surgery is associated with a more rapid recovery time with reduced immobility, keeing this client at lower risk then option C.
The nurse is preparing to ambulate a postoperative patient following cardiac surgery. The nurse plans to do which of following to enable the client to best tolerate the ambulation?
a. Provide the client with a walker
b. Remove the telemetry equipment
c. Encourage the client to cough and deep breathe
d. Premedicate the client with an analgesic prior to ambulating
- Rationale: the nurse should encourage regular use of pain medication for the first 48-72 hours after cardiac surgery, because analgesia will promote rest, decrease myocardial oxygen consumption caused by pain, and allow better, participation in activities such as coughing and deep breathing and ambulation.
A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse’s station. The nurse sees no issues on the screen what would the nurse do first?
a. Call a code blue
b. Call the DR
c. Check the clients status and lead placement
d. Press the recorder button on the ECG console
- Rationale: sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Assessment of the client and the equipment would be the first action of the nurse.
A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain, and shortness of breath, and is visibly anxious. The nurse immediately checks for signs and symptoms of?
b. Pulmonary edema
c. Pulmonary embolism
d. Myocardial infarction
- Rationale: pulmonary embolism is a life-threatnening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common syptom, which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include: dyspnea, cough, diaphoresis and apprehension.
A client with myocardial infarction suddenly becomes tachycardiac, shows signs of air hunger, and begins coughing frothy pink –tinged sputum. A nurse listens to lung sounds expecting to hear bilateral:
d. diminished breath sounds
- Rationale: pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy pink tinged sputum. Auscultation of the lungs reveal crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema.
A nurse is collecting data on a client with right sided heart failure. The nurse would expect to see what specific characteristic of this condition?
b. Hacking cough
c. Dependent edema
d. Crackles on lung auscultation
- Rationale: right sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure.
A nurse is monitoring a client with an abdominal aortic aneurysm, which finding is probably unrelated to AAA? a. Pulsatile abdominal mass
b. Hyperactive bowel sounds in the area
c. Systolic bruit over the area of the mass
d. Subjective sensation of the “heart beating” in the abdomen
- Rationale: not all clients with AAA exhibit symptoms. Those who do may describe a feeling of the “heart beating” in their abdomen when supine, or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not specifically related to an AAA
A client with a MI is transferred from the cardiac care unit to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in the care of this client expects to note which type of prescribed activity. a. Strict bedrest for 24 hours
b. Bathroom privileges and self care activities
c. Unrestricted activities because the client is monitored d. Unsupervised hallway ambulation with distances less then 200 feet.
- Rationale: upon transfer from the CCU, the client is allowed self-care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged with distances gradually increasing.
A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse suspects pulmonary edema. The LPN immediately notifies the RN and expects what interventions to be prescribed? (check all that apply)
a. Administer O2
b. Insert a Foley cath.
c. Administer Lasix
d. Administer Morphine IV
e. Transporting the client to the coronary care unit
f. Place the client in low fowlers side-lying position
- A, B, C, D
- Rationale: pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in the high fowlers position to ease the work of breathing, Lasix a rapid acting diuretic, will eliminate accumulated fluid, a foley cath will be placed to monitor output. IV morphine reduces venous return, decreases anxiety, and reduces the work of breathing, transporting the client to the cardiac care unit is not an intervention, in fact may not even be necessary if the clients response to the treatment is successful.
A client has suffered an acute MI and is receiving Alteplase (tPA). Which of the following is a priority nursing intervention while caring for this client?
a. Monitor for renal failure
b. Monitor for psychosocial status
c. Monitor for signs of bleeding
d. Have heparin sodium available
A, B, C, D,
A client with a diagnosis of CHF is seen in the clinic. The client is being treated with a variety of medications. Including Digoxin (Lanoxin) and Lasix (Furosemide). Which findings on data collection would lead the nurse to suspect that the client is hypokalemic?
b. Intermittent intestinal colic
c. Tingling of fingers and toes
d. Muscle weakness and leg cramps
Hydrochlorothiazide (HydroDIURIL) is prescribed for a client. The nurse checks the client’s record for documentation of which of the following before administering the medication.
a. Sulfa allergy
c. Penicillin allergy
d. History of osteoporosis
A nurse has an order to administer a dose of nitroglycerine ointment to a client. The nurse would avoid doing which of the following in preparing the medication for administration.
a. Applying the dose in an even layer
b. Washing off the previous application
c. Use the fingers to spread the ointment
d. Using the manufactures applicator papers
A client taking Digoxin (Lanoxin) has a serum potassium level of 3.0 mEq/L and is complaining of anorexia. The physician orders a digoxin level to be obtained to rule out digoxin toxicity. The nurse checks the results of the test. Knowing that the therapeutic serum level for digoxin is which of the following:
a. 1-3 ng/ml
b. 0.5-2 ng/ml
c. 0.3-0.8 ng/ml
d. 0.1-0.5 ng/ml
A nurse is caring for a client who is taking propranolol (Inderal). Which data would indicate an adverse reaction associated with this medication?
a. A development of complains of insomnia
b. A development of audible expiratory wheezes
c. A baseline BP of 150/80 followed by a BP of 138/72 after two doses of the med.
Isosorbide Mononitrate (Imdur) is prescribed for a client with angina pectoris. The client tells the nurse that the medication is causing a chronic headache. The nurse appropriately suggests that the client:
a. Cut the dose in half
b. Contact the physician
c. Discontinue the medication
d. Take the medication with food
A client with coronary artery disease complains of substernal chest pain. After assessing the client’s heart rate and blood pressure, a nurse administers Nitro 0.4 mg sublingually. After 5 mins the client states “my chest still hurts” Select the appropriate actions that the nurse should take. SELECT ALL THAT APPLY
a. Call a code blue
b. Contact the physician
c. Contact the clients family
d. Assess the clients pain
e. Check the clients blood pressure
f. Administer a second Nitro 0.4 mg sublingually
D, E, F
A nurse is explaining the purpose of an electrocardiogram to a group of nursing students. The nurse would be correct if she said:
a. “it allows the Dr. to view inside the heart”
b. “it produces a picture of the electrical activity of the heart”
c.“it is used to increase the diameter of the heart”
d. “it is a device that temporarily takes over the function of the SA node”
A client has received instructions on his new pacemaker. Which of these comments indicates a need for further teaching?
a. “I’ll carry my pacemaker card in my wallet”
b. “If my pulse drops lower than the set rate. I’ll take a rest break”
c. “I will call my Dr. if I have any chest pain”
d. “I should see my Dr. on a regular schedule”
Several hours after a client has returned from a coronary angiography, you notice the dressing is saturated with blood. Your next action should be to:
a. call the Dr.
b. check for a pulse distal to the incision
c. reinforce the dressing apply pressure to the site
d. apply pressure to the site
Setting up a sterile field: put these steps in order:
__ preform hand hygiene
__ open sterile package; first open the top flap away from the body
__ don sterile gloves
__ open side flaps
__ open flap nearest your body
__open other sterile packages, open first the packages that will be used last, dropping contents onto the sterile field
__ gather materials and select an area for the sterile field
__ pour sterile solutions
- 1. gather materials and select an area for the sterile field
- 2. preform hand hygiene
- 3. open sterile package; first open the top flap away from the body
- 4. open side flaps
- 5. open flap nearest your body
- 6. open other sterile packages, open first the packages that will be used last, dropping contents onto the sterile field
- 7. pour sterile solutions
- 8. don sterile gloves
Children riding in a car should use a booster seat until they are ___________
at least 4' 9" tall or weigh 40 pounds (usually around 4 - 8 years old)
A child should use a rear facing car seat until she is __________
one year old and weighs 20 pounds.
The setting on the hot water heater should be no higher than _________
120 degrees F