2050 Exam 1 iClicker

Matching: 1. Contracture 2. Atrophy 3. Orthostatic Hypotension A. Muscles decrease in size when not used- leading to a loss of both strength and muscle mass B. Permanent fixation of joints and muscles as a result of disuse C. Drop in systolic BP of 15mmhg or more when going from a sitting to standing position

*Contracture* = Permanent fixation of joints and muscles as a result of disuse *Atrophy* = Muscles decrease in size when not used- leading to a loss of both strength and muscle mass *Orthostatic Hypotension* = Drop in systolic BP of 15mmhg or more when going from a sitting to standing position

Which point requires correction regarding the use of restraints? 1. Less restrictive interventions must have been unsuccessful before applying restraints. 2. All other alternatives must have been tried and exhausted before applying restraints. 3. Restraints may be applied to ensure the physical safety of the resident or other residents. 4. A written order for restraints is not required.

4. A written order for restraints is not required.

What best describes measurement of post-void residual (PVR)? A. Bladder scan the patient immediately after voiding. B. Catheterize the patient 30 minutes after voiding. C. Bladder scan the patient when they report a strong urge to void. D. Catheterize the patient with a 16 Fr/10 mL catheter

A. Bladder scan the patient immediately after voiding.

Which of the following interventions would be most appropriate for a client who has urge incontinence? A. Have the client urinate on a timed schedule. B. Provide a bedside commode. C. Administer prophylactic antibiotics. D. Teach the client intermittent self-catheterization technique.

A. Have the client urinate on a timed schedule.

A client who is weak, dyspneic, and jaundiced has an elevated bilirubin level. With which problem are these clinical findings consistent? A. Hemolytic anemia B. Pernicious anemia C. Iron Deficiency anemia D. Anemia of chronic disease.

A. Hemolytic anemia

The implementation of diagnosis-related groups (DRGs) by Medicare in 1983 affected hospitals in which way? A. Medicare pays only the amount of money preassigned to a treatment for a diagnosis. B. This reimbursement method focuses on preventing illness through screening and health promotion. C. It decreased in hospital admission rates significantly D. It offered a discount rate for the beneficiaries.

A. Medicare pays only the amount of money preassigned to a treatment for a diagnosis.

The nurse is caring for a child with neutropenia. Which beverage is unsuitable for the client with a low neutrophil count? A. 2% milk B. Fresh squeezed lemonade C. Kool-aid D. Coffee

B. Fresh squeezed lemonade

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse explain increases the risk of these thromboses? A. Elevated blood pressure B. Increased blood viscosity C. Fragility of the blood cells D. Immaturity of red blood cells (aplastic)

B. Increased blood viscosity

An adolescent male with a history of spinal cord injury reports a leaking of urine at fairly regular intervals. A nurse should document in the client's plan of care a nursing diagnosis of: A. Functional urinary incontinence. B. Reflex urinary incontinence. C. Stress urinary incontinence. D. Urge urinary incontinence.

B. Reflex urinary incontinence.

Which statement by the patient indicates the development of a deep vein thrombosis? A."My legs itch." B."My left leg is swollen compared to my right." C."The skin on my legs is dry and scaly." D."My left leg feels cool when I touch it."

B."My left leg is swollen compared to my right."

The maximum amount of any medication that can be given in one site for a subcutaneous injection is: A. 5 mL B. 3 mL C. 1 mL D. 0.5 mL

C. 1 mL

A nurse discovers that she made a medication error. What should be the nurse's FIRST response? A. Record the error in the EMR B. Notify the primary care provider C. Asses the patient for any possible side effects of the error D. Complete an incident report explaining how the error was made.

C. Asses the patient for any possible side effects of the error

The hospital readmission reduction program looks at: A) The illness level of all patients admitted to that hospital for the past year. B) The infection rates within the hospital correlated with readmission rates. C) The number of prescriptions the patient filled 30 days prior to readmission. D) Readmission rates of patients during a 30-day period after discharge.

D) Readmission rates of patients during a 30-day period after discharge.

1. The equipment (syringe, needle) you choose for injections are based on: 2. Quantity of solution 3. Route to be administered 4. Type of medication 5. Body size 6. Viscosity of solution A. 1, 2, 3 B. 2, 3, 4 C. 3, 5 D. All the above

D. All the above

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom Catheter B. Apply a skin protectant C. Encourage increased fluid intake D. Assess for bladder distention

D. Assess for bladder distention

The nurse performs range of motion exercises on an immobile client to avoid which complication associated with immobility? A. Urinary stasis B. Constipation C. Dependent edema D. Contractures

D. Contractures

The nurse is administering a medication by intravenous bolus when the client reports pain and burning at the IV site. What is the next action by the nurse? A. Encourage the client to take deep breaths during the administration to minimize pain. B. Place a warm pack on the IV site and continue to administer the medication. C. Flush the site with normal saline to verify patency of the IV site. D. Stop the infusion and assess for signs of infiltration.

D. Stop the infusion and assess for signs of infiltration.

1. Protein responsible for osmotic/oncotic pressure 2. Breakdown of hemoglobin 3. Estimate of Renal function A. GFR B. Bilirubin C. Albumin

*GFR* = Estimate of Renal function *Bilirubin* = Breakdown of hemoglobin *Albumin* = Protein responsible for osmotic/oncotic pressure

Matching: 1. Medicaid 2. Medicare A 3. Medicare B 4. Medicare D A. Covers medication cost B. Covers In patient Hospitalization C. Covers Outpatient costs and equipment D. Income based

*Medicaid*- Income based *Medicare A*- Covers In patient Hospitalization *Medicare B*- Covers Outpatient costs and equipment *Medicare D*- Covers medication cost

A primary health care provider writes a prescription of "Restraints PRN (as needed)" for a client who has a history of violent behavior. Which action would the nurse take? 1. Ask the health care provider to specify the type of restraint in the prescription. 2. Notify the provider that PRN prescriptions for restraints are unacceptable. 3. Implement the restraint prescription when the client begins to act out. 4. Ensure that the entire staff is aware of the prescription for the restraints.

2. Notify the provider that PRN prescriptions for restraints are unacceptable.

The nurse is providing restraint education to a group of nursing students. Which reason to use restraints is *incorrect* to teach? 1. To prevent a confused client from pulling out an intravenous (IV) line 2. To prevent an adult client from getting up at night when there is insufficient staffing on the unit 3. To prevent ventilated patient from dislodging the ventilator 4. To keep an older adult client from falling out of bed after a surgical procedure

2. To prevent an adult client from getting up at night when there is insufficient staffing on the unit

An immobile postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? A. Pneumonia B. Hypothermia C. Fluid imbalance D. Pulmonary embolism

A. Pneumonia

A nurse is assessing the extremities of a client who had wrist restraints applied 2 hours ago. Which assessment finding, if present, is of greatest concern? A. The client is able to wiggle the fingers. B. The restraint is secured to the bed's frame. C. The skin of the hand feels cool to the touch and is pale. D. The nurse is able to insert two fingers under the restraints

C. The skin of the hand feels cool to the touch and is pale.

Matching: 1. Never Events 2. Hospital Acquired Conditions 3. Hospital acquired infections 4. Re-admission rates A. An admission to an inpatient hospital within 30 days of a discharge B. Medical error/events that should never occur or could be preventable C. Infections acquired while receiving treatments for another condition D. Undesirable situation or condition that arose during a hospital stay

*Never Events* = Medical error/events that should never occur or could be preventable *Hospital Acquired Conditions* = Undesirable situation or condition that arose during a hospital stay *Hospital acquired infections* = Infections acquired while receiving treatments for another condition *Re-admission rates* = An admission to an inpatient hospital within 30 days of a discharge

Matching: 1. Lab value monitoring for Coumadin therapy 2. Lab value monitoring for Heparin Therapy 3. Antidote for Coumadin 4. Antidote for Heparin A. Protamine Sulfate B. PT/INR C. PTT D. Vitamin K

*Protamine Sulfate* = Antidote for Heparin *PT/INR* = Lab value monitoring for Coumadin therapy *PTT* = Lab value monitoring for Heparin Therapy *Vitamin K* = Antidote for Coumadin

The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important? A. If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. B. If you continue to breathe shallowly or cough ineffectively, this can lead to deep vein thrombosis (DVT) by preventing poor oxygen exchange in the cardiac and peripheral circulatory system. C. If you continue to breathe shallowly or cough ineffectively, this can lead to dizziness, falling, or an inability to ambulate because of shortness of breath. D. If you continue to breathe shallowly or cough ineffectively, this can lead to respiratory obstructive disease

A. If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia.

The medical/surgical nurse watches a student nurse prepare a sterile field. Which of the following actions, if performed by the student nurse, requires further instruction? A. The student nurses places the sterile drape, then turns to grab a packaged set of sterile gloves from the table behind her. B. The student nurses' hands, once in the sterile gloves, do not go above her head or below her waist. C. The student nurse drops the sterile gauze into the sterile field from a 6 inch height D. The student nurse performs hand hygiene prior to putting on sterile glove

A. The student nurses places the sterile drape, then turns to grab a packaged set of sterile gloves from the table behind her.

Which intervention should a nurse plan to incorporate in the care of a surgical client to decrease the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE)? A. Use of intermittent compression devices on the lower extremities B. Administration of heparin intravenously C. Coughing and deep breathing exercises D. Turn patient every 2 hours

A. Use of intermittent compression devices on the lower extremities

You are giving a community presentation on Medicare Part D. Medicare Part D: A) Pays for over-the-counter medications. B) Pays a portion of prescription drug costs. C) Pays for physical therapy. D) Pays for laboratory work needed for medication monitoring.

B) Pays a portion of prescription drug costs.

An outpatient care nurse is providing instructions to a patient who is scheduled for a colonoscopy to remove a polyp. Which instructions are appropriate for client preparation for this procedure? A. Clear liquids may be consumed starting 24 hours after the procedure. B. A bowel preparation will be required in preparation for the procedure. C. Clear liquids only are allowed on the day of the scheduled procedure. D. You can drive back from the procedure by yourself

B. A bowel preparation will be required in preparation for the procedure.

A female client is being discharged from the hospital to home with an indwelling urinary catheter after the surgical repair of the bladder after trauma. The nurse determines that the client understands the principles of catheter management to prevent complications if the client states to: A. Cleanse the perineal area with soap and water once a day. B. Keep the drainage bag lower than the level of the bladder. C. Limit fluid intake so that the bag will not become full so quickly. D. Coil the tubing and place it under the thigh when sitting to avoid tugging on the bladder.

B. Keep the drainage bag lower than the level of the bladder.

A nurse is teaching a patient about the urinary system. In which order will the nurse present the structures, following the flow of urine? A. Kidney, urethra, bladder, ureters B. Kidney, ureters, bladder, urethra C. Bladder, kidney, ureters, urethra D. Bladder, kidney, urethra, ureters

B. Kidney, ureters, bladder, urethra

Mrs. Redor, age 55 years, was hospitalized. She takes 5 medications. She is being discharged home. In preparing her discharge, which of the following is *least* likely to be helpful? A) Assess her knowledge about the medications B) Explain to her how she should take the medications C) Leave medication brochures by her bed D) Explore her feelings about her medications and diagnoses

C) Leave medication brochures by her bed

Which assessment question should the nurse ask if stress incontinence is suspected? A. "Do you think your bladder feels distended?" B. "Do you empty your bladder completely when you void?" C. "Do you experience urine leakage when you cough or sneeze?" D. "Do your symptoms increase with consumption of alcohol or caffeine?"

C. "Do you experience urine leakage when you cough or sneeze?"

The nurse is caring for a client with cancer who is neutropenic. Which plan would be inappropriate? A. Notify the doctor of any temperature over 100° F. B. Use sterile technique when performing invasive procedures. C. Avoid any spicy foods. D. Avoid client exposure to anyone who is ill.

C. Avoid any spicy foods.

Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately? A. Do you leak urine when you cough or sneeze? B. Do you need help getting to the toilet? C. Do you dribble urine constantly? D. Does it burn when you pass your urine?

C. Do you dribble urine constantly?

A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this condition? A. Using adult diapers B. Inserting a Foley catheter C. Establishing a toileting schedule D. Padding the bed with an absorbent cotton pad

C. Establishing a toileting schedule

The nurse is caring for a postoperative patient. Four hours after surgery, the patient voids 200 mL of urine with a specific gravity of 1.019. The nurse should: A. palpate the patient's lower abdomen for distention B. encourage an increased intake of oral fluids. C. record the time and the amount of urine. D. encourage the patient to void again in two hours.

C. record the time and the amount of urine.

The nurse is caring for a patient the first day postoperative after a transurethral prostatectomy (TURP). The patient has a continuous bladder irrigation (CBI). The patient's wife asks why he has to have the CBI. Which of the following responses by the nurse is BEST? A."The CBI prevents urinary stasis and infection." B."The CBI dilutes the urine to prevent infection." C."The CBI enables urine to keep flowing." D."The CBI delivers medication to the bladder."

C."The CBI enables urine to keep flowing."

A nurse is caring for a client scheduled for a CT scan with contrast. Which action is most appropriate? A. Checking the history for and asking the patient about metal or clips in or on the body B. Keeping the patient NPO after midnight the night before the procedure C. Assessing the client's hemoglobin and hematocrit D. Checking the client's creatinine level

D. Checking the client's creatinine level Rationale: kidneys will be affected by contrast, if poor BUN/creatinine/GFR, kidneys will get shot from trying to excrete dye from contrast

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? A. Prepare to administer an antidote. B. Draw a sample for type and crossmatch and transfuse the client. C. Draw a sample for an activated partial thromboplastin time (aPTT) level. D. Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

D. Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

A patient with diabetes mellitus self monitors blood sugar at home. Now the primary care provider wants to assess the client's average blood sugar over a 3-month period. The best test for this would be: A. Fasting plasma glucose B. Urine dipstick for glucose C. Glucose tolerance test D. Hemoglobin A1C

D. Hemoglobin A1C

A patient with atrial fibrillation is receiving warfarin (Coumadin) 5 mg each day. His INR today is 2.4 (N= 0.8-1.2). What is the expected change in medication dosage? A. His INR is too low. His warfarin dose needs to be increased. B. His INR is too high. His warfarin dose needs to be decreased. C. His INR is too high. His warfarin dose needs to be increased. D. His INR is within desired range. No change in warfarin dose is needed.

D. His INR is within desired range. No change in warfarin dose is needed.

To obtain a clean-catch urine specimen from a female patient, what should the nurse teach the patient to do? A. Cleanse the urethral meatus from the area of most contamination to least. B. Initiate the first part of the urine stream directly into the collection cup. C. Drink fluids 5 minutes before collecting the urine specimen. D. Hold the labia apart while voiding into the specimen cup.

D. Hold the labia apart while voiding into the specimen cup.

Which of following interventions would a nurse utilize for a patient with thrombocytopenia? A. Instruct the client on foods to eat that are high in iron B. Assess the client for an allergic reaction C. Place the client on neutropenic precautions and limit visitors D. Use an electric razor when shaving and avoid taking rectal temperature

D. Use an electric razor when shaving and avoid taking rectal temperature