CLOTTING AND MOBILITY QUIZ
What procedure should a nurse use when elevating the head of an infant in a spica cast? A.Padding the edge of the cast with folded diapers B.Inserting pillows under the shoulders C.Raising the entire mattress at the head of the crib D.Changing this position after an hour
C When elevation of the head is desired, the entire mattress or crib should be raised at the head of the crib. There is no reason to place such a short time limit on this position. Pillows under the head or shoulders of a child in a spica castLinks to an external site. will thrust the chest forward against the cast, resulting in discomfort and respiratory distress. Padding the edge of the cast with folded diapers will not help elevate the infant's head.
A nurse teaches a client about Coumadin and concludes that the teaching is effective when the client agrees not to drink which juice? A.Cranberry juice B.Apple juice C.Orange juice D.Grape juice
A Antioxidants in cranberry juice may inhibit the mechanism that metabolizes warfarin, causing elevations in the international normalized ratio, resulting in hemorrhage. Apple juice, grape juice, and orange juice are fine to drink.
Which term should the nurse use to describe bone loss greater than normal but less than that caused by osteoporosis? A.Osteopenia B.Osteomalacia C.Osteoarthritis D.Osteomyelitis
A Osteopenia is defined as bone loss that is more than normal but not yet at the level for a diagnosis of osteoporosis. Osteomyelitis is infection of bone or bone marrow. Osteomalacia is softening of bones due to calcium or vitamin D deficiency. Osteoarthritis is cartilage deterioration in the joints.
A school-aged child is to receive a blood transfusion. What should the nurse do first if an allergic reaction to the blood occurs? A.Shut off the infusion. B.Slow the rate of flow. C.Call the healthcare provider. D.Administer an antihistamine.
A The child is experiencing an allergic reaction, and the infusion must be stopped immediately to prevent serious complications. Slowing the rate of infusion will not halt the allergic reaction to the transfused blood. Administering an antihistamine is dangerous as an initial action because the degree of allergic reaction cannot be determined at this time. Also, it requires a healthcare provider's prescription. The healthcare provider should be notified after the infusion has been stopped.
To prevent excessive bruising when administering subcutaneous heparin, what technique will the nurse employ? A.Avoid massaging the injection site after the injection B.Administer the injection via the Z-track technique C.Inject the drug into the vastus lateralis muscle in the thigh D.Use 2 mL of sterile normal saline to dilute the heparin
A The site of the injection should not be massaged to avoid dispersion of the heparinLinks to an external site. around the site and subsequent bleeding into the area. The Z-track technique and the intramuscular route are not used with heparin; subcutaneous injection and intravenous administration are the routes appropriate for heparin administration. The drug should be injected into the subcutaneous tissue slowly, not quickly. Diluting heparin with normal saline is unnecessary. Generally heparin is provided by the pharmacy department in single-dose syringes.
A healthcare provider prescribes two units of blood for a client who is bleeding. Which nursing interventions are necessary before the blood transfusion is administered? Select all that apply. A.Determining typing and crossmatching of blood B.Monitoring hemoglobin and hematocrit levels C.Allowing the blood to reach room temperature D.Obtaining the client's vital signs E.Using a Y-type infusion set to initiate 0.9% normal saline
A,D,E Obtaining the client's vital signs provides a baseline and should be done before the transfusion is initiated. Using a Y-type infusion set with 0.9% saline on one side of the Y is necessary to prevent an acute immunologic reaction if the donated blood is not compatible with the client's blood. A Y-type infusion set is specific for blood administration. It has a special blood filter, the drop factor is different, and it allows for quick shutoff and the administration of normal saline in the event of a transfusion reaction. The laboratory results for hemoglobin and hematocrit levels were part of the data used to determine the need for blood initially and do not need to be performed again until after the transfusion is completed. Blood must be kept cold until ready for use; if blood is kept at room temperature for 30 minutes before administration, it should be returned to the blood bank; after it is started, blood must be administered within 4 hours. STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.
Which information about a patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? A.The patient has relapsing-remitting MS. B.The patient has an increased creatinine level. C.The patient enjoys walking for relaxation. D.The patient complains of pain with neck flexion.
B Dalfampridine should not be given to patients with impaired renal function. The other information will not impact on whether the dalfampridine should be administered.
The nurse is caring for an elderly client who has a right hip fracture. Which priority intervention should be included in the plan of care? A.Cardiac monitoring B.Venous thromboembolism (VTE) prevention C.Nutrition supplements D.Oxygen therapy
B VTELinks to an external site. is common after hip surgery and must be prevented; this is a component of core measures. Nutritional supplements, cardiac monitoring, and oxygen therapy may be necessary in some clients with hip fractures, but not in all. Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation
A client with a fracture is found to have compartment syndrome. Which interventions will be contraindicated? Select all that apply. A.Splitting the cast in half B.Applying cold compresses C.Loosening the client's bandage D.Reducing the traction weight E.Elevating the extremity above heart level
B,D Cold compresses and elevating above the heart level are contraindicated for compartment syndrome. Compartment syndrome is a condition in which swelling and increased pressure within a limited space (a compartment) press on and compromise the function of blood vessels, nerves, and tendons that run through that compartment. Application of cold compresses could result in vasoconstriction and exacerbate compartment syndrome. Elevating the extremity above heart level could lower venous pressure and slow arterial perfusion. Splitting the cast in half decreases pressure and is beneficial in treating compartment syndrome. Reducing traction weight is beneficial because it decreases external circumferential pressure. Loosening the bandage is beneficial because it decreases pressure. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options are likely related to the situation, but only some of the options may be related directly to the situation.
While receiving a blood transfusion, a client develops acute dyspnea, generalized urticaria, a heart rate of 128, and a blood pressure of 70/38. What type of reaction does the nurse conclude that the client probably is experiencing? A.Pyrogenic B.Hemolytic C.Panic D.Anaphylactic
D Anaphylactic reactionsLinks to an external site. result from hypersensitivity to a product in the blood. Signs and symptoms are due to bronchospasm, systemic vasodilation, and compensatory tachycardia. The client may go into life-threatening shock without prompt treatment. Panic reactions (also known as panic attacks) involve high levels of anxiety and may be coupled with autonomic symptoms such as tachycardia. Bacterial pyrogens are present in contaminated blood and can cause a febrile transfusion reaction; signs include fever and chills. Hemolytic reaction results from the incompatibility of a recipient's antibodies with transfused red blood cells (RBCs); the reactions result from RBC hemolysis, agglutination, and capillary plugging
The nurse is caring for a client who has sustained blunt trauma to the forearm. The nurse assesses the client for which early sign of compartment syndrome? A.Bounding radial pulse in the injured arm B.Warm skin at the site of injury C.Rapid capillary refill in affected hand D.Escalating pain in the fingers
D Elevated tissue pressure restricts blood flow, causing increasing ischemia and increasing pain; it is the cardinal early symptom of compartment syndromeLinks to an external site.. The arm will feel cool, not warm, because of a decrease in circulation. Sluggish, not rapid, capillary refill is a sign of compartment syndrome. The pulse will be diminished, not bounding; increasing edema impairs circulation.
A client develops thrombophlebitis in the right calf. Bed rest is prescribed, and an IV of heparin is initiated. What drug action will the nurse include when describing the purpose of this drug to the client? A.Reduces the size of the thrombus B.Dissolves the blood clot in the vein C.Facilitates absorption of red blood cells D.Prevents extension of the clot
D Heparin interferes with activation of prothrombin to thrombin and inhibits aggregation of platelets. Heparin does not reduce the size of a thrombus. Heparin does not dissolve blood clots in the veins. Heparin does not facilitate the absorption of red blood cells
A client is admitted to the hospital with a diagnosis of deep vein thrombosis, and intravenous (IV) heparin sodium is prescribed. If the client experiences excessive bleeding, what should the nurse be prepared to administer? A.Oprelvekin B.Warfarin sodium C.Vitamin K D.Protamine sulfate
D Protamine sulfateLinks to an external site. binds with heparin sodium to form a physiologically inert complex; it corrects clotting deficits. Vitamin K counteracts the effects of drugs like warfarin sodium (Coumadin). Oprelvekin is a thrombopoietic growth factor that stimulates the production of platelets. It would not be appropriate for emergency management. Warfarin sodium is an oral anticoagulant that interferes with the synthesis of prothrombin
The nurse is caring for a client who is 1 day postoperative for a left hip fracture repair. During the assessment, which finding should the nurse assess further? A.Decreased range of motion to the left extremity B.Small amount of serosanguinous drainage C.Pain at the surgical site D.Sudden shortness of breath
D The sudden onset of shortness of breath is indicative of a fat embolism, which can occur after a fracture of the long bones. This is a serious complication that could result in death. It is normal to have pain at the surgical site, a small amount of serosanguinous drainage, and decreased range of motion to the affected extremity.
Ten minutes after the initiation of a blood transfusion, a client reports lumbar pain. What is the next nursing action? A.Assess the pain further. B.Increase the flow of normal saline C.Obtain the vital signs. D.Stop the transfusion.
D This is a sign of an acute hemolytic transfusion reactionLinks to an external site., indicating that the recipient's blood is incompatible with the transfused blood; pain is caused by hemolysis, agglutination, and capillary plugging in the kidneys. Obtaining the vital signs and assessing the pain further are unsafe actions; more incompatible blood will be infused, increasing the severity of the transfusion reaction. Increasing the flow of normal saline is unsafe; the transfusion must be stopped first, and then normal saline should be infused to keep the line patent and to maintain blood volume.