comp exam 3

The nurse assigns an unlicensed assistive personnel (UAP) to care for a client who has a newly applied long-leg plaster cast. What should the nurse tell the UAP about proper care of the cast while it is drying? "Keep the cast covered with a sheet to protect it while drying." "Turn the client every 2 hours to promote even drying of the cast." "Use a blow dryer on the cast for 15 minutes every 2 hours until the cast is dry." "Carefully use your fingers to lift the cast and reposition the legs."

"Turn the client every 2 hours to promote even drying of the cast." Explanation: The client should be repositioned every 2 hours to promote even drying of the cast. The cast should be kept uncovered while drying to allow air to circulate around the cast and prevent heat from building up within it. It takes 24 to 72 hours for a plaster cast to dry; using a blow dryer may cause a heat burn and does not reduce the time for the cast to dry. The palms of the hands, not the fingers, should be used to move a drying cast in order to prevent indentations that can cause pressure points to develop.

A 72-year-old female client is brought by ambulance to the hospital's psychiatric unit from a nursing home where she has been a client for 3 months. Transfer data indicate that she has become increasingly confused and disoriented. In which way should the hospital admission process be modified for the client? Leave her alone to promote recovery of her faculties and composure. Medicate her to ensure her calm cooperation during the admission procedure. Allow her sufficient extra time in which to gain an understanding of what is happening to her. Give her a tour of the unit to acquaint her with the new environment in which she will live.

Correct response: Allow her sufficient extra time in which to gain an understanding of what is happening to her. Explanation: When admitting an elderly client, especially one who is confused and disoriented, it is best to give the client extra time in which to gain an understanding of what is happening to her. This will help her to get her bearings and adjust to a new environment. Leaving the client alone will not help her confusion and disorientation and will increase her fear and anxiety. Medication would not be appropriate until the cause of the client's confusion and disorientation is determined. Overmedicating elderly clients is sometimes a cause of their confusion. A tour of the unit will not be helpful for the client who is confused and disoriented.

A client with cancer of the stomach tells the nurse, "I cannot bear the pain anymore. Please give me some poison to free myself from this agonizing pain." The nurse faces a value conflict. Which of the following is true in such a condition? The nurse should solely consider the values of the client. Value conflict has no effect on the client's compliance. Human need may affect the values conflict. Values conflict is always destructive in nature.

Human need may affect the values conflict. Explanation: Human need may affect values conflict. Though the client is refusing further treatment, the nurse should be aware that the client needs the treatment. The nurse should not consider only the values of the client. When faced with a values conflict, nurses should examine their own values regarding the conflict. Value conflict may affect the client's compliance. Values conflict is not always destructive in nature. At times, it may even be constructive.

Which action should the nurse take to provide the most effective emergency care at the accident site for a victim with a heat burn? Pour cool water over the burned area. Apply clean, dry dressings to the area. Rinse the area with a warm, mild soap solution. Apply a mild antiseptic ointment to the area.

Pour cool water over the burned area. Explanation: The recommended emergency treatment for a heat burn is immersion in cool water or application of clean, cool wet packs. This treatment helps relieve pain and diminishes tissue damage by cooling the tissue. The burn should be kept moist to prevent the dressing adhering to the wound. Warm, mild soap solutions would be contraindicated because they are irritating to the injured tissue. Antiseptics or ointments are contraindicated because they can lead to further tissue damage.

A nurse is caring for a client with anorexia nervosa. Which interventions would be appropriate for this client? Select all that apply. Provide small, frequent meals Monitor weight gain Allow the client to skip meals until the antidepressant levels are therapeutic Encourage the client to keep a journal Encourage the client to eat three substantial meals per day

Provide small, frequent meals Monitor weight gain Encourage the client to keep a journal Explanation: Due to self-starvation, clients with anorexia can rarely tolerate large meals three times per day. Small, frequent meals may be tolerated better by the anorexic client, and they provide a way to gradually increase daily caloric intake. The nurse should monitor the client's weight carefully because a client with anorexia may try to hide weight loss. The client may be emotionally restrained and afraid to express her feelings; therefore, keeping a journal can serve as an outlet for these feelings. An anorexic client is already underweight and should not be permitted to skip meals.

A primigravida at 8 weeks' gestation tells the nurse that she wants an amniocentesis because there is a history of hemophilia A in her family. The nurse informs the client that she will need to wait until she is at 15 weeks' gestation for the amniocentesis. Which is the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation? Fetal development needs to be complete before testing. The volume of amniotic fluid needed for testing will be available by 15 weeks. Cells indicating hemophilia A are not produced until 15 weeks' gestation. Performing an amniocentesis prior to 15 weeks' gestation carries a greater infection rate.

The volume of amniotic fluid needed for testing will be available by 15 weeks. Explanation: The volume of fluid needed for amniocentesis is 15 mL, and this is usually available at 15 weeks' gestation. Fetal development continues throughout the prenatal period. Cells necessary for testing for hemophilia A are available during the entire pregnancy but are not accessible by amniocentesis until 12 weeks' gestation. Amniocentesis carries a slight risk of infection regardless of when the procedure is performed.

Which reaction to learning about a diagnosis of being HIV positive would put the client at the greatest need of intervention by the nurse? A person who is angry, hostile, and alienated from their family. A person who is obsessed with cleanliness and showers many times a day. A person who is unable to make decisions and is helpless and tearful. A person who says, "I have found a solution for this mess."

A person who says, "I have found a solution for this mess." Explanation: The statement by the person who says "I have found a solution for this mess" contains suicidal ideation, and that person is more of a safety risk than the angry, alienated client or the obsessed or helpless one. The other clients may need intervention as well, but the potentially suicidal client has the greatest need for nursing intervention.

The nurse is to administer an I.M. injection into a client's left vastus lateralis muscle. The nurse notes that the muscle is quivering as landmarks are assessed. How should the nurse respond? Have the client lie supine and flex their foot. Choose another site for injection. Have the client lie on the left side. Distract the client during the injection.

Choose another site for injection. Explanation: The nurse should never inject into sensitive muscles, especially those that twitch or tremble when you assess site landmarks and tissue depth. Injections into these trigger areas may cause sharp or referred pain, such as the pain caused by nerve trauma. Positioning the client supine and flexing their foot is correct for the injection site, but ignores the assessment findings. Positioning the client on his left or right side would allow access to the ventrogluteal site. Distraction also ignores the assessment finding.

When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris? "The pain lasted about 45 minutes." "The pain resolved after I ate a sandwich." "The pain got worse when I took a deep breath." "The pain occurred while I was mowing the lawn."

Correct response: "The pain occurred while I was mowing the lawn." Explanation: Decreased oxygen supply to the myocardium causes angina pectoris. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and may precipitate this chest pain. Anginal pain typically is self-limiting, lasting 5 to 15 minutes. Food consumption doesn't reduce angina pain, although it may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.

An experienced nurse is precepting a new nurse in a psychiatric emergency room and is discussing criteria for involuntary commitment. Which client would signal to the experienced nurse that the new nurse understands the criteria? The parent who leaves her minor children unattended and stays out all night snorting cocaine A client with schizophrenia who can manage activities of daily living but has grandiose delusions A man who threatens to kill his wife of 38 years A woman with depression who says she is tired of living and does not have a suicidal plan

Correct response: A man who threatens to kill his wife of 38 years Explanation: One of the criteria for involuntary commitment is an emergency in which the client is a threat to himself or others. A parent might have a child removed from the home because of neglect, but that doesn't meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and don't require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to himself.

Which nursing diagnosis takes highest priority for a client with a compound fracture? Imbalanced nutrition: Less than body requirements related to immobility Impaired physical mobility related to trauma Risk for infection related to effects of trauma Activity intolerance related to weight-bearing limitations

Correct response: Risk for infection related to effects of trauma Explanation: A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of defense against infection, any skin opening places the client at risk for infection. Imbalanced nutrition: Less than body requirements is rarely associated with fractures. Although Impaired physical mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don't take precedence because they aren't as life-threatening as infection.

An adolescent girl is being treated for anogenital warts caused by the human papillomavirus (HPV). What is the nurse's priority intervention for this client? Educate the client about the need to adhere to antibiotic therapy Educate the client about the accompanying risk of cervical cancer Assess the client's knowledge of hormonal contraceptives Assess the client for signs and symptoms of systemic infection

Educate the client about the accompanying risk of cervical cancer Explanation: This client's external lesions should be treated, and she should receive education regarding the relationship between HPV and cervical cancer. Antibiotics are would be ineffective because of the viral etiology of HPV. Hormonal contraceptives are of no benefit, and HPV is not normally the cause of systemic infection.

A client is typed and cross-matched for three units of packed cells. What are important precautions for the nurse to take before initiating the transfusion? Select all that apply. Initiate an IV with dextrose. Have two nurses check the blood type and identity. Warm the blood to room temperature. Initiate an IV with normal saline. Take baseline vital signs.

Have two nurses check the blood type and identity. Initiate an IV with normal saline. Take baseline vital signs. Explanation: Prior to administrating blood, the unit must be checked by two registered nurses. Baseline vital signs are obtained before the transfusion is started so any changes would be identified. Blood is always transfused with normal saline as other IV fluids are incompatible with blood. Warming to room temperature is not necessary.

The nurse is assessing a client with a spinal cord injury for the development of deep vein thrombosis. Which is the most effective way to determine deep vein thrombosis in this client? Detect positive Homans' sign. Rate the amount of pain. Assess for tenderness. Measure leg girth.

Measure leg girth. Explanation: Measuring the leg girth is the most appropriate method because the usual signs, such as a positive Homans' sign, pain, and tenderness, are not present. Other means of assessing for deep vein thrombosis in a client with a spinal cord injury are through a Doppler examination and impedance plethysmography.

The nurse is caring for a client in the recovery room after electroconvulsive therapy (ECT). Which of the following would be the priority nursing assessment? Response to ECT Recent memory and orientation Vital signs Bowel sounds

Vital signs Explanation: Although ECT is an operative procedure, and a failure or reduction of peristalsis (also known as paralytic ileus) can accompany some surgical procedures, it is least expected after ECT procedure. Headache, disorientation, and memory loss are common short-term side effects, but the priority assessment would be client vital signs in the postictal state. The nurse would not be able to assess the client's response to ECT immediately postprocedure.

A nurse is frustrated by her inability to make much progress establishing a therapeutic relationship with a client with bipolar disorder. Her most professional response would be to: ask to be reassigned to another, less-challenging client. keep trying to talk with the client even though the nurse is frustrated. discuss the situation with a more experienced peer. ask the physician to reevaluate the client's medication.

discuss the situation with a more experienced peer. Explanation: A collaborative approach is always a better way to address challenging situations; additional input may provide insight to help the nurse provide more effective client care. Asking to be reassigned and suggesting that another nurse might provide more effective care are avoidant responses that do not address the underlying issues. At this time, there is no indication that a medication reevaluation is necessary.

After giving birth to an 8-lb (3.6-kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of: sterile water. glucose water. standard infant formula. iron-fortified infant formula.

iron-fortified infant formula. Explanation: For a bottle-fed neonate, the first feeding usually consists of iron-fortified formula. It isn't necessary to start with sterile water or glucose water.

Which statement indicates that the client understands the home care of a colostomy? "I can attach my colostomy pouch directly to my skin as long as it is not irritated." "I can anticipate some pain around my stoma when I clean it." "I can expect to see some blood in my stool on occasion." "I should be able to establish a regular pattern of elimination with my colostomy."

"I should be able to establish a regular pattern of elimination with my colostomy." Explanation: Many colostomies, especially those located in the descending colon, can be regulated to evacuate on a schedule. All ostomy appliances should be applied using a peristomal skin barrier. There should be no pain associated with touching the stoma. After the immediate postoperative period, it is not normal for blood to be present in the stool. Bleeding should be reported to the client's health care provider.

When educating the client with type 1 diabetes, the nurse knows that the client needs more education when he or she says: "I will be able to switch to insulin pills when my sugar is under control." "I will need to eliminate sugar from my diet." "I will need to give myself insulin every day." "I will need to go to the podiatrist to get my toenails cut so I don't get an infection."

"I will be able to switch to insulin pills when my sugar is under control." Explanation: Oral antidiabetic agents are effective only in adult clients with type 2 diabetes. Oral antidiabetic agents aren't effective in type 1 diabetes. The need to eliminate sugar, give insulin, and receive proper foot care are all items that indicate the client understands the teaching.

The client has been prescribed vaginal cream for a yeast infection to be administered via a vaginal applicator. In which position would the nurse instruct the client to take for appropriate administration? supine position low Fowler's position Sims' position dorsal recumbent position

dorsal recumbent position Explanation: The dorsal recumbent position (supine with the hips and knees bent) allows easy access to the vaginal orifice and proper placement for the medication. The other positions do not allow access to the vaginal orifice as the legs are closed.

While admitting a client to the alcohol treatment program, the nurse asks the client how long she has been drinking, how much she has been drinking, and when she had her last drink. The client replies that she has been drinking about a liter of vodka a day for the past week and her last drink was about an hour ago. This information helps the nurse to determine which factor? the severity of the disease the severity of withdrawal symptoms the possibility of alcoholic hallucinosis the occurrence of delirium tremens

the severity of withdrawal symptoms

A client who is using a patient-controlled analgesia (PCA) pump after bowel surgery states, "I'm afraid that I'll become addicted if I use too much morphine." Which would be the best response by the nurse? "Morphine is not addicting in these circumstances. Why are you worried about it?" "You need to take the morphine to help you rest and recuperate from the surgery; you can deal with the addiction later." "When morphine is used to alleviate severe pain for 2 to 3 days, there is little likelihood of becoming addicted." "Have you had problems with drug addiction before?"

"When morphine is used to alleviate severe pain for 2 to 3 days, there is little likelihood of becoming addicted." Explanation: Morphine is a narcotic. Clients need to understand that when pain is present and morphine is used therapeutically, there is less likelihood of addiction. If morphine is taken in the absence of pain, addiction can result. Telling the client that morphine is not addicting is incorrect because, although it acknowledges the addictive nature of morphine, it does not inform the client regarding its effect in pain management. It is also nontherapeutic because it asks a "why" question. Asking about prior drug addiction is not appropriate at this time.

The nurse is performing a health history for a woman in her first trimester of pregnancy who lives alone with two cats. What education should the nurse provide so that the client may protect herself from illness? The client should apply bleach to her hands after cleaning the litter box. The client should wear disposable gloves and wash hand with soap and warm water after cat litter exposure. The client should apply protective barrier cream to the hands after coming in contact with cat litter The client should avoid any exposure to cat litter because they may contract rubella.

Correct response: The client should wear disposable gloves and wash hand with soap and warm water after cat litter exposure. Explanation: Toxoplasmosis is contracted primarily through exposure to uncooked meat or through handling cat litter or soil in which cat feces is present. The pregnant mother should be sure to have someone else handle the litter or use a hands free litter box. If exposure is unavoidable, the client should wear disposable gloves and be sure to wash hands with soap and warm water after exposure.

A client asks to be discharged from the health care facility against medical advice (AMA). What should the nurse do first? Prevent the client from leaving. Notify the physician. Have the client sign an AMA form. Call a security guard to help detain the client.

Notify the physician. Explanation: If a client requests a discharge AMA, the nurse should notify the physician immediately. If the physician can't convince the client to stay, the physician will ask the client to sign an AMA form, which releases the facility from legal responsibility for any medical problems the client may experience after discharge. If the physician isn't available, the nurse should discuss the AMA form with the client and obtain the client's signature. A client who refuses to sign the form shouldn't be detained because this would violate the client's rights. After the client leaves, the nurse should document the incident thoroughly and notify the physician that the client has left.

A 12-year-old child sustains a moderate burn injury. The mother reports that the child last received a tetanus injection when he was five years old. Which immunization would the nurse anticipate an for this child? 0.5 ml of tetanus toxoid IM 0.5 ml of tetanus toxoid IV 250 units of tetanus immune globulin IM 250 units of tetanus immune globulin IV

0.5 ml of tetanus toxoid IM Explanation: Tetanus prophylaxis is given to all clients with moderate to severe burn injuries if it has been longer than five years since the last immunization, or if there is no history of immunization. The correct dosage is 0.5 ml IM, one time, if the child was immunized within 10 years. If it has been more than 10 years, or the child hasn't received tetanus immunization, the dosage is 250 units of tetanus immune globulin, one time. There is no IV form of tetanus immune globulin available.

A mother tells a nurse that her child has been exposed to roseola. After teaching the mother about the illness, which finding, if stated by the mother as the most characteristic sign of roseola, indicates successful teaching? fever and sore throat normal temperature followed by a low-grade fever high fever followed by a drop and then a rash cold-like signs and symptoms and a rash

Correct response: high fever followed by a drop and then a rash Explanation: Children with roseola have a high fever for 3 days, which drops suddenly. Then a nonpruritic rash appears, typically lasting for 1 to 2 days. High fever followed by a rash is a characteristic sign. Associated symptoms include cold symptoms, cough, and lymphadenopathy.

A client with diabetes mellitus has a foot ulcer. The physician orders bed rest, a wet-to-damp dressing change every shift, and blood glucose monitoring before meals and at bedtime. Why are wet-to-damp dressings used for this client? They contain exudate and provide a moist wound environment. They protect the wound from mechanical trauma and promote healing. They debride the wound and promote healing by secondary intention. They prevent the entrance of microorganisms and minimize wound discomfort.

They debride the wound and promote healing by secondary intention. Explanation: For this client, wet-to-damp dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Dry, sterile dressings protect the wound from mechanical trauma and promote healing. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort.

After administering a prescribed medication to a client who becomes restless at night and has difficulty falling asleep, which nursing action is most appropriate? sitting quietly with the client at the bedside until the medication takes effect engaging the client in interaction until the client falls asleep reading to the client with the lights turned down low encouraging the client to watch television until the client feels sleepy

sitting quietly with the client at the bedside until the medication takes effect Explanation: To promote adequate rest (6 to 8 hours per night) and to eliminate hyposomnia, the nurse should sit with the client at the bedside until the medication takes effect. The presence of a caring nurse provides the client with comfort and security and helps to decrease the client's anxiety. Engaging the client in interaction until the client falls asleep, reading to the client, or encouraging the client to watch television may be too stimulating for the client, consequently increasing rather than decreasing the client's restlessness.