Elevate 3

A client has been admitted with advanced Cirrhosis. The nurse's assessment reveals an abdominal girth increase of 5 inches (12.7 cm) and a weight increase of 6 lbs.(2.71 kg) since yesterday's measurements. What further assessment findings would the nurse expect? 1. Hypotension 2. Cool extremities 3. Bradycardia 4. CVP readng of 8 mm/Hg 5. Radial pulses 4+/4+

1. & 2. Correct: These are signs and symptoms of FVD due to 3rd spacing and shock is what you are afraid of. 3. Incorrect: We would expect the heart rate to increase in FVD in an effort to move what little volume you have left through the system. 4. Incorrect: This is a high CVP, and with FVD you would expect it to be low. 5. Incorrect: Pulses are evaluated on a 4 point scale, so 4 would be a bounding pulse which would indicate fluid volume excess.

The nurse is to administer oxytocin 0.5 milliunits/min IV to a client admitted for labor induction. Oxytocin is available as 10 units/1000 ml 0.9% normal saline. How many mL/hour of the oxytocin should be administered? 1. 3 mL/hour 2. 6 mL/hour 3. 10 mL/hour 4. 12 mL/hour

1. Correct: 3 mL/hour will deliver oxytocin 0.5 milliunits/min. Calculations for IV Oxytocin Solution NOTE 1 Unit = 1,000 milliunits TO MAKE SINGLE-STRENGTH IV SOLUTION: Add 10 Units of Oxytocin to 1 liter of compatible IV fluid. TO INFUSE: Convert prescribed milliunits/min to mL/hr and set infusion pump. AMOUNT PRESCRIBED: 0.5 milliunits/min CALCULATIONS: 10 Units/1 L = 10,000 milliunits/1,000 mL OR 10 milliunits/1 mL. 10 milliunits/1 mL = 0.5 milliunits/X mL Cross-multiply to get: 0.5 = 10X X = 0.05, so 0.05 mL/min Multiply by 60 minutes to get amount infused per hour. THINK: 0.05 milliunits = 0.05 mL/min 0.05 mL/min x 60 min/hr = 3 mL/hr (0.05 x 60 = 3) Set the infusion pump for 3 mL/hr.

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client? 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen

1., 2., 4., & 5. Correct: An alternating pressure mattress will help to prevent pressure ulcers. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. The client with hepatic encephalopathy is unresponsive and may need suctioning if unable to clear secretions from the oropharynx. The client at the end stages of liver disease will be hypoxemic, so oxygen therapy is provided. 3. Incorrect: The unresponsive client will not need a walker.

Which statements should the nurse include when teaching a client about osteomyelitis? 1. Osteomyelitis is a risk factor for people with impaired immune systems. 2. Weight bearing activity is restricted to avoid stress on the affected bone. 3. Intravenous antibiotics will be administered for at least 3 to 6 weeks. 4. The affected extremity will be elevated. 5. Osteomyelitis requires subcutaneous administration of calcitonin.

1., 2, 3., & 4. Correct: Clients who are at high risk for osteomyelitis include those who are poorly nourished, elderly, or obese. Others at risk include those with impaired immune systems and chronic illnesses such as diabetes and rheumatoid arthritis. Treatment regimens restrict activity. The bone is weakened by the infective process and must be protected by immobilization devices and by avoidance of stress on the bone. IV antibiotic therapy is provided for a period of 3-6 weeks with around the clock dosing to maintain a high therapeutic blood level. Elevation of the extremity reduces swelling and thus associated pain. 5. Incorrect: Calcitonin is used for Paget's disease. A disorder of localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae.

In which client should the nurse question a prescription for a contraction stress test? 1. Client at 26 weeks gestation. 2. Client with a history of 4 Cesarean section deliveries. 3. Client at 38 weeks with gestational diabetes. 4. Client at 37 weeks gestation. 5. Client with placenta previa.

1., 2., & 5. Correct: 26 weeks is too early to stimulate contractions. This could lead to a preterm delivery. Stimulating contractions in a client with previous cesarean deliveries is not recommended. This may lead to uterine rupture. Stimulating contractions in a client with placenta previa is not recommended. This may lead to hemorrhage. 3. Incorrect: There is no reason to suspect complications from a contraction stress test for this client. 4. Incorrect: There is no reason to suspect complications from a contraction stress test for this client.

A client is preparing to be discharged after a total hip replacement. Which client statement would indicate teaching has been successful regarding prevention of hip prosthesis dislocation? 1. "I should not cross my affected leg over my other leg." 2. "I should not bend at the waist more than 90 degrees." 3. "While lying in bed, I should not turn my affected leg inward." 4. "It is necessary to keep my knees together at all times." 5. "When I sleep, I should keep a pillow between my legs."

1., 2., 3. & 5. Correct: These are appropriate actions to prevent hip prosthesis dislocation. Until the hip prosthesis stabilizes it is necessary to follow these instructions for proper positioning to avoid dislocation. 4. Incorrect: The knees should be kept apart to prevent dislocation.

What sign and symptom should the nurse expect to find during the physical assessment of a client who has a history of rheumatoid arthritis? 1. Nodules over bony prominences 2. Reports of morning stiffness lasting over 1 hour 3. Reports of weight loss 4. Cool, swollen joints 5. Joint deformity

1., 2., 3., & 5. Correct: Firm bumps of tissue (nodules) over bony prominences, such as on elbows, are called rheumatoid nodules, and are a sign of rheumatoid arthritis. Morning stiffness that can last for hours is a symptom of rheumatoid arthritis. Over time, rheumatoid arthritis can cause joints to deform and shift out of place. Weight loss is a common symptom of rheumatoid arthritis. 4. Incorrect: Affected joints will be tender, red, warm, and swollen.

The nurse recognizes that Rho(D) immune globulin would be indicated for which Rh negative client? 1. Elective abortion at sixteen weeks gestation 2. Involved in a major car accident 3. Requires amniocentesis 4. Diagnosed with an ectopic pregnancy 5. Forty-eight hours post delivery of term Rh positive baby 6. Twenty weeks gestatation

1., 2., 3., 4. & 5. Correct: All of these clients may need to receive the Rho(D) immune globulin because they could have some bleeding and therefore develop antibodies against a Rh positive fetus. 6. Incorrect: An optional Rho(D) immune globulin dose may have been given during pregnancy by the practitioner, but it is 28 weeks, not 20 weeks.

The nurse cares for a client after a gastroscopy examination. Which nursing interventions are appropriate post-procedure? 1. Maintain NPO status until the gag reflex returns. 2. Observe for hematemesis. 3. Monitor intake and output. 4. Assess bowel elimination. 5. Monitor respirations. 6. Connect to oxygen saturation monitor.

1., 2., 5, & 6. Correct: A gastroscopy examination uses a flexible fiber-optic tube to visualize the esophagus and/or stomach. The throat is numbed before the procedure to inhibit the gag reflex and to allow the scope to pass freely. Therefore, it is important to maintain NPO status until the gag reflex returns. The nurse should monitor for hematemesis, respirations, and oxygen saturation to ensure the scope did not damage any structures like the esophagus or lungs. 3. Incorrect: Because the kidneys are not affected during this procedure, monitoring intake and output is not an important intervention. 4. Incorrect: Because the bowels are not affected during this procedure, this is not an important intervention.

A nurse auscultates the bowel sounds of a client suspected of having a bowel obstruction in the transverse colon. What sounds would the nurse expect to hear in the abdominal quadrants? 1. Absent RLQ 2. Increased RLQ 3. Decreased RLQ 4. Increased LLQ 5. Decreased LLQ

2. & 5. Correct: Peristalsis should increase in the ascending colon (RLQ) in an attempt to clear the blockage resulting in hyperactive bowel sounds. There will be little or no peristalsis distal to the obstruction (LLQ) resulting in decreased or absent bowel sounds. 1. Incorrect: Bowel sounds should be present proximal to the blockage (RLQ). 3. Incorrect: Peristalsis will increase proximal (RLQ) to the obstruction. 4. Incorrect: Peristalsis will be decreased or absent distal to the obstruction (LLQ).

Immediately following a below-the-knee amputation (BKA), the nurse positions the client to prevent complications. What intervention related to position of the residual limb is a priority at this time? 1. Flat on the bed 2. Elevate foot of the bed 3. Position of comfort 4. Dependent position

2. Correct: It is normal to experience post-operative swelling after a BKA. Immediately after surgery, the foot of the bed should be elevated to reduce swelling. An ACE compression bandage will be used to reduce swelling and prevent hemorrhage. The other positions would not be as appropriate since swelling is an issue after a below the knee amputation. 1. Incorrect: Flat on the bed will not relieve swelling. Post-operatively for a BKA, hemorrhage and swelling are the biggest concerns immediately following surgery. 3. Incorrect: Position of comfort may increase swelling. Immediately following a BKA, elevating the foot of the bed and the ACE compression wrap are used to prevent hemorrhage and swelling. Positioning for comfort is not appropriate. 4. Incorrect: Placing in a dependent position will increase swelling. Swelling post-operatively is a normal occurrence, and elevating the foot of the bed along with the use of an ACE wrap will help prevent swelling.

The nurse is preparing a seminar for a group of clients diagnosed with irritable bowel syndrome. Which point should the nurse include? 1. Teach about a low fiber diet. 2. Schedule meals at regular times. 3. Fluid should be taken with meals. 4. Become active in yoga classes. 5. Keep a food diary for 2 weeks.

2., 4. & 5. Correct: Eating at regular intervals and chewing foods slowly and thoroughly will help to manage symptoms. Additional strategies include maintaining good dietary habits with avoidance of food triggers. Stress management via relaxation techniques, yoga, or exercise are recommended. Identify irritating foods by keeping a food diary for 1-2 weeks. 1. Incorrect: This client needs a high soluble fiber diet to help control diarrhea and constipation. Dietary fiber and bulk help the client by establishing regular bowel elimination patterns with soft, bulky stools. 3. Incorrect: Although adequate fluid intake is necessary, fluid should not be taken with meals because this results in abdominal distention.

A client diagnosed with celiac disease has been prescribed a gluten-free diet. Which meal, if chosen by the client, would indicate to the nurse that the client understands this diet? 1. Cream based chicken soup 2. Breaded baked chicken with peas 3. Grilled catfish with mixed vegetables 4. Marinated talapia with green beans

3. Correct: Fresh meats, fish and poultry (not breaded, batter-coated or marinated), fruits and vegetables are allowed on a gluten-free diet. 1. Incorrect: This may contain hidden gluten as wheat may be used as a thickener. 2. Incorrect: Fresh meats, fish, and poultry are allowed, but not if breaded, batter-coated, or marinated. 4. Incorrect: Fresh meats, fish, and poultry are allowed, but not if breaded, batter-coated, or marinated.

A child with a radial fracture reports itching below the casted area. What is the appropriate nursing action to relieve itching? 1. Allow the child to use a Q-tip to scratch the area. 2. Assess the fingers and areas above the cast to identify areas of irritation. 3. Apply an ice pack for 10-15 minutes. 4. Raise the cast above the level of the heart to reduce itching sensation.

3. Correct: This will change the sensation. Normally the answer is use a cool blow dryer, but they wanted to see if you would be flexible with what you know. Use an ice pack that will not get the cast wet. 1. Incorrect: A Q-tip is soft, trying to make you feel like this is okay to put into a cast. But objects should never be placed under the cast. 2. Incorrect: How does assessing the fingers decrease itching? It doesn't. 4. Incorrect: Raising the cast above the level of the heart will help reduce swelling under the cast in the first 24 to 72 hours after a cast is applied, but it does not help with itching.

Post epidural anesthesia, a laboring client's blood pressure drops to 92/42. Which intervention by the nurse takes priority? 1. Elevate the head of the bed 2. Administer oxygen by face mask 3. Position client side-lying 4. Begin dopamine 5 mcg/kg/min

3. Correct: When you turn them on their side, this relieves pressure on the vena cava and the BP will go UP. 1. Incorrect: This will drop the pressure more. 2. Incorrect: O2 doesn't bring up the BP. 4. Incorrect: Stay away from drugs as long as you can.

What interventions can an occupational health nurse discuss with a client in an effort to improve lateral epicondylitis (tennis elbow) pain? 1. Avoid activities that make the pain worse. 2. An oral, nonsteroidal, anti-inflammatory drug may be prescribed. 3. Immediately start stretching and exercising the muscle and tendon. 4. If pain persists, a cortisone injection into the inflamed area may be recommended. 5. Apply ice for 45 minutes, six times a day.

1., 2., & 4. Correct: General activities that make the pain worse should be avoided or at least cut back. While continued activity in the presence of mild discomfort is not harmful, activities that cause severe pain will only prolong the necessary recovery time and should be avoided. Oral, nonsteroidal, anti-inflammatory drugs are very helpful in controlling the pain and inflammation of tennis elbow. The medicine is taken daily for at least four to six weeks when treating severe cases. For less severe cases, these medicines may be taken only when needed. Cortisone injections are considered when the other measures have not worked and the pain is severe. The cortisone is injected into the area of the inflamed tendons in order to decrease the inflammation. 3. Incorrect: Stretching and exercising of the involved muscle and tendon unit is one of the mainstays of treatment for this condition once pain and inflammation have subsided, but not during the acute phase. A gentle stretching program is started through a range of motion at the elbow and wrist. This is combined with a program of muscle strengthening. 5. Incorrect: It is recommended to apply ice to the area two to three times a day, for 20 to 30 minutes each time.

The house supervisor has sent an LPN to assist on a busy medical-surgical unit. Which client could the charge nurse assign to the LPN? 1. Being discharged with a new Hickman port. 2. With a deep vein thrombosis (DVT) on a heparin infusion. 3. Two-days post gastric bypass taking clear liquids. 4. With Alzheimer's disease awaiting transfer to nursing home. 5. New transfer from post-anesthesia care unit (PACU) following a mastectomy.

3 and 4. CORRECT: An LPN should be assigned stable clients who do not require initial teaching or frequent assessments. The client who is two days post gastric bypass has already advanced to clear liquids and would be appropriate for an LPN. Also, a client who has Alzheimer's disease awaiting transfer would have needs that could be addressed by an LPN, and therefore is a suitable assignment. 1. INCORRECT: This client has a new Hickman port which is an implanted access device used for chemotherapy or medications given long term. There is a great deal of teaching necessary regarding the care of this port. This client should be assigned to an RN. 2. INCORRECT: This client will need frequent assessment of circulation in the area of the DVT and monitoring for evidence of bleeding complications. Additionally, PTT levels will be drawn every 6 hours that may require the nurse to adjust the heparin infusion rate. This client is not appropriate for an LPN. 5. INCORRECT: This fresh post-op client will require frequent vitals and assessment of the surgical dressing following this surgery. This client would be assigned to an RN.

The nurse is developing the plan of care for a child with a fractured femur in Bryant's traction. The nurse is aware that planned interventions should focus on assessing for what major complication? 1. Infection at the pin sites. 2. Slipping counter traction. 3. Neurovascular impairment. 4. Skin breakdown and decubiti.

3. Correct: Bryant's traction is a type of skin traction with the potential for several complications. Though the traction is important, this child is being treated for a fractured femur. The major complication with any fracture is neurovascular integrity. Nursing assessment priority is neurovascular assessment, including areas such as pulses, sensation, motor function, edema, skin temperature and capillary refill in bilateral toes. 1. Incorrect: Bryant's traction is a type of skin traction, not skeletal traction. Skin traction is non-invasive so there are no pin sites or invasive wires. 2. Incorrect: Any type of traction has the potential for slippage of knots since the pulley weights are attached by ropes or held by tape to skin. While the nurse needs to frequently verify those attachments are secure, loss of counter traction is not the worst complication. 4. Incorrect: Because the client is kept supine in this traction, there is a high potential for skin breakdown to the buttocks or sacral area. Special interventions are required to prevent development of decubiti for clients in Bryant's traction.

A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure? Elevate head of bed to Fowler's position. Measure distal NG tube from nose tip to earlobe to xiphoid process. Lubricate 2-3 inches (5.08-7.62 cm) of distal NG tube. Insert NG tube into unobstructed naris. Advance NG tube upward and backward. Rotate catheter and pass the tube into nasopharynx. Have client swallow ice as NG tube advances into stomach. Secure NG tube.

First, raise the client's head of bed to fowler's position Second, measure the distal NG tube from the nose tip to the earlobe to the xiphoid process. Third, lubricate 2-3 inches (5.08-7.62 cm) of the distal NG tube. Fourth, insert the NG tube into unobstructed naris. Fifth, advance NG tube upward and backward. Sixth, rotate catheter and advance into nasopharynx. Seventh, have client swallow ice to pass the NG tube into the stomach. Eighth, secure the NG tube. During this process, the tube is advanced past the nasopharynx. The client is then asked to take sips of water or swallow ice chips to help with tube advancement into the stomach. Finally, the tube is taped once placement is assured. The core issue of the question is knowledge of the insertion procedure for a nasogastric tube. Use nursing knowledge to sequence the steps that the nurse needs to take. Visualize the procedure to aid in answering the question.

A client diagnosed with ulcerative colitis has a new prescription for a biologic agent. What is the priority education the nurse needs to make certain the client receives? 1. If you miss a dose, take it as soon as you remember. 2. Stay away from people who are sick. 3. Do not receive a live vaccine while using a biologic agent. 4. Common side effects include headache and cold symptoms.

2. Correct: Biologics are immunomodulators which means that they alter the body's immune response. Since these agents can suppress the immune system, making the client more prone to infection. Biologics are used to treat many inflammatory conditions, such as ulcerative colitis, rheumatoid arthritis, and psoriatic arthritis. They can also be used in adults and children to treat Crohn's disease or juvenile idiopathic arthritis. 1. Incorrect: If the client misses a dose of the medicine, they should take it as soon as they remember, and then go back to your regular injection schedule. Do not use extra medicine to make up the missed dose. But this is not the priority at of the options available. 3. Incorrect: Although clients taking a biologic agent should not receive a "live" vaccine, this is not the priority. The vaccine may not work as well during this time, and may not fully protect the client from disease. Live vaccines include measles, mumps, rubella (MMR), polio, rotavirus, typhoid, yellow fever, varicella (chickenpox), or zoster (shingles). 4. Incorrect: Common side effects do include headache and cold symptoms. However, is this the priority for client education? No.

Which statement made by a client diagnosed with Addison's disease indicates to the nurse that the client needs further teaching about fludrocortisone therapy? 1. "Taking my medicine at night will help me sleep." 2. "It is important to wear a medical alert bracelet all of the time." 3. "My medication dose may change based on my daily weight." 4. "I may need more medication if I feel weak or dizzy."

1. Correct: Steroids can cause insomnia so the client does not need to take the medication prior to going to bed. 2. Incorrect: This is a correct statement of understanding by the client. Wearing a medical alert bracelet is an excellent way of informing healthcare providers of a life threatening condition if the client is unable to verbalize that information. 3. Incorrect: Another correct statement. Steroid therapy is adjusted according to the client's weight and signs of fluid volume status. 4. Incorrect: This statement indicates that the client understands therapy. Signs of being undermedicated include weakness, fatigue, and dizziness. The client will need to report these symptoms so more medication can be given to the client.

After a cholecystectomy, a client experiences palpitations, weakness and diarrhea following meals. Which teachings would be appropriate for the nurse to provide the client? 1. Avoid drinking liquids with meals. 2. Increase high sugar foods as they are well tolerated. 3. Take adequate vitamins, iron and calcium. 4. Lie down on right side after meals. 5. Eat at least six small meals per day.

1., 3., & 5 Correct: Dumping syndrome is associated with meals having a hyperosmolar composition. To decrease hyperosmolar components, you decrease the carbs and electrolytes. You should avoid fluids with meals because they increase the size of the food bolus. Vitamins, iron, and calcium may become depleted after stomach surgery and due to dumping syndrome so taking these will help to maintain good health. Small frequent meals decrease the extremes of the hyperosmolar content and keep a steady blood sugar level. 2. Incorrect: High sugar foods and carbs speed through the GI tract. Fats and proteins digest slower and stay in the stomach longer. 4. Incorrect: Lying down on the left side slows emptying of the stomach. Lying on the right side will speed up emptying and make the symptoms worse. Sit upright for 30-60 minutes after eating.

An occupational health nurse is planning to teach a group of manufacturing workers how to prevent back injuries. What teaching points should the nurse plan to include? 1. When sitting, keep knees slightly lower than the hips. 2. Avoid movements that require spinal flexion with straight legs. 3. Squarely face the direction of anticipated movement. 4. Pivot to turn while holding an object. 5. Wear comfortable, low-heeled shoes.

2., 3., 4., & 5. Correct: Flexion of the spine with the legs straight (toe-touches, sit-ups) can injure the back. Avoid twisting of the back by squarely facing the direction of movement. Move toward or away from your center of gravity. Pivoting is a technique in which the body is turned in a way that avoids twisting of the spine. Comfortable, low heeled shoes provide good foot support and reduce the risk of slipping, stumbling, or turning your ankle. 1. When sitting, keep knees slightly higher than the hips.

A client arrives to the emergency department after an altercation resulting in a knife wound to the abdomen. The nurse makes the following observation. Which intervention should the nurse perform? 1. Place the client in trendelenburg position. 2. Instruct the client to lie quietly in a low Fowler's position. 3. Apply abdominal binder to gently place the intestines back in the abdominal cavity. 4. Cover exposed intestine with sterile dressings moistened with sterile saline. 5. Notify the surgeon at once.

2., 4. & 5. Correct: Low Fowler's position and staying calm and quiet help to minimize protrusion of body tissues. Cover exposed intestines with sterile dressings moistened with sterile saline solution. Have someone notify the surgeon at once and you stay with the client and stay calm. 1. Incorrect: The client should be placed in the low Fowler's position and instructed to lie quietly. These actions minimize protrusion of body tissues. 3. Incorrect: Never push eviscerated abdominal contents back! And do not apply pressure with an abdominal binder. This client needs to go back to surgery.

A client has been admitted with advanced cirrhosis. The nurse's assessment reveals an abdominal girth increase of 5 inches (12.7 cm) and a weight increase of 6 lbs. (2.72 kg) since yesterday's measurements. Based on this data, what would be the nurse's priority assessment? 1. Stool for occult blood 2. Ammonia blood level 3. Blood pressure 4. Level of consciousness

3. Correct: In ascites, the client is in FVD and we worry about shock. If my blood pressure drops, I will have decreased perfusion of my vital organs. Poor perfusion leads to organ damage and failure. 1. Incorrect: We are worried about bleeding because the liver is sick, but this is not the first priority in this case. Third spacing (ascites) has increased placing the clietn at risk for FVD and shock. 2. Incorrect: Ammonia level would indicate a worsening liver condition, but this is not a priority here. 4. Incorrect: LOC is a good indicator of perfusion, but it may be affected by other factors, such as the ammonia level, as well. The BP will tell us the most about shock, and that is what I am worried about here.