handpicked questions and rationales
116. Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 F orally. Which of the following is the appropriate nursing action? 1. Begin the transfusion as prescribed. 2. Delay hanging the blood and notify the physician. 3. Administer an antihistamine and begin the transfusion. 4. Administer two tablets of acetaminophen (Tylenol) and begin the transfusion.
116. 2 Rationale: If the client has a temperature higher than 100 F, the unit of blood should not be hung until the physician is notified and has the opportunity to give further prescriptions. The physi- cian likely will prescribe that the blood be administered regard- less of the temperature, but the decision is not within the nurse's scope of practice to make. The nurse needs a physician's prescription to administer medications to the client. Test-Taking Strategy: Use the process of elimination. Elimi- nate options 1, 3, and 4 because they all indicate beginning the transfusion. Additionally, options 3 and 4 indicate administering medication to the client, which is not done without a physician's prescription. Review the nursing responsibilities before administering a blood transfusion if you had difficulty with this question.
119. The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should immediately be taken next? 1. Remove the intravenous (IV) line. 2. Run a solution of 5% dextrose in water. 3. Run normal saline at a keep-vein-open rate. 4. Obtain a culture of the tip of the catheter device removed from the client.
119. 3 Rationale: If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein- open rate pending further physician prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravas- cular volume. The nurse would not remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump. Test-Taking Strategy: Note the strategic word next. Knowing that the IV should not be removed assists in eliminating options 1 and 4. Recalling that normal saline, not dextrose, is used when administering a unit of blood will direct you to option 3. Review care for the client experiencing a transfu- sion reaction if you had difficulty with this question.
15. A client is admitted to the hospital after vom- iting bright red blood and is diagnosed with a bleed- ing duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. These clinical manifesta- tions most likely indicate which of the following? ■ 1. An intestinal obstruction has developed. ■ 2. Additional ulcers have developed. ■ 3. The esophagus has become inflamed. ■ 4. The ulcer has perforated.
15. 4. The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in boardlike abdominal rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation. An intestinal obstruction would not cause midepigas- tric pain. The development of additional ulcers or esophageal inflammation would not cause a rigid, boardlike abdomen.
165. The nursing team on an oncology unit con- sists of a registered nurse (RN), a licensed vocational nurse (LVN-LPN), and unlicensed assistive person- nel (UAP). Which client should be assigned to the registered nurse? A 52-year-old client with lung cancer admit- ted for acute dyspnea.
165. 1. Ongoing assessment by the RN is required to evaluate the client with dyspnea to monitor for potential deterioration of the respiratory status. If the RN is the care provider, she will have greater interaction with the individual client. The RN is responsible for assessment of all the clients. The other clients would not be considered unstable, and maintaining a patent airway is always the priority in providing care. Care for the other clients could be assigned safely, according to the abilities of the LVN- LPN and UAP.
21. Postoperative nursing management of the cli- ent following a radical neck dissection for laryngeal cancer requires: Frequent suctioning of the laryngectomy tube.
21. 4. The nurse must maintain patency of the airway with frequent suctioning of the laryngectomy tube that can become occluded from secretions,blood, and mucus plugs. Once the client is hemo- dynamically stable, getting out of bed should be encouraged to prevent postoperative complications. Vital signs should be monitored more frequently in a postoperative client. A swallow study is done at approximately 5 to 7 days after surgery, prior to starting oral intake.
25. The client with a laryngectomy communi- cates to the nurse that he does not want his family to see him. He indicates that he thinks the opening in his throat is disgusting. Which of the following nursing diagnoses would be most appropriate? Vertigo. Bell's palsy. Hypoventilation. Loss of gag reflex. Disturbed body image related to neck surgery.
25. 3. Disturbed body image is the most appropriate nursing diagnosis based on the client's statements at this time. Most clients are concerned about how their family members will respond to the physical changes that have occurred as a result of radical neck surgery. The nurse should allow the client to communicate any negative feelings or concerns that exist because of the surgery. Referral to a support group for laryngectomy clients may be helpful to the client and family members in coping with the changes in their lives. The client's feelings are not related to a knowledge deficit, but rather to a permanent change in physical appearance and functioning. The diagnosis of Disturbed personal identity refers to a client's inability to distinguish self from nonself. Hopelessness may be an issue for
25. A client with advanced ovarian cancer takes 150 mg of long-acting morphine orally every 12 hours for abdominal pain. When the client develops a small bowel obstruction, the physician discontin- ues the oral morphine and begins morphine 6 mg/ hour I.V. After calculating the equianalgesic conver- sion from oral to intravenous morphine, the nurse should: ■ 4.Clarify the order to recommend the initial morphine dose of 4 mg/hour.
25. 4. The conversion ratio for morphine is 10 mg I.V. equals 30 mg oral, or 1:3. The client is receiving 300 mg orally per 24 hours, which is equivalent to 100 mg of I.V. morphine. Morphine 100 mg I.V./24 hours = approximately 4 mg/hour I.V. The effect of the I.V. morphine is quick and the oral morphine should be discontinued prior to starting the I.V. morphine. Morphine at 6 mg or higher are above the initial conversion dose from oral to I.V. and can cause untoward side effects.
26. What areas of education should the nurse provide employees in a factory making products that cause respiratory irritation to reduce the risk of laryngeal cancer? Select all that apply. Smoking cessation concurrent with counseling. Limiting alcohol use.
26. 1, 3. The primary risk factors for laryngeal cancer are smoking and alcohol abuse. Smoking cessation is most successful with a support group or counseling. Heavy drinking should be avoided since the risk increases with amount of alcohol consump- tion. HEPA filters help trap small particles and aller- gens to reduce allergy symptoms and asthma. Poor oral hygiene is not a risk factor, nor is over-using the voice.
28. A client is having a blood transfusion reac- tion. The nurse must do the following in what order of priority from first to last? 1. Notify the attending physician and blood bank. 2. Complete the appropriate Transfusion Reaction Form(s). 3. Stop the transfusion. 4. Keep the I.V. open with normal saline infusion.
3. Stop the transfusion. 4. Keep the I.V. open with normal saline infusion. 1. Notify the attending physician and blood bank. 2. Complete the appropriate Transfusion Reaction Form(s). When the client is having a blood transfusion reac- tion, the nurse should first stop the transfusion and then keep the I.V. open with normal saline infu- sion. Next, the nurse should notify the physician and blood bank, then complete the required form(s) regarding the transfusion reaction.
33. A client has been prescribed allopurinol (Zyloprim) for renal calculi that are caused by high uric acid levels. Which of the following indicate the client is experiencing adverse effect(s) of this drug? Select all that apply. ■ 1. Nausea. ■ 2. Rash. ■ 3. Constipation. ■ 4. Flushed skin. ■ 5. Bone marrow depression.
33. 1, 2, 5. Common adverse effects of allopurinol (Zyloprim) include gastrointestinal distress, such as anorexia, nausea, vomiting, and diarrhea. A rash is another potential adverse effect. A potentially life-threatening adverse effect is bone marrow depression. Constipation and flushed skin are not associated with this drug.
35. A client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should? Warm the solution in the warmer.
35. 4. Solution for peritoneal dialysis should be warmed to body temperature in a warmer or with a heating pad; do not use the microwave. Cold dialysate increases discomfort. Assessment for a bruit and thrill is necessary with hemodialysis when the client has a fistula, graft, or shunt. An indwelling urinary catheter is not required for this procedure. The nurse should position the client in a supine or low Fowler's position.
36. A client has been admitted with acute renal failure. What should the nurse do? Select all that apply. ■ 1. Elevate the head of the bed 30 to 45 degrees. ■ 2. Take vital signs. ■ 3. Establish an I.V. access site. ■ 4. Call the admitting physician for orders. ■ 5. Contact the hemodialysis unit.
36. 1, 2, 3, 4. Elevation of the head of the bed will promote ease of breathing. Respiratory mani- festations of acute renal failure include shortness of breath, orthopnea, crackles, and the potential for pulmonary edema. Therefore, priority is placed on facilitation of respiration. The nurse should assess the vital signs because the pulse and respirations will be elevated. Establishing a site for I.V. therapy will become important because fluids will be admin- istered I.V. in addition to orally. The physician will need to be contacted for further orders; there is no need to contact the hemodialysis unit.
42. The client with an intestinal obstruction con- tinues to have acute pain even though the nasoen- teric tube is patent and draining. Which action by the nurse would be most appropriate? ■ 1. Reassure the client that the nasoenteric tube is functioning. ■ 2. Assess the client for a rigid abdomen. ■ 3. Administer an opioid as ordered. ■ 4. Reposition the client on the left side.
42. 2. The client's pain may be indicative of peri- tonitis, and the nurse should assess for signs and symptoms, such as a rigid abdomen, elevated tem- perature, and increasing pain. Reassuring the client is important, but accurate assessment of the client is essential. The full assessment should occur before pain relief measures are employed. Repositioning the client to the left side will not resolve the pain.
43. Before abdominal surgery for an intestinal obstruction, the nurse monitors the client's urine output and finds that the total output for the past 2 hours was 35 mL. The nurse then assesses the client's total intake and output over the last 24 hours and notes that he had 2,000 mL of I.V. fluid for intake, 500 mL of drainage from the naso- gastric tube, and 700 mL of urine for a total output of 1,200 mL. This would indicate which of the following? ■ 1. Decreased renal function. ■ 2. Inadequate pain relief. ■ 3. Extension of the obstruction. ■ 4. Inadequate fluid replacement.
43. 4. Considering that there is usually 1 L of insensible fluid loss, this client's output exceeds his intake (intake, 2,000 mL; output, 2,200 mL), indicating deficient fluid volume. The kidneys are concentrating urine in response to low circulat- ing volume, as evidenced by a urine output of less than 30 mL/hour. This indicates that increased fluid replacement is needed. Decreasing urine output can be a sign of decreased renal function, but the data provided suggest that the client is dehydrated. Pain does not affect urine output. There are no data to suggest that the obstruction has worsened.
45. The client in acute renal failure has an external cannula inserted in the forearm for hemo- dialysis. Which of the following nursing measures is appropriate for the care of this client? Use the unaffected arm for blood pressure measurements.
45. 1. The unaffected arm should be used for blood pressure measurement. The external can- nula must be handled carefully and protected from damage and disruption. In addition, a tourniquet or clamps should be kept at the bedside because dislodgment of the cannula would cause arterial hemorrhage. The arm with the cannula is not used for blood pressure measurement, I.V. therapy, or venipuncture. Patency is assessed by auscultating for bruits every shift. Heparin is not injected into the cannula to maintain patency. Because it is part of the general circulation, the cannula cannot be heparinized.
51. The client with acute renal failure is recover- ing and asks the nurse, "Will my kidneys ever func- tion normally again?" The nurse's response is based on knowledge that the client's renal status will most likely: ■ 4. Continue to improve over a period of weeks. Result in the need for permanent hemodialysis. Improve only if the client receives a renal transplant.
51. 1. The kidneys have a remarkable ability to recover from serious insult. Recovery may take 3 to 12 months. The client should be taught how to rec- ognize the signs and symptoms of decreasing renal function and to notify the physician if such prob- lems occur. In a client who is recovering from acute renal failure, there is no need for renal transplan- tation or permanent hemodialysis. Chronic renal failure develops before end-stage renal failure.
53. A client with a well-managed ilesostomy calls the nurse to report the sudden onset of abdom- inal cramps, vomiting, and watery discharge from the ileostomy. The nurse should: 4 ADVISE THE CLIENT TO NOTIFY THE PHYSICIAN.
53. 4. Sudden onset of abdominal cramps, vomit- ing, and watery discharge with no stool from an ileostomy are likely indications of an obstruction. It is imperative that the physician examine the client immediately. Although the client is vomiting, the client should not take an antiemetic until the physi- cian has examined the client. If an obstruction is present, ingesting fluids or taking milk of magnesia will increase the severity of symptoms. Oral intake is avoided when a bowel obstruction is suspected.
60. Which of the following should be included in the teaching plan for a cancer client who is expe- riencing thrombocytopenia? Select all that apply. Use an electric razor. Use a soft-bristle toothbrush. Avoid frequent flossing for oral care. Report bleeding, such as nosebleed, petetichiae, or melena, to a health care professional.
60. 1, 2, 3, 6. Thrombocytopenia places the client at risk for bleeding. Therefore, electric razors will reduce the potential for skin nicks and bleeding. Oral hygiene should be provided with a soft tooth- brush and with minimal friction to gently clean without trauma. Clients should be instructed to read labels on all over-the-counter medications and avoid medication such as aspirin or NSAIDs due to their effect on platelet adhesiveness. Clients should evaluate mucous membranes, skin, stools, or other sources of potential bleeding. Monitoring tempera- ture may be an important part of assessment but is focused on neutropenia instead of the problem of thrombocytopenia.
60. When receiving a client from the postanes- thesia care unit after a splenectomy, which should the nurse assess after obtaining vital signs? ■ 1. Nasogastric drainage. ■ 2. Urinary catheter. ■ 3. Dressing. ■ 4. Need for pain medication.
60. 3. After a splenectomy, the client is at high risk for hypovolemia and hemorrhage. The dress- ing should be checked often; if drainage is present, a circle should be drawn around the drainage and the time noted to help determine how fast bleed- ing is occurring. The nasogastric tube should be connected, but this can wait until the dressing has been checked. A urinary catheter is not needed. The last pain medication administration and the client's current pain level should be communi- cated in the exchange report. Checking for hem- orrhage is a greater priority than assessing pain level.
61. A 28-year-old client with cancer is afraid of experiencing a febrile reaction associated with blood transfusions. He asks the nurse if this will happen to him. The nurse's best response is which of the fol- lowing? 1. The client receiving chemotherapy who complains of a loss of appetite. 2. The client who underwent a mastectomy 2 weeks ago who called for information on the Reach for Recovery program. 3. The client receiving spinal radiation for bone cancer metastases who complains of urinary incontinence. 4. The client with colon cancer who has questions about a high-fiber diet.
61. 2. The administration of antipyretics and antihistamines before initiation of the transfusion in the frequently transfused client can decrease the incidence of febrile reactions. Febrile reactions are immune-mediated and are caused by antibodies in the recipient that are directed against antigens pres- ent on the granulocytes, platelets, and lymphocytes in the transfused component. They are the most common transfusion reactions and may occur with onset, during transfusion, or hours after transfusion is completed.
65. A terminally ill 82-year-old client in hospice care is experiencing nausea and vomiting because of a partial bowel obstruction. To respect the client's wishes for conservative management of the nausea and vomiting, the nurse should recommend the use of: ■ 1. A nasogastric (NG) suction tube. ■ 2. I.V. antiemetics. ■ 3. Osmotic laxatives. ■ 4. A clear liquid diet.
65. 4. The use of diet modification is a conservative approach to treat the terminally ill or hospice clients who have nausea and vomiting related to bowel obstruction. Osmotic laxatives would be harder for the client to tolerate. An NG tube is more aggressive and invasive. I.V. antiemetics are also invasive. The hospice philosophy involves comfort and palliative care for the terminally ill.
73. A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications? ■ 1. Deficient fluid volume. ■ 2. Intestinal obstruction. ■ 3. Bowel ischemia. ■ 4. Peritonitis.
73. 4. Complications of acute appendicitis are perforation, peritonitis, and abscess development. Signs of the development of peritonitis include abdominal pain and distention, tachycardia, tachyp- nea, nausea, vomiting, and fever. Because peritonitis can cause hypovolemic shock, hypotension can develop. Deficient fluid volume would not cause a fever. Intestinal obstruction would cause abdomi- nal distention, diminished or absent bowel sounds, and abdominal pain. Bowel ischemia has signs and symptoms similar to those found with intestinal obstruction.
91. The nurse empties a Jackson-Pratt drainage bulb. Which of the following nursing interventions ensures correct functioning of the drain? ■ 1. Irrigating it with normal saline. ■ 2. Connecting it to low intermittent suction. ■ 3. Compressing it and then plugging it to estab- lish suction. ■ 4. Connecting it to a drainage bag and clamping it off.
91. 3. After emptying a Jackson-Pratt drainage bulb, the nurse should compress the bulb, plug it to establish suction, and then document the amount and type of drainage emptied. Irrigating a Jackson- Pratt drain is inappropriate because it could con- taminate the wound. The Jackson-Pratt drain is not usually connected to wall suction. The purpose of the Jackson-Pratt drain is to remove bloody drainage from the deep tissues of the incision; clamping the drain would be counterproductive.