HESI PN Module Exam 10
A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which potassium reading does the nurse associate this finding? A) 3.1 mEq/L B) 4.2 mEq/L C) 4.5 mEq/L D) 5.4 mEq/L
A) 3.1 mEq/L Rationale: A serum potassium level below 3.5 mEq/L is indicative of hypokalemia, the most common electrolyte imbalance, which is potentially life-threatening. ECG changes in hypokalemia include peaked P waves, flat T waves, a depressed ST segment, and prominent U waves. Readings of 4.5 mEq/L and 4.2 mEq/L are normal potassium levels; 5.4 mEq/L indicates hyperkalemia.
A nurse is working in the emergency department. Which client should be assessed first? A) A client with new onset dizziness B) A client admitted with a recent ear injury C) A client who has been experiencing nausea and vomiting for 12 hours D) A client with new-onset atrial fibrillation with a rate of 118
D) A client with new-onset atrial fibrillation with a rate of 118 Rationale: The client with new-onset atrial fibrillation is at risk for complications associated with the tachydysrhythmia. This dysrhythmia may result in decreased cardiac output because of ineffective atrial contractions. Thrombi form in the atria as a result of the pooling of blood. All of the other clients will require the nurse's attention, but the client who requires immediate attention and is the most hemodynamically unstable is the one with atrial fibrillation.
A client arrives at the emergency department with complaints of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first? A) Administration of normal saline solution B) Administration of IV glucocorticoid C) Administration of pain medication to relieve the client's headache D) Administration of a subcutaneous injection of epinephrine (Adrenalin)
A) Administration of a subcutaneous injection of epinephrine Rationale: Once airway has been established, the client would be given subcutaneous epinephrine. IV corticosteroids and IV fluids may also be prescribed. Pain medication may or may not be prescribed.
The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction? A) "I need to keep the sun off the radiation site." B) "I can use OTC cortisone cream on the radiation site if it gets red." C) "I need to be careful not to wash off the marks that the radiologist made on my skin." D) "I need to wash the skin at the radiation site with a mild soap and water and pat it dry."
B) "I can use OTC cortisone cream on the radiation site if it gets red." Rationale: The client should use no powders, ointments, lotions, or creams on the skin at the radiation site unless they have been prescribed by the health care provider. Avoiding sun exposure of the radiation site, not removing marks made on the skin by the radiologist, and washing the skin with mild soap and water and patting it dry are all correct measures. The client should also be instructed to avoid using harsh detergents to wash clothing.
A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client makes which statement? A) "It's important for me to drink a lot of fluids." B) "A fad diet or starvation diet can cause an acute attack." C) "I don't need medication unless I'm having a severe attack." D) "Physical and emotional stress can cause an attack."
C) "I don't need medication unless I'm having a severe attack." Rationale: Treatment of gout includes both nutrition and medication therapy. The client should be encouraged to limit the use of alcohol and reduce the consumption of foods high in purines. Such foods include sardines, herring, mussels, liver, kidney, goose, venison, and sweetbreads. Medication therapy is a primary component of management for clients with gout, and the health care provider normally prescribes a medication that will promote uric acid excretion or reduce its production. Fluid intake is important in preventing the development of uric acid stones. Fad or starvation diets can precipitate an acute attack because of the rapid breakdown of cells they induce. Excessive physical and emotional stress can exacerbate the disease.
The nurse is participating in a care planning conference for a patient with acquired immunodeficiency syndrome (AIDS). What is the nurse's highest priority in providing care to this client? A) Providing emotional support to the client B) Discussing the cause of AIDS with the client C) Instituting measures to prevent infection in the client D) Identifying risk factors related to contracting AIDS with the client
C) Instituting measures to prevent infection in the client Rationale: The client with AIDS has inadequate immune bodies and is at risk for infection. The priority nursing intervention is protecting the client from infection. The nurse would also provide emotional support to the client. Discussing the cause of AIDS and the ways in which AIDS is contracted are not priority interventions.
A nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver? A) 15 B) 30 C) 50 D) 100
D) 100 Rationale: In an infant or child, the rate of chest compressions is at least 100/min.
The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression/ventilation ratio is correct? A) 15:1 B) 15:2 C) 20:2 D) 30:2
D) 30:2 Rationale: A 30:2 ratio of compressions to ventilations is recommended for CPR in adults. The other options are incorrect.
A nurse is assessing a client with a diagnosis of acquired immunodeficiency syndrome (AIDS) for signs of Pneumocystis jiroveci infection. Which sign of the infection is the earliest manifestation? A) Fever B) Dyspnea C) Dyspnea on exertion D) Nonproductive cough
D) Nonproductive cough Rationale: The client with P. jiroveci infection usually has a cough as the first symptom, which begins as nonproductive then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.
A client has just had a plaster leg cast applied, and the nurse has given the client instructions on cast care. Which statement by the client indicates the need for further instruction? A) "I may feel cool while the cast is drying." B) "I shouldn't use anything to scratch underneath the cast." C) "If I smell any odor from the cast, I should call the doctor." D) "I can dry the cast faster if I use a hairdryer on the hot setting."
D) "I can dry the cast faster if I use a hairdryer on the hot setting." Rationale: Using a blow dryer on the hot setting to dry the cast is not advised because it may burn the client's skin under the cast and crack the cast. While the cast is still damp, the client may feel cold and may experience a decrease in body temperature. The client should never insert any item under the cast because of the risk skin compromise. An odor coming from the cast could indicate the presence of infection, warranting health care provider notification.
A nurse enters a client's room and finds the client unconscious. The nurse quickly determines that the client is not breathing. Which action does the nurse take first? A) Beginning chest compressions B) Checking the client's pulse oximetery reading C) Placing an oxygen mask on the client D) Counting the client's carotid pulse for 15 seconds
A) Beginning chest compressions Rationale: According to the American Heart Association, detecting a pulse may be difficult. The health care provider should take not more than 10 seconds to check for a pulse; if the rescuer does not definitely feel a pulse within that period, he or she should start chest compressions. The acronym CAB (circulation, airway, and breathing) is used to prioritize the steps of cardiopulmonary resuscitation (CPR). Effective chest compressions are essential for providing blood flow during CPR. To provide effective chest compressions, the provider must push hard and fast. Current guidelines for CPR call for the initiation of compressions before ventilations. Oxygen may be helpful at some point, but the airway is opened before the administration of oxygen. Checking the client's pulse oximetry reading delays implementation of lifesaving measures.
A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client's personal care items in which manner? A) Within the client's reach on the left side B) Within the client's reach on the right side C) Just out of the client's reach on the left side D) Just out of the client's reach on the right side.
B) Within the client's reach on the right side Rationale: Unilateral neglect is unawareness of one side of the body. The client behaves as if that part is not there. It is possible for the client to relearn to look for and to move the affected limb(s). Therefore in this condition the client's personal care items are placed within the client's reach on the right side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. This reduces client frustration and aids in ensuring client safety because the client does not have to strain and reach for needed items. The nurse adapts the client's environment to the deficit by focusing on the client's unaffected side and by placing the client's personal care items on the affected side within reach.
A nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly notes that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next? A) Use the AED B) Stop resuscitation efforts C) Perform CPR until emergency medical services arrives D) Check for a pulse for 30 seconds before continuing CPR
A) Use the AED Rationale: Basic components of CPR include immediate recognition of the sudden cardiac arrest (unresponsiveness and absence of normal breathing) and activation of the emergency response system, early CPR, and rapid defibrillation with the use of an AED.
A nurse is participating in a care planning session for a client with a sealed radiation implant. Which stipulation does the nurse expect to see included in the plan? A) Visitors must be limited to 1/2 hour per day B) Visitors must remain at least 2 feet from the client C) A dosimeter badge must be placed on the client's bedside stand D) The client may be maintained in a semiprivate room as long as the client uses a commode
A) Visitors must be limited to 1/2 hour per day Rationale: The nurse would limit each visitor to a half-hour per day and be sure that visitors remain at least 6 feet from the radiation source. The nurse would wear the dosimeter badge when caring for the client. The dosimeter badge measures an individual's exposure to radiation and should be used by only one individual. The dosimeter badge is not left in the client's room. The client is assigned to a private room with a private bath to keep other clients from being exposed to radiation.
A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client's blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, the nurse takes which immediate action? A) Suctions the client B) Contacts the HCP C) Obtains a pulse oximeter D) Increases the rate of the client's IV solution
B) Contacts the HCP Rationale; In the immediate postoperative period, the nurse assesses the client for signs of bleeding. A drop in blood pressure and an increase in pulse are indicators of bleeding. The health care provider is notified immediately if either of these events occurs. Suctioning is performed to remove secretions that cannot be expectorated by the client. Increasing the rate of the client's IV solution is not done without a health care provider's prescription. A pulse oximeter may be needed, but this is not the action to be taken immediately.
A nurse is reviewing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. The nurse reinforces which information? A) Sit in soft, deep chairs B) Rock back and forth to start movement C) Exercise in the evening to combat fatigue D) Perform tasks with only the hand that has the tremor
B) Rock back and forth to start movement. Rationale: The client with Parkinson disease should rock back and forth to initiate movement with bradykinesia (slowed movement). The client should avoid sitting in soft, deep chairs to prevent rigidity and because they are difficult to get up from. The client should exercise in the morning, when the energy level is at its highest. The client with a tremor is instructed to use both hands to accomplish a task.
A client who is recovering from a brain attack (stroke) has residual dysphagia. Which measure does the nurse plan to implement at mealtimes? A) Giving the client thin liquids B) Thickening all liquids served C) Giving foods that are primarily liquid D) Placing food in the affected side of the client's mouth
B) Thickening all liquids served Rationale: The client with dysphagia may be started on a diet once the gag and swallow reflexes have returned. Liquids should be thickened to help prevent aspiration. Food is placed on the unaffected side of the mouth. The client is assisted with meals as needed and is given ample time to chew and swallow.
A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client's request? A) Short walks are OK B) You need to stay in your room for now. C) Yes, it's fine to take a walk around the nursing unit D) Do you think that a walk around the unit will tire you out?
B) You need to stay in your room for now Rationale: The client with a sealed radiation implant must remain in a private room to keep others from being exposed to radiation. The other options are all incorrect.
A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which of the following clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply. A) Paresthesias B) Muscle weakness C) Increased urine output D) Chvostek sign E) Hyperactive deep tendon reflexes
B, C Rationale: Signs of hypercalcemia include muscle weakness, diminished deep tendon reflexes or an absence thereof, increased urine output, decreased gastrointestinal motility, and increased heart rate and blood pressure. Hyperactive deep tendon reflexes, the presence of the Chvostek sign, and paresthesias are signs of hypocalcemia.
A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mg/dL. Which assessment findings does the nurse expect to note? Select all that apply. A) Hypotension B) Abdominal distention C) Trousseau sign D) Skeletal muscle weakness E) Decreased deep tendon reflexes
B, C Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL reflects hypomagnesemia. Assessment signs include hypertension; gastrointestinal manifestations such as anorexia, nausea, abdominal distention, and decreased bowel sounds; shallow respirations; neuromuscular manifestations such as twitches, paresthesias, hyperreflexia, and the Trousseau and Chvostek signs; and irritability and confusion.
A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. A) Decreased Pulse B) Decreased urine output C) Increased BP D) Increased RR E) Decreased respiratory depth
B, D Rationale: A client with dehydration has an increased depth and rate of respirations. The diminished fluid volume is perceived by the body as a decreased oxygen level (hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other assessment findings in insufficient fluid volume are decreased urine volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. Increased blood pressure, decreased pulse, and increased urine output occur with fluid-volume overload.
A nurse provides instructions to a client with rheumatoid arthritis about joint exercises that are important to prevent deformity and reduce pain. Which statement by the client indicates the need for further instruction? A) "I should always maintain good posture." B) "I should stop my exercises if I get tired." C) "I should avoid all exercise when my joints are inflamed." D) "Doing ROM exercises every day will ease the pain."
C) "I should avoid all exercise when my joints are inflamed." Rationale: The client should avoid activities (other than gentle range of motion) when the joints are inflamed. Isometric exercises are also helpful when the joints are inflamed. Daily range-of-motion exercises are an important component of the program and will help relieve pain, but the client should exercise only to the point of fatigue or discomfort. All clients are taught to maintain good posture.
A nurse arrives at the scene of a client experiencing a cardiac/respiratory arrest and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest to which depth? A) 1 inch B) 1 1/2 inches C) 2 inches D) 4 inches
C) 2 inches Rationale: When CPR is being performed on an adult, the sternum should be depressed at least 2 inches (5 cm). The other options are incorrect because they are too shallow to be effective or are too deep, which can cause damage to internal organs. The rescuer should allow complete recoil of the chest after each compression to allow the heart to fill completely before the next compression.
A nurse is assigned to care four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment? A) A client admitted with pneumonia with a fever of 100°F and some diaphoresis B) A client with congestive heart failure with clear lung sounds on the previous shift C) A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema D) A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms
C) A client with new-onset of shortness of breath and history of pulmonary edema Rationale: The client who should be seen first is the one with SOB and a history of pulmonary edema. In light of such a history, SOB could indicate that fluid-volume overload has once again developed. The client with a fever and who is diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid through the skin, but this client is not the priority.
A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse interprets this as an expected finding in the client with? A) Diarrhea B) Wound drainage C) Addison disease D) Heart failure being treated with loop diuretics
C) Addison disease Rationale: A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia, and the nurse would report the finding to the health care provider. Adrenal insufficiency (Addison disease) is a cause of hyperkalemia. Other common causes of hyperkalemia include tissue damage, such as that in burn injuries, renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or wound drainage or the client being treated with diuretics is at risk for hypokalemia.
A nurse is reviewing the medical records of the clients for the assigned 7 a.m.-7 p.m. shift. Which client will the nurse monitor most closely for excessive fluid volume? A) A 48yo client receiving diuretics to treat hypertension B) A 35yo client who is vomiting undigested food after eating C) An 85yo client receiving IV therapy at a rate of 100 mL/hr D) A 65yo client with an NG tube attached to low suction following partial gastrectomy
C) An 85yo client receiving IV therapy at a rate of 100mL/hr Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk for excessive fluid volume because of the diminished cardiovascular and renal function that occur with aging. Other causes of excessive fluid volume include renal failure, heart failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. A client who is receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at risk for deficient fluid volume.
A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly arrives at the bedside and notes that the client is diaphoretic, his blood pressure has increased, and his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client's bed and takes which immediate action? A) Documents the event B) Notifies the HCP C) Checks the client's bladder for distention D) Checks to see whether the client has a prescription for an antihypertensive
C) Checks the client's bladder for distention Rationale: Autonomic dysreflexia is an emergency that occurs as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A variety of stimuli may trigger this response, including a distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (as a result of constipation or impaction); or stimulation of the skin. When autonomic dysreflexia occurs, the client is immediately placed in a sitting position to lower the blood pressure. The nurse then performs a rapid assessment to identify and alleviate the cause. The client's bladder is emptied immediately by way of a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or compromise. The health care provider is notified, and then the nurse documents the occurrence and the actions taken.
A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. The nurse reinforces which client instruction? A) Wear eyeglasses 24 hours a day B) Wear a patch on the affected eye C) Turn the head to scan the lost visual field D) Keep all objects in the impaired field of vision
C) Turn the head to scan the lost visual field Rationale: Homonymous hemianopsia is loss of half of the visual field. The nurse instructs the client to scan the environment to overcome the visual deficit. The nurse encourages the use of personal eyeglasses to improve overall vision, but it is not necessary to wear the glasses 24 hours a day. The client should keep objects in the intact field of vision whenever possible. An eye patch is of no use because the client does not have double vision.
A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. A) Slow pulse B) Decreased urine output C) Skeletal muscle weakness D) Hyperactive bowel sounds E) Hyperactive deep tendon reflexes
C, D Rationale: Signs of hyponatremia include a rapid, thready pulse; skeletal muscle weakness; diminished deep tendon reflexes; abdominal cramping and hyperactive bowel sounds; increased urine output; headache; and personality changes. The nurse must assess these changes from baseline. If muscle weakness is detected, the nurse should immediately check respiratory effectiveness because ventilation depends on strength of the respiratory muscles.
An emergency department (ED) nurse receives a telephone call from emergency medical services and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first? A) Inserting a Foley catheter B) Initiating an intravenous (IV) line C) Cleansing the burn wound D) Administering 100% humidified oxygen
D) Administering 100% humidified oxygen Rationale; When a victim who sustains a burn injury arrives at the ED, breathing is assessed, a patent airway is established, and the client is given 100% humidified oxygen. Inserting a Foley catheter, initiating an IV line, and cleansing the burn wound are also components of the plan of care for a burned client, but these are not the immediate actions.
A nurse attending a recertification course in basic life support (BLS) for health care professionals is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant's pulse? A )Neck B) Wrist C) Behind the knee D) Antecubital fossa of the arm
D) Antecubital fossa of the arm Rationale: An infant's pulse should be checked at the brachial artery. The relatively short, fat neck of an infant makes palpation of the carotid artery (neck) difficult. Palpation of the pulse in the radial (wrist) and popliteal (behind the knee) area would also be difficult.
A client who sustained a fracture of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves which step? A) Administering a local anesthetic to the fractured arm B) Soaking the left arm in a warm-water bath for 2 hours before cast application C) Debriding any open wounds and applying antibiotic ointment before the cast material is applied D) Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material
D) Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material Rationale: o apply a cast, the skin is washed and dried well, but it is not soaked in a warm-water bath. Padding is applied and a stockinette is placed smoothly and evenly over the area to be casted. The plaster is then rolled onto the padding and the edges are trimmed or smoothed as needed. Local anesthesia of the fractured extremity is not necessary, although an analgesic may be administered to alleviate pain. A local anesthetic will block nerve sensation, and it is important for the client to be able to report any changes in sensations after the cast is applied. If the client has open wounds on the fractured extremity, a window will be cut in the cast to allow visualization and treatment of the wound. A wound would not be covered with cast material.
Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse expect to see included in the plan of care? A) Assessing the pin sites at least every 8 hours B) Removing the traction weights to provide skin care C) Applying lanolin to the skin of the right leg once per shift D) Checking the skin integrity of the right leg at least every 8 hours
D) Checking the skin integrity of the right leg at least every 8 hours Rationale: Buck extension traction is a type of skin traction. It is important with skin traction to inspect the skin underneath at least once every 8 hours for irritation or inflammation. The nurse never releases the weights of traction unless specifically asked to do so by the health care provider. Applying lanolin to the skin could leave the skin slippery, making it difficult to maintain the belt or boot used for the skin traction. There are no pins to care for with skin traction.
A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect? A) Diarrhea B) Dyspnea C) Headache D) Dysphagia
D) Dysphagia Rationale: In general, skin reactions and fatigue may occur with radiation therapy of any site, whereas other side effects occur only when a specific area lies in the treatment field. A client undergoing radiation therapy of the larynx is most likely to experience dysphagia. Diarrhea may occur with irradiation of the gastrointestinal tract. Dyspnea may occur with lung irradiation. Headache may occur with irradiation of the head.
A nurse is providing instructions to a nursing assistant about effective measures for communicating with a hearing-impaired client. The nurse instructs the nursing assistant communicate with the client in which way? A) Raise his voice when talking to the client B) Talk directly into the client's impaired ear C) Be cordial and smile when talking to the client D) Face the client when talking, keeping the hands away from the mouth
D) Face the client when talking, keeping the hands away from the mouth Rationale: To facilitate communication with a client who is hearing impaired, the nurse should speak in a normal tone, not shout or raise the voice. The nurse should speak clearly and directly while facing the client and keep the hands away from the mouth so that the client can read the nurse's lips. It may be helpful for the nurse to move closer to the client and toward the better ear to facilitate communication, but it is not helpful to talk directly into the client's impaired ear. Smiling while talking will make it difficult for the client to lip-read.
A nurse provides home care instructions to a client with a below-the-knee amputation (BKA) about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction? A) "I should wear a sock over my stump." B) "I can wash my leg with a mild soap." C) "I need to check my leg for irritation every day." D) "I'll put lotion on my stump a few times a day."
D) I'll put lotion on my stump a few times a day." Rationale: The client should be instructed to don the prosthesis immediately on arising and to keep it on all day (once the incision has healed completely) to reduce residual limb swelling. "I can wash my leg with a mild soap," "I need to check my leg for irritation every day," and "I should wear a sock over my stump" are correct statements regarding residual limb and prosthesis care. The client should not use any lotions, alcohol-containing powders, or oils on the residual limb unless told to do so by the health care provider. The client should also perform range-of-motion exercises of the joints, as well as strengthening exercises, including the upper extremities, every day.
A health care provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. The nurse should reinforce which client instructions? A) A catheter will be inserted to drain your bladder B) A large intravenous line will be inserted into your chest vein C) This infusion requires use of a large caliber IV tubing D) This medication is diluted in a large bag of IV fluid and infused slowly into your vein
D) The medication is diluted in a large bag of IV fluid and infused slowly into your vein Rationale: Potassium chloride administered IV must always be diluted in IV fluid. Undiluted potassium chloride given IV can cause cardiac arrest. Potassium chloride is never administered as a bolus (IV push) injection; an IV push would result in sudden severe hyperkalemia, which could precipitate cardiac arrest. Although urine output is monitored carefully during administration, it is not necessary to insert a Foley catheter unless this is specifically prescribed. Potassium chloride should be administered with the use of a controlled IV infusion device to avoid bolus infusion and increased risk of cardiac arrest. A central IV line is not necessary; potassium chloride may be administered through a peripheral IV line.
A client with a leg fracture who has been placed in skeletal traction is transported to the orthopedic unit after surgery. Which finding would indicate the need to take action? A) The traction knots are intact B) the traction weights are hanging freely C) The clamps on the traction frame are tight D) The traction ropes are unable to move over the pulleys
D) The traction ropes are unable to move over the pulleys Rationale: After skeletal traction pins are inserted and traction is applied, all ropes, knots, and pulleys are inspected to ensure that they are positioned properly. Traction knots and ropes must be intact and secure. Ropes should move easily over pulleys and weights, and the weights should hang freely at all times. The clamps on the traction frame should be tight.
A nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first? A) Calling the HCP B) Reinserting the implant into the client's vagina C) Picking up the implant with gloved hands and placing it in sterile water D) Using long-handled forceps to place the implant in a lead container
D) Using long-handled forceps to place the implant in a lead container Rationale: A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. If the implant is dislodged, the nurse should pick it up with long-handled forceps and place it in the lead container. Reinserting the implant into the vagina and picking up the implant with gloved hands and placing it in sterile water are both incorrect nursing actions. The health care provider is called after action is taken to maintain the safety of the client.
A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which finding causes the nurse to determine that the client's condition has improved? A) Dyspnea B) 1+ edema in legs C) Moist crackles in the lower lobes of the lungs D) Weight loss of 4 lb in 24 hours
D) Weight loss of 4 lb in 24 hours Rationale: One sign that excessive fluid volume is resolving is loss of body weight. It is important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb (1 liter = 2.2 lb = 1 kg). The other options listed indicate that the client is retaining fluid. Assessment findings associated with excessive fluid volume include cough, dyspnea, rales or crackles, tachypnea, tachycardia, increased blood pressure and bounding pulse, increased central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. These symptoms must be reversed if the fluid-volume excess is to be resolved.
