N405 Exam 1 (Practice Questions)

A client with severe burns over 85% of the body is being transported to the ED. The paramedic tells the nurse over the phone that IV access could not be established in the field. What type of IV device does the nurse anticipate will be ordered upon the client's arrival? A. Intraosseous catheter B. PICC line C. Central line D. Subcutaneous Infusion

A. Intraosseous catheter Intraosseous (IO) therapy allows access to the rich vascular network located in the long bones. Victims of trauma, burns, cardiac arrest, and other life-threatening conditions benefit from this therapy because often clinicians are unable to access these clients' vascular systems for traditional IV therapy. If IV access cannot be obtained within the first few minutes of resuscitation procedures, IO may be attempted. After establishing IO access, efforts should continue to obtain IV access as well.

While assessing a client with Graves disease, the nurse notes that the client's temperature has risen 1° F (1° C). What does the nurse do first? A. Turn the lights down and shut the patient's door. B. Call for an immediate electrocardiogram (ECG). C. Calculate the client's apical-radial pulse deficit. D. Administer a dose of acetaminophen.

A. Turn the lights down and shut the patient's door. (Graves disease --> Hyperthyroidism) A temperature increase of 1° F (5/9° C) may indicate the development of thyroid storm, and the primary health care provider or RRT needs to be notified. But before notifying the provider, the nurse should first take measures to reduce environmental stimuli that increase the risk of cardiac complications. The nurse can then call for an ECG. The apical-radial pulse deficit would not be necessary, and acetaminophen is not needed because the temperature increase is due to thyroid activity. DIF: Applying KEY: Thyroid disorder, Emergency care MSC: Integrated Process: Nursing Process: Planning and Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

The nurse is caring for a client who was camping overnight. The client is vomiting and has severe pain in the left foot. Blood pressure is 90/60, and the left lower leg is swollen and red. For which condition will the nurse assess as the priority? Snakebite Heat exhaustion Altitude sickness Brown recluse spider bite

ANS: A • Effects of snakebite include weakness, nausea, vomiting, hypotension, seizures, coagulopathy, severe pain, and localized tissue swelling or redness. The brown recluse spider produces an ulcerative lesion. Leg pain is not characteristic of altitude sickness or heat exhaustion.

A client at the urgent care reports being stung, but not seeing the stinging insect. The electronic health record indicates a history of allergies to bee stings. What is the appropriate nursing action? Prepare to administer epinephrine IM, oral diphenhydramine, and oxygen. Remove the stinger, apply ice to the sting site, administer oral diphenhydramine. Obtain vital signs, administer oxygen, prepare to administer epinephrine IV. Establish an IV infusion with normal saline, apply heat to the sting site, administer acetaminophen.

ANS: A • Once in a clinical setting, clients with reactions to bee or wasp stings need epinephrine administration IM. An antihistamine such as diphenhydramine or chlorpheniramine is also given. Oxygen administration and continuous cardiac and blood pressure monitoring are also initiated. The nurse will also establish an IV infusion with normal saline solution to support blood pressure. Advanced life support drugs and equipment should be immediately available.

The nurse is caring for a hospitalized client on a medical marijuana plan (MMP) who asks for the nurse to administer cannabis. What is the appropriate nursing action? "You must administer your own cannabis." "Nurses need special training to give cannabis." "I will be right back as soon as I gather up the supplies." "I can take you to the smoking area to provide the drug."

ANS: A • Only the patient or designated caregiver identified through the MMP can administer cannabis. The nurse is correct in stating that only the client (who is lucid) can administer his or her own cannabis. Nurses do not need special training to administer cannabis, as only the client and caregiver are authorized to administer it. The nurse who indicates that he or she is gathering supplies or is taking the client to a smoking area to administer cannabis is in violation of the MMP.

During IV catheter insertion, a client with dehydration reports feeling "pins and needles" in the arm. What is the appropriate nursing response? "Nerve puncture may have occurred." "That is a normal sensation that will go away." "It is likely that the vein I was accessing has collapsed." "That means that the catheter is placed in the appropriate location."

ANS: A • Reports of tingling, feeling "pins and needles" in the extremity, or numbness during the venipuncture procedure can indicate nerve puncture. The procedure should be stopped immediately, the catheter removed, and a new site chosen. Transsection of the nerve can result in permanent loss of function, and local nerve damage can become a chronic systemic pain syndrome.

A client phones the telehealth nurse reporting nausea and development of a throbbing headache while on a climbing expedition. Which teaching will the nurse provide first? Rest to regain strength Drink water to rehydrate Descend to a lower altitude Take acetazolamine if available

ANS: A • The best treatment for altitude sickness is to first descend to a lower altitude. Once that has been accomplished, the client can drink water, rest, and take acetazolamine if available.

A competent patient who has just been diagnosed with a brain tumor and two years to live asks about physician-assisted death (PAD). What is the appropriate nursing response? "It sounds like this is a very scary time for you." "This process is illegal, and I cannot discuss it." "I will not be able to care for you from this point forward." "Your health care provider will have to talk with you about this."

ANS: A • The nurse's role is to assess what the client is saying. Because the client has just been diagnosed, it is likely the client is frightened. The nurse can provide an open-ended statement and then further assess the client's concerns and needs based on the client's response. Although PAD is illegal in some places, it has been legalized in certain states, and legislation is open in other states who are seeking to approve this process. The nurse cannot participate in PAD, but can still (at this time) provide care for the client. Turning the client over to the health care provider without further assessing the client's needs is inappropriate. The client may simply be fearful and need to verbally express concern, or may benefit from therapeutic dialogue which the nurse can provide.

While applying compression stockings and pneumatic compression devices, a client questions the purpose of these devices. What is the appropriate nursing response? "These will help to prevent blood clots." "They make your legs feel more comfortable." "These prevent skin breakdown from immobility." "The use of these right after surgery makes is easier to start to ambulate."

ANS: A • VTE prophylaxis may involve devices and drug therapy, depending on a specific patient's evaluated risk. Devices may be used during and after surgery along with leg exercises and early ambulation to promote venous return.

The oncoming nurse has received report regarding a 79-year-old client with delirium. Which assessment finding does the nurse anticipate may be present? Select all that apply. A. Psychosis B. Bacteria in urine C. Temperature 101.9°F D. Oxygen saturation 89% E. Has been present for 6 months

ANS: A, B, C, D • Delirium is condition with an acute and fluctuating onset (not a long-term condition) that is characterized by inattentiveness, disorganized thinking, and an altered level of consciousness. Psychosis may be present. Infections and poor oxygenation often contribute to delirium. Therefore, psychosis, bacteria in the urine, a fever, and low oxygen saturation may all be anticipated.

To advocate for safe transition in care, for which process will the nurse advocate? Select all that apply. Providing patient history and current assessment information Communicating updates and changes in condition Verbally verifying that the receiving nurse understands the report Using a standardized hand-off communication tool Encouraging the receiving nurse to interrupt to ask questions during report

ANS: A, B, C, D • Patient care quality and safety can be improved during hand-offs all providers of health care follow best practices in providing effective communication. Effective hand-off should reduce human error through adoption of a standardized process for effective hand-off communication. Essential elements of hand-off communication include limited interruptions, interactive opportunities to question and clarify, and the ability to verify information with check-backs and read-backs. Elements of care that should be discussed include patient history, current assessment information, updates, and changes in condition. Use of ambiguous language should be restricted, and medical jargon, confusing terms, and unacceptable abbreviations should be avoided.

• The nurse is delegating a specific client's morning hygiene to a nursing assistant (NA). What teaching will the nurse provide to the NA? Select all that apply. • "Use a soft toothbrush for brushing." • "The client can help by combing hair." • "Fully dry the client's skin after bathing with gentle soap." • "Use an electric razor, not a blade, on facial hair." • "If you have questions, don't hesitate to page me." • "Please let me know how the client tolerates care."

ANS: A, B, C, D, E, F The nurse will observe all of the "rights" (below) of delegation. He or she will give specific information about the task to the NA, provide supervision, and have the NA communicate results back. In this scenario: Right task - hygiene, which is within the NA's abilities Right circumstances - morning, so the timing and circumstances are specific Right person - specific client Right communication - instructions given regarding toothbrushing, fully drying the skin, using a gentle soap and an electric razor. Also explained what the client can do (comb hair). Right supervision - offered to be paged; has asked for report when care is done

As the nurse evaluates a laboratory report for a client scheduled for surgery, which finding requires nursing intervention? Hemoglobin 10.4 g/dL Serum potassium 2.5 mEq/L Serum sodium level 145 mEq/L Fasting blood glucose 110 mg/dL

ANS: B • Although all the laboratory results listed are not within normal ranges, the presence of hypokalemia (normal serum potassium levels should be between 3.0 and 5.5 mEq/L) increases the risk for toxicity if the patient is taking digoxin, slows recovery from anesthesia, and increases cardiac irritability. Potassium problems must be corrected before the surgery.

A client who was in a skiing accident has been diagnosed with paraplegia. Which nursing intervention is appropriate to address the client's psychosocial needs? Contact a spiritual leader to talk with the client. Perform a thorough assessment to determine the client's needs. Ask the family to give the client extra support during this difficult time. Request a prescription for antidepressants from the health care provider.

ANS: B • Assessing the patient is the appropriate way to anticipate psychosocial needs of the client. The nurse should not assume that a spiritual leader is desired by the client without performing the assessment to determine the client's needs and wishes. The nurse should not assume that the family will be of appropriate support without performing a thorough assessment, nor should the nurse assume the client will experience depression. The key to choosing an appropriate intervention is to first assess the situation, and then to design the plan of care accordingly thereafter.

A new nurse is preparing to insert a vascular access device in a client. Which action by the new nurse requires intervention by the experienced nurse? Performing hand hygiene prior to insertion. Preparing for insertion immediately following cleaning with iodophors. Using friction to clean the skin around the insertion site. Clipping the hairs in the preferred insertion area.

ANS: B • Current recommendations call for using friction when cleaning the skin to penetrate the layers of the epidermis. Iodophors such as povidone-iodine require contact with the skin for a minimum of 2 minutes to be effective. Skin should never be shaved before venipuncture, but excessive amounts of hair should be clipped.

The nurse is preparing to discharge a client who has been prescribed an opioid analgesic after knee replacement surgery. What teaching will the nurse provide? A. Do not take with grapefruit juice B. Eat plenty of foods that are high in fiber C. Take entire prescription even if pain is gone D. Only take 1-2 pills to avoid becoming addicted

ANS: B • Opioids inhibit peristalsis in the GI tract. Patients who take opioids frequently become constipated. Interventions such as diet modifications (eating foods high in fiber) and laxative agents may be needed to prevent or minimize the problem of constipation. Grapefruit juice does not interfere with absorption of opioid drugs. The client should take the drug only as prescribed, and should not continue taking the medication if the pain is gone. Although the smallest dose of opioids taken over the shortest amount of time is recommended, the nurse should not tell the client to only take 1-2 pills to avoid addiction. That amount will not foster addiction, and pain may be inadequately managed.

The nurse is caring for four clients. Which client will benefit from palliative care? 69-year old with ovarian cancer and three months to live 74-year old with chronic obstructive pulmonary disease 77-year old who underwent hip replacement surgery after falling 81-year old with end-stage dementia after living with the condition 12 years

ANS: B • Palliative care is both a philosophy of care and an organized, structured system for delivering care for people with serious illness who may not meet hospice eligibility criteria. The desired outcome for palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. Clients with under 6 months to live benefit from hospice care. Clients who have restorative surgery (e.g., hip replacement) and no other comorbid conditions benefit from rehabilitation.

The nurse on a postoperative unit is caring for four clients. Which client does the nurse discuss with the surgeon that may benefit from PCA? A. 37-year old who broke both arms in skiing accident B. 47-year old who underwent bariatric surgery for weight loss C. 59-year-old with temperature of 103° following surgery for bowel obstruction D. 66-year old with cognitive deficit who had hip replacement

ANS: B • The mentally alert patient is the best candidate to receive PCA. When a patient is cognitively impaired or unable to push the PCA button, another method of administration should be considered. In this scenario, the client with both arms broken may not be able to manipulate the PCA pump. The client with the fever is at risk for delirium which would preclude use of PCA. The client with the cognitive deficit is not a candidate for PCA.

The hospice nurse is caring for a Roman Catholic client with lung cancer who is expected to live less than two weeks. When the client requests to be baptized, what is the appropriate nursing response? Perform the act of baptism Contact a priest to visit with the client Ask the client if he or she has been baptized before Request that the family contact the client's spiritual leader

ANS: B • The nurse's role is to act as an advocate for the client. When the client requests some type of spiritual care (e.g., baptism), the nurse will contact the appropriate spiritual authority (e.g., the priest) to honor the client's request. In the Roman Catholic faith, only in emergency circumstances can a layperson baptize an individual; otherwise, baptism is performed by a priest. Asking the client if he or she has been baptized before is not the concern of the nurse. Requesting that the family contact the client's spiritual leader is incorrect, as the family may be grieving during this time of loss also. The nurse can address the client's request by directly arranging for a priest to visit.

The nurse has discussed rehabilitation goals with a client who is recovering from a mild stroke. Which client statement demonstrates understanding of the rehabilitation process? Select all that apply. "I am glad that I will be cured through rehabilitation." "Rehab will help me work to my fullest potential." "This will keep me from having more strokes." "I'll expect to see occupational and physical therapists." "Rehabilitation will focus on my physical needs only."

ANS: B, D • Rehabilitation is the continuous process of learning to live with and manage chronic and disabling conditions. The main outcome of rehabilitation is not curative; however, it is that the client will return to the best possible physical, mental, social, vocational, and economic capacity possible. Rehabilitation does not keep clients from having further health concerns (e.g., strokes), and is not limited to physical needs only. Occupational and physical therapists are part of the large interprofessional team that helps clients rehabilitate.

The nurse is caring for a female client who has been seen at the ED multiple times recently for sexually transmitted infections and various physical concerns. When the client's boyfriend goes for coffee, what is the priority nursing action? Look for tattooing or 'branding' marks. Complete a psychosocial assessment. Ask, "Does anyone you know make you feel unsafe?" Follow agency policy for contacting local authorities to report the concern

ANS: C • After establishing a therapeutic relationship, the nurse should ask the client if she feels unsafe as soon as the boyfriend leaves to get coffee. It is important to obtain information quickly while the client is alone before the boyfriend returns, so that the client can freely express any concerns she has. The nurse can then complete the other portions of the assessment and report, if indicated, to authorities.

The nurse is reviewing the orders for a client with COPD who was admitted for chest pain. Laboratory results indicate reveal mild respiratory acidosis. Which order will the nurse question? Encourage oral fluids Keep head of bed elevated Oxygen therapy at 4 L/min as needed Bedrest with bathroom privileges only

ANS: C • The bedrest order will help the client conserve energy. The upright position (mid-Fowler's to high-Fowler's position) helps increase lung expansion. Increasing fluid intake may reduce the thickness of lung secretions and assist in their removal. Oxygen therapy helps promote gas exchange for clients with respiratory acidosis. However, use caution when giving oxygen to clients with COPD and CO2 retention as evidenced by a high Paco2 level. The only breathing trigger for these clients is a decreased arterial oxygen level. Giving too much oxygen to these clients decreases their respiratory drive and may lead to respiratory arrest.

While performing a history, a client becomes unconscious. What is the priority nursing action? Obtain vital signs. Assess the airway. Contact the ED physician. Evaluate the patient's level of consciousness.

ANS: C • The primary survey organizes the approach to the patient so that immediate threats to life are rapidly identified and effectively managed. The primary survey is based on a standard "ABC" mnemonic with a "D" and "E" added for trauma patients: airway/cervical spine (A), breathing (B), circulation (C), disability (D), and exposure (E). The highest priority intervention is to establish a patent airway. All other actions can be completed after the airway is established.

The nurse is caring for a client with a traumatic brain injury who is currently unconscious. Which rehabilitative nursing intervention is appropriate? Select all that apply. Consult with a recreational therapist. Perform active range of motion exercises. Delegate hygiene care to assistive personnel. Perform turning and repositioning every 1-2 hours. Collaborate with the RDN to assess nutrition needs.

ANS: C, D, E • The client who is unconscious needs full care. The nurse can delegate hygiene care to assistive personnel, and follow up per delegation processes. The client should be turned and repositioned every 1-2 hours to decrease the risk for pressure injuries and compromise of tissue integrity. The nurse will also perform passive (not active) range of motion exercises since the client cannot self-perform these exercises at this time. The nurse will collaborate with the RDN to determine appropriate nutrition needs for the client who currently cannot perform self-feeding. A recreation therapist can be helpful after the client regains consciousness.

The nurse is caring for four clients. Which individual does the nurse identify at highest risk for a cognitive concern? 29-year-old with the common cold and an ankle fracture 40-year-old who just received a tetanus immunization after stepping on a rusty nail 59-year-old with diabetes who is meeting with the registered dietician nutritionist (RDN) 71-year-old who drinks 6 beers daily and had surgery under general anesthesia this morning

ANS: D Risk factors for cognitive concerns include: Advanced age Brain trauma at any age Disease or disorder Environmental exposure to toxins Substance use disorder Genetic disorders Depression General anesthesia (especially older adults) Fluid/electrolyte imbalances In this scenario, the older adult (71 years old) who drinks 6 beers daily (substance use disorder) and had surgery with general anesthesia is at highest risk for developing a cognitive concern. The 29-year old does not have high risk factors, as the common cold is not a high risk disease or disorder. The 40-year old has received treatment for the exposure of a rusty nail. The 59-year old is seeking nutrition support from the RDN. Even having diabetes, this client is not at higher risk than the 71-year old with three risk factors. In this scenario, the older adult (71 years old) who drinks 6 beers daily (substance use disorder) and had surgery with general anesthesia is at highest risk for developing a cognitive concern. The 29-year old does not have high risk factors, as the common cold is not a high risk disease or disorder. The 40-year old has received treatment for the exposure of a rusty nail. The 59-year old is seeking nutrition support from the RDN. Even having diabetes, this client is not at higher risk than the 71-year old with three risk factors.

A client tells the nurse, "I just don't feel like being sexually intimate with my partner anymore." What is the appropriate nursing response? "How often do you expect to have sex?" "Do you not find your partner attractive?" "Would you consider seeing a mental health professional?" "Have you experienced pain or difficulty with intercourse?"

ANS: D The nurse will respond by further assessing the cause of the client's concern. Asking if the client has pain or difficulty with intercourse can help to demonstrate whether a physiologic concern (e.g., dry vaginal membranes that cause pain, or erectile dysfunction) may be the cause of the client's concern. Asking how often the client expects to have sex does not address the client's concern, and asking whether the client finds the partner attractive is inappropriate. It is premature to offer a referral to a mental health professional, because the cause of the client's concern has not been determined.

The nurse is caring for a 69-year old female client with multiple chronic health conditions, who is taking 8 types of drugs. What assessment finding will the nurse prioritize? ALT 30 units/L and AST 20 units/L Hemoglobin 14 g/dL, hematocrit 40% Sodium 140 mEq/L and potassium 4.8 mEq/L Serum creatinine 0.3 mg/dL, creatinine clearance 60 mL/min

ANS: D • All values in this scenario are within normal limits with the exception of the serum creatinine and creatinine clearance. Both of these values are low, indicating that kidney function is impaired. Many drugs are excreted by the kidneys. Renal drug excretion decreases as people age normally. When kidney function is impaired, renal drug excretion is even slower, which can increase the effects of drugs remaining in the body. The nurse will address this assessment finding of low serum creatinine and creatinine clearance, recognizing that polypharmacy can complicate this concern.

The ED nurse receives communication about a major and catastrophic explosion that took place in a local city warehouse. How does the nurse classify this event? Epidemic Pandemic Internal disaster External disaster

ANS: D • An external disaster, like the explosion in this example, is any event outside the health care facility or campus, somewhere in the community, which requires the activation of a facility's emergency management plan. External disasters can be either natural, such as a tornado or hurricane, or technological, such as a biological terror attack. An internal disaster is any event inside a health care facility or campus such as a fire, explosion, or violence that could endanger patients or staff. A pandemic is a general epidemic spread over a wide geographic area.

Which client will the emergency nurse triage as the priority? 21-year old with ankle fracture 33-year old with with vomiting, flank pain, and a history of kidney stones 49-year-old with profound weakness and 103° F fever 59-year-old with sweating, jaw pain, and pain in the left arm

ANS: D • Based on the information provided, the patient experiencing sweating, jaw pain, and left arm pain should be triaged first. Jaw and left arm pain are signs of referred chest pain which may indicate a myocardial infarction—an emergent condition. The emergent triage category implies that a condition exists that poses an immediate threat to life or limb. The urgent triage category indicates that the patient should be treated quickly but that an immediate threat to life does not exist at the moment. Examples of patients who typically fall into the urgent category are those with kidney stones, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temperature greater than 101° F (38.3° C).

Following management of a disaster, a patient care technician tells the nurse, "I keep seeing the faces of people that died when I close my eyes." What is the appropriate nursing response? "The memories will fade eventually; it's just so fresh right now." "Can you take a few days off to rest and try to feel better?" "If we just lean on each other, we will get stronger and get through this." "I will go with you to the occupational nurse who can help you explore your feelings."

ANS: D • Critical incident stress debriefing addresses post-crisis interventions for small to large groups, including communities. After working through the turmoil and the emotional impact of the incident as well as the aftermath, the staff may find it difficult to "get back to normal." Without intervention during and after the emergency, they may develop acute stress disorder (ASD) or post-traumatic stress disorder (PTSD) with multiple characteristic psychological and physical effects, including flashbacks, avoidance, less interest in previously enjoyable events, and detachment, as well as rapid heart rate and insomnia. Ultimately, professional "burnout" can stem from the inability to cope with the stress effectively. Specially-trained individuals can help the health care team deals with a particularly devastating or disturbing incident.

The nurse is performing triage after a mass shooting in a shopping mall. To which client does the nurse assign a black tag? 21-year-old with confusion 23-year-old with an open femur fracture 26-year-old with uncontrollable anxiety 29-year-old with full-thickness extremity burns

ANS: D • Emergent (class I) patients are identified with a red tag; patients who can wait a short time for care (class II) are marked with a yellow tag; nonurgent or "walking wounded" (class III) patients are given a green tag; and patients who are expected to die or are dead are issued a black tag (class IV). Typical examples of black-tagged patients are those with massive head trauma, extensive full-thickness body burns, and high cervical spinal cord injury requiring mechanical ventilation. The rationale for this decision is that limited resources must be dedicated to saving the most lives rather than expending valuable resources to save one life at the possible expense of many others.

The nurse is caring for a client who is receiving genetic testing results today. Which client statement requires immediate nursing intervention? A. "I am going to share my results with my spouse." B. "I'm getting kind of nervous about hearing the results." C. "I am dialing in my best friend on speaker phone to listen." D. "I don't know what I am going to do if I have the breast cancer gene."

ANS: D • The nurse should always be aware of patient indication that he or she may have a degree of anxiety, psychological instability, or the ability to accomplish self-harm. In the case of a patient undergoing genetic testing, it is important that the patient understand the result and be prepared for possible psychological, social, and/or familial risks. In this scenario, the nurse should immediately intervene to investigate further the patient's statement about not knowing what to do if he or she has the breast cancer gene. All other statements by the client can be addressed after ensuring the client is safe.

What is the appropriate nursing response when a client asks, "Do you think I should have genetic testing"? A. "I would do it so that you have accurate information about your health." B. "Yes, as there is no other way to know what condition you are facing." C. "You will just worry if you have a positive result so I recommend against it." D. "How are you feeling about proceeding with the testing process?"

ANS: D • The nurse should never provide directive information to convince or coerce a client to proceed or halt genetic testing. Rather, the nurse should reflect the question to the patient to allow him or her to continue exploring feelings before making an autonomous decision.

A 21-year-old client presents to the student health center reporting vomiting and diarrhea all night. She has not eaten or drunk in the past 24 hours. Which prescription does the nurse anticipate the health care provider will recommend? IV fluid replacement Drink 8 glasses of water No fluid replacement is needed at this time Oral rehydration therapy with a solution containing glucose and electrolytes

ANS: D • Whenever possible, fluids are replaced by the oral route. When dehydration is severe or life threatening, or the client is not able to tolerate oral fluids, IV fluid replacement is needed. Oral rehydration therapy (ORT) is a cost-effective way to replace fluids for the client with dehydration. Specifically formulated solutions containing glucose and electrolytes are absorbed even when the client is vomiting or has diarrhea.

When assessing a client who smells of alcohol, which question will the nurse ask? Select all that apply. "Do you drink like this often?" "Why were you out drinking tonight?" "Are you telling the truth about drinking?" "Do people annoy you by criticizing your drinking?" "Have you ever tried to cut down on your drinking?" "Have you ever had a drink in the morning to settle your nerves?"

ANS: D, E, F • These three answers are part of the CAGE questionnaire (seen below). Options A, B, and C do not provide useful nor constructive information that can contribute to the proper care of the client. • Have you ever tried to cut down on your drinking? • Have people annoyed you by criticizing your drinking? • Have you ever felt bad or guilty about your drinking? • Have you ever had a drink first thing in the morning to settle your nerves? (eye-opener)

A client reports purchasing a direct-to-consumer genetic/genomic testing (DTC-GT) to the nurse. What teaching will the nurse provide? Select all that apply. This is an excellent way to learn about genetic risk. A health care provider from the DTC-GT will go over results with you. Several DTC-GT companies are approved to provide personal risk information to patients. The company will definitely test for total sequencing of genes. Use caution as receiving incomplete or inaccurate information is possible.

ANS: E (only E) • DTC-GT companies are not regulated regarding the techniques used in for testing to assess for mutations that increase risk for some disorders. The nurse will explain this to the client, and refrain from stating that this is an excellent way to learn about genetic risk. DTC-GTs do not have health care providers that go over results with the client. Only 23andMe Is currently cleared by the FDA to identify personal risk for development of certain specific geneti—based health problems. Very few DTC-GTs test for total sequencing of genes.

Which symptom requires immediate intervention during a hypoglycemic episode? Confusion Anxiousness Hunger Tachycardia

Answer: A Rationale: Glucose is necessary for brain function. Thus confusion is a marker of severe hypoglycemia requiring immediate intervention.

What is a priority intervention for an older female with a history of hyperparathyroidism? Encourage small frequent meals. Implement fall precautions. Provide pain medications as prescribed. Encourage fluid hydration by mouth.

Answer: B Rationale: Manifestations of hyperparathyroidism may present as bone lesions, pathologic fractures, bone cysts, and osteoporosis. Preventing falls is a priority nursing intervention. Fluid hydration may be used to treat hypercalcemia. Small frequent meals can assist with nutritional need.

A 34 your old female is diagnosed with hypothyroidism. Which signs/symptoms with the nurse expect to assess? (select all that apply) 1. Rapid pulse 2. Decreased energy and fatigue 3. Weight gain of 10 pounds 4. Fine, thin hair with hair loss 5. Constipation A. 1,4 B. 2,3,5 C. 1,4,5 D. 2,3,4

Answer: B Rationale: These are symptoms that result from hypothyroidism.

When should a type 1 diabetic patient avoid exercise? When serum glucose is less than 150 During colder months When ketones are present in the urine When emotional stressors are high for the patient

Answer: C Rationale: Exercise should be avoided if ketones are present in the urine. Ketones indicate that current insulin levels are not adequate and that exercise would elevate blood glucose levels.

A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment in event of need to: A. begin total parenteral nutrition B. start a cutdown infusion C. administer tube feedings D. perform a tracheostomy

Answer: D Equipment for an emergency tracheostomy should be kept in the room, in case tracheal edema and airway occlusion occur. The others are not needed in an emergent situation.

For which electrolyte imbalance will the nurse monitor a client with Clostridium difficile infection and significant diarrhea? A. hypocalcemia B. hypokalemia C. dehydration D. hyponatremia

B. Hypokalemia Potassium re-absorption primarily occurs through the renal system. However, approximately 10% of potassium regulation occurs in the gut. Hypokalemia can result when clients experience significant diarrhea.

While monitoring a client with fluid overload, which assessment findings requires immediate nursing intervention? A. Neck Vein Distension B. Presence of crackles in the lungs C. Pitting edema in the feet D. Bounding Pulse

B. Presence of crackles in the lungs. (in terms of emergencies, remember ABC, airway, breathing, circulation) Fluid overload may lead to pulmonary edema and heart failure. Any client with fluid overload, regardless of age, is at risk for these complications. Older adults or those with cardiac problems, kidney problems, pulmonary problems, or liver problems are at greater risk. The presence of crackles in the lungs may be indicative of pulmonary edema, which can occur very quickly and lead to death in clients with fluid overload.

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. What action would the nurse take first? A. Document the finding in the client's chart B. Assess tactile sensation in the client's hands C. Examine the client's feet for signs of injury D. Notify the primary health care provider

C. Examine the client's feet for signs of injury Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse would inspect them for any signs of injury. After assessment, the nurse would document findings in the client's chart. Testing sensory perception in the hands may or may not be needed. The primary health care provider can be notified after assessment and documentation have been completed. DIF: Applying KEY: Diabetes mellitus, Complications MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse is caring for a client with elevated triiodothyronine and thyroxine, and normal thyroid-stimulating hormone levels. What actions does the nurse take? (Select all that apply.) A. Administer levothyroxine B. administer propranolol C. Monitor the apical pulse D. Assess for Trousseau sign E. Initiate telemetry monitoring

C. Monitor the apical pulse E. Initiate telemetry monitoring The client's laboratory findings suggest that the client is experiencing hyperthyroidism. The increased metabolic rate can cause an increase in the client's heart rate, and the client should be monitored for the development of dysrhythmias. Placing the client on a telemetry monitor might also be a precaution. Levothyroxine is given for hypothyroidism. Propranolol is a beta blocker often used to lower sympathetic nervous system activity in hyperthyroidism. Trousseau sign is a test for hypocalcemia. DIF: ApplyingKEY: Thyroid disorder, Diagnostic tests MSC: Integrated Process: Nursing Process: Planning and Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A client with a history of COPD is brought to the ED with respiratory depression. What acid-base imbalance does the nurse anticipate? A. Metabolic Alkalosis B. Respiratory Alkalosis C. Respiratory Acidosis D. Metabolic Acidosis

C. Respiratory Acidosis Respiratory acidosis results when respiratory function is impaired and the exchange of oxygen (O2) and carbon dioxide (CO2) is reduced. This problem causes CO2 retention, which leads to the same increase in hydrogen ion levels and acidosis

A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? A. 19-year-old Caucasian B. 22-year-old African American C. 44-year-old Asian American D. 58-year-old American Indian

D. 58-year-old American Indian Diabetes is a particular problem among African Americans, Hispanics, and American Indians. The incidence of diabetes increases in all races and ethnic groups with age. Being both an American Indian and middle age places this patient at highest risk. DIF: Understanding KEY: Diabetes mellitus, Risk factors MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse is caring for a client who has acromegaly. What physical change would the nurse expect to observe? A. Thin, dry skin B. Short height C. Truncal obesity D. Large hands and face

D. Large hands and face The client who has acromegaly has an excess of growth hormone as an adult and therefore has a large musculoskeletal structure that is readily observed. DIF: Remembering KEY: Pituitary disorder/Assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

The nurse is evaluating laboratory assessment data of a client with uncontrolled metabolic acidosis. What finding does the nurse anticipate? A. bicarbonate 38 mEq/L B. PaO2 98 mmHg C. pH 7.40 D. potassium 5.7 mEq/L

D. potassium 5.7 mEq/L Metabolic acidosis is reflected by several changes in ABG values. The pH is low (<7.35). The bicarbonate level is low (<21 mEq/L). The partial pressure of arterial oxygen (Pao2) is normal because gas exchange is adequate. The serum potassium level is often high in acidosis as the body attempts to maintain electroneutrality during buffering.

The nurse is assessing a client who smokes and consumes fast food several times daily. Which assessment finding requires immediate nursing intervention? Cool, pale feet Temperature of 99.9° F Body mass index of 34 Cat allergy that causes shortness of breath

• ANS: A • The client with cool, pale feet may have impaired peripheral perfusion; this should be further assessed immediately. Although the client's temperature is slightly above normal, and the BMI is in the category indicating obesity, these findings can be assessed later. The cat allergy should be further assessed as well, yet this can be deferred until after the perfusion of the distal extremities has been addressed; the question does not indicate that the client is having respiratory difficulty at this time.

• The medical-surgical nurse notices that many clients return often for readmission for heart failure. What is the nurse's appropriate action? • Inform the unit manager of the concern. • Evaluate trends and develop a plan for improvement. • Contact the hospital quality improvement nurse to ask what to do about readmissions. • Give other nurses a journal article that addresses national readmission rates for heart failure.

• ANS: B • To meet the quality improvement competency, nurses are expected to "use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems" (www.qsen.org). Options A, C, and D transfer the nurse's direct involvement in quality improvement processes to other people. The medical-surgical nurse should evaluate trends and develop a plan for improvement, and then share this information with others.

• The nurse is caring for a client with abdominal pain. Which documentation reflects the QSEN competency of Teamwork and Collaboration? • Pain is rated as 7 on 1-10 scale • Maintained on NPO status at this time • Paged for consultation from surgical team • Reviewed nursing literature for best practices

• ANS: C • The nurse practicing with Teamwork and Collaboration has paged for a consultation from the surgical team; this nurse is working with other members of the health care team to provide quality care for the patient. • Evaluating the client's pain on a 1-10 scale reflects providing Patient-Centered Care. • Maintaining the client on NPO status in case surgery is needed reflects providing Safety. • Reviewing nursing literature for best practices reflects Evidence-Based Practice.

• Which nursing statement reflects an awareness of systems thinking? • "My client values spirituality when receiving care." • "I looked at our unit policy to be sure it was evidence-based." • "The care we provide to prevent pressure injuries should work on other units." • "Appropriate documentation enhances continuity of care."

• ANS: C • The nurse who has an awareness of systems thinking looks at the care given to an individual that generates favorable outcomes, and translates that into how it could favorably affect others in a system. The nurse could also look at care that generated favorable outcomes at a systems level, and think about how adopting that into individual care could improve individual outcomes. • Recognizing that a client values spirituality is important at the individual point of care. • Looking at a unit policy to be sure it is evidence-based is practicing evidence-based care. • Documenting appropriately enhances continuity of care at the individual level.