NRN171 Quiz 2 Clinical Decision making and judgement
A client at 39 weeks' gestation calls the OB triage and questions the nurse concerning a bloody mucus discharge noted in the toilet after an OB office visit several hours earlier. What is the best response from the triage nurse? -"It might be nothing. If it happens again call your provider who is on-call." -"If the provider did an exam, it might be just normal vaginal secretions, so don't worry about it." -"A one time discharge of bloody mucus in the toilet might have been your mucus plug." -"Bloody mucus is a sign you are in labor. Please come to the hospital."
"A one time discharge of bloody mucus in the toilet might have been your mucus plug."
Which client statement would lead the nurse to suspect that the client is experiencing bacterial conjunctivitis? -"My eyes feel like they are on fire." -"My eyelids were stuck together this morning." -"It feels like there is something stuck in my eye." -"My eyes hurt when I'm in the bright sunlight."
"My eyelids were stuck together this morning." Burning, a sensation of a foreign body, and pain in bright light (photophobia) are signs and symptoms associated with any type of conjunctivitis. The drainage related to bacterial conjunctivitis is usually present in the morning, and the eyes may be difficult to open because of adhesions caused by the exudate.
The nurse is providing care to a group of terminally ill clients. The client who is most likely experiencing the anger stage of grief is the one who states: "Why did this have to happen to me?" "I do not believe I have this disease." "I just want to see my son have a family of his own." "I don't care about anything. I have no energy."
"Why did this have to happen to me?"
Which client requires priority intervention by a nurse providing care on a medical-surgical unit? -A newly admitted client who is upset due to a new cancer diagnosis -An older adult client who is yelling and angry with family members -A postsurgical client who is feeling dizzy and has a heart rate of 45 beats/min -A client with a blood pressure of 98/40 mm Hg who needs to ambulate to the bathroom
A postsurgical client who is feeling dizzy and has a heart rate of 45 beats/min
A nurse obtained a client's fasting blood sugar (FBS) at 0700, which was 144 mg/dL (8 mmol/L). The client has an order for regular insulin 8 units every morning. What should the nurse do next? -Administer the insulin as ordered. -Hold the insulin due to the FBS result. -Contact the healthcare provider with the FBS result. -Offer the client orange juice and a piece of toast.
Administer the insulin as ordered. The nurse knows that a normal fasting blood sugar is between 72 and 108 mg/dL (4 and 6 mmol/L). The result of 144 mg/dL indicates that the client requires insulin to lower the blood glucose level. The nurse would not hold the insulin dose. Because there is already a prescription for insulin, it is not necessary to contact the healthcare provider at this time. Based on the FBS result, the nurse would administer insulin before offering the client food.
What should a nurse recognize as a property of ibuprofen/Motrin? (Select all that apply.) Anti-inflammatory -Analgesic -Antipruritic -Antipyretic -Antibacterial
Anti-inflammatory Analgesic Antipyretic Like the salicylates, the NSAIDS have anti-inflammatory, antipyretic, and analgesic effects.
A 40-year-old pregnant client tells her nurse that she would like to give birth in a birthing center because she wants several friends and family members to be there and will have more freedom at the center. What would be the most important factor for the nurse to point out when discussing this option with the client? -Birthing centers allow the client to eat and move around during labor. -Birthing centers allow the client to give birth in any position. -Birthing centers do not always have pediatricians on staff if the newborn has special needs. -Birthing centers limit the number of friends and family who can attend the birth.
Birthing centers do not always have pediatricians on staff if the newborn has special needs. With this particular client, the nurse should point out that many birthing centers do not have pediatricians on site. The nurse should include all information related to birthing centers, such as the freedom to eat, move around, and give birth in any position so that the client can make the best decision. Birthing centers do not limit the number of friends and family who can attend the birth.
A client informs the nurse of having abdominal pain that is relieved when having a bowel movement. The health care provider diagnosed the client with irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder? -Weight loss due to malabsorption -Blood and mucus in the stool -Chronic constipation with sporadic bouts of diarrhea -Client is awakened from sleep due to abdominal pain.
Chronic constipation with sporadic bouts of diarrhea Most clients with irritable bowel syndrome (IBS) describe having chronic constipation with sporadic bouts of diarrhea. Some report the opposite pattern, although less commonly. Most clients experience various degrees of abdominal pain that defecation may relieve. Weight usually remains stable, indicating that when diarrhea occurs, malabsorption of nutrients does not accompany it. Stools may have mucus, but blood is not usually found because the bowel is not locally inflamed. The sleep is not disturbed from abdominal pain.
The nurse enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results? -Placement of the probe on an earlobe -Diagnosis of peripheral vascular disease -Reduced lighting in the room -Increased temperature of the room
Diagnosis of peripheral vascular disease Pulse oximetry is a noninvasive method of monitoring oxygen saturation of hemoglobin. A probe is placed on the fingertip, forehead, earlobe, or bridge of nose. Inaccuracy of results may be from anemia, bright lights, shivering, nail polish, or peripheral vascular disease.
A nurse notes that a client's I.V. insertion site is red, swollen, and warm to the touch. Which action should the nurse take first? -Discontinue the I.V. infusion. -Apply a warm, moist compress to the I.V. site. -Check the I.V. infusion for patency. -Apply an ice pack to the I.V. site.
Discontinue the I.V. infusion.
Which source of information helps the nurse formulate nursing diagnoses for a specific client? -Research articles -Essential assessment data -Outcome criteria -Admission criteria
Essential assessment data In the diagnostic phase of the nursing process, the client's nursing problems are defined through analysis of client data. Establishing a plan comes after collecting and analyzing data, evaluating a plan is the last step of the nursing process, and assigning a positive value to each consequence is not done.
A 47-year-old client has been admitted to the hospital after being found unconscious in a park. Upon regaining consciousness, the client admits to heavy alcohol use over many years. Assessment reveals a low body mass index, low electrolyte levels, and impaired skin integrity. Vital signs are within normal ranges. What nursing diagnosis should be prioritized in the care of this client? -Risk for injury related to chronic alcohol intake -Deficient knowledge regarding the effects of alcohol intake -Imbalanced nutrition: less than body requirements related to chronic alcohol intake -Ineffective coping related to effects of chemical use
Imbalanced nutrition: less than body requirements related to chronic alcohol intake
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? -Transient ischemic attack (TIA) -Left-sided cerebrovascular accident (CVA) -Right-sided cerebrovascular accident (CVA) -Completed Stroke
Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
Which positioning strategy should be used for the client diagnosed with hypovolemic shock? -Supine -Modified Trendelenburg -Prone -Semi-Fowler's
Modified Trendelenburg
Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following? -Myopia -Astigmatism -Hyperopia -Emmetropia
Myopia Myopia, or nearsightedness, refers to the condition in which the client can see near objects but has blurred distant vision. Astigmatism is an irregularity in the curve of the cornea, which affects both near and distant vision. Hyperopia, or farsightedness, refers to the client's ability to see distant objects clearly but near objects as blurry. Emmetropia refers to normal eyesight in which the image focuses precisely on the retina.
Which of the following assessments should the nurse perform to determine the development of peptic ulcers when caring for a patient with Cushing's syndrome? -Observe the color of stool. -Monitor bowel patterns. -Monitor vital signs every 4 hours. -Observe urine output.
Observe the color of stool. The nurse should observe the color of each stool and test the stool for occult blood. Bowel patterns, vital signs, and urine output do not help in determining the development of peptic ulcers.
When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? -Contact the surgeon for debridement. -Using sterile technique, debride the wound. -Off-load pressure from the heel. -Place an antiembolism stocking on the client's leg.
Off-load pressure from the heel.
The nurse is caring for an 85-year-old client hospitalized for dehydration. The nurse notices that the client is shivering and takes the client's temperature. The nurse notes an oral temperature of 97.8°F (36.6°C). The client also reports being "chilly." Which nursing action is most appropriate? -Notify the physician. -Offer the client an extra blanket. -Increase the client's oral fluid intake. -Assess the client's respiratory rate.
Offer the client an extra blanket.
The most common cause of cholinergic crisis includes which of the following? -Overmedication -Infection -Undermedication -Compliance with medication
Overmedication
You notify the physician that your client is third-spacing fluid. What orders would you expect the physician to give you? -Restrict fluids -Administer diuretics -Start IV fluids and blood products -Increase sodium in diet
Start IV fluids and blood products This is done by administering IV solutions—sometimes at rapid rates—and blood products, such as albumin, to restore colloidal osmotic pressure. The restriction of fluids; the administration of diuretics and the increase of sodium in the diet are not orders the physician would be expected to give for a client is third-spacing fluids.
A client has been treated for migraine headaches for several months and comes to the clinic reporting no improvement. The nurse is talking with the client and hears an audible click when the client is moving the jaw. What does the nurse suspect may be happening? -Trigeminal neuralgia -Temporomandibular disorder -Loose teeth -Dislocated jaw
Temporomandibular disorder
A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? -Bell's palsy -Trigeminal neuralgia -Migraine headache -Angina pectoris
Trigeminal neuralgia
A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client? -Anxiety or irritability -Hyperactivity -Uncontrolled rhythmic movements of the face or limbs -Dry mouth not relieved by sugar-free hard candy
Uncontrolled rhythmic movements of the face or limbs Metoclopramide is a prokinetic agent that accelerates gastric emptying. Because metoclopramide can have extrapyramidal side effects that are increased in certain neuromuscular disorders, such as Parkinson's disease, it should be used only if no other option exists, and the client should be monitored closely for uncontrolled rhythmic movements of the face or limbs. Metoclopramide side effects are headache, confusion, and drowsiness. Anxiety, hyperactivity, and a dry mouth are not common side effects.
The nurse is teaching a client about cancer prevention. The nurse evaluates teaching as most effective when a female client states that she will -Use sunscreen when outdoors. -Decrease tobacco smoking from one pack/day to half a pack/day. -Exercise 30 minutes 3 times each week. -Obtain a cancer history from her parents.
Use sunscreen when outdoors.
A client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride PO q.i.d. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client is also confused and incontinent, the nurse suspects neuroleptic malignant syndrome. What steps should the nurse take? -Give the client the next dose of fluphenazine, call the physician, and monitor the client's vital signs. -Withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs. -Give the client the next dose of fluphenazine and restrict the client to an empty room to decrease stimulation. -Withhold the client's next dose of fluphenazine, administer an antipyretic agent, and increase the client's fluid intake.
Withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs. Neuroleptic malignant syndrome is a dangerous adverse effect of neuroleptic drugs such as fluphenazine. The nurse should withhold the next dose, notify the physician, and continue to monitor the client's vital signs. Although an antipyretic agent may be used to reduce fever, increased fluid intake is contraindicated because additional fluid may further increase the client's fluid volume, elevating the blood pressure even more.
While standing on the right side of the client, the nurse observes that the client does not respond when spoken to. After assessing the client the nurse charts, "The client's hearing may be impaired on the right side." This statement is an example of: -a cue. -an inference. -duplicate data. -erroneous data.
an inference.
A client is color blind. The nurse understands that this client has a problem with: -rods. -cones. -lens. -aqueous humor.
cones Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid and isn't involved with color perception.
A nurse is caring for an infant born with a cleft lip and palate. The priority of care would address: -malnutrition. -facial appearance. -speech patterns. -repeat occurrences in other pregnancies.
malnutrition The immediate problem in infants with cleft lip and palate is feeding because of their inability to suck to breast-feed or drink from a bottle. The others will be of concern at a later time and are not life threatening.
A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? -postpartum psychosis -postpartum blues -postpartum depression -postpartum panic disorder
postpartum psychosis
A nurse just received a shift report for a group of clients on the telemetry unit. Which client should the nurse assess first? -the client with a history of cardioversion for sustained ventricular tachycardia 2 days ago -the client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block -the client with a history of heart failure who has bibasilar crackles and pitting edema in both feet -the client admitted for unstable angina who underwent percutaneous coronary intervention (PCI) with stenting yesterday
the client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block
The student nurse is learning about pain. The nurse educator asks the student, "Pain is best described as what?" What is the student's most appropriate response? Select all that apply. -neurologic -unpleasant -objective -subjective -visceral
unpleasant subjective The International Association for the Study of Pain defines pain as "a subjective, unpleasant, sensory, and emotional experience associated with actual or potential tissue damage."
Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia? -Implement neutropenic precautions -Eliminate direct contact with others who are infectious -Apply prolonged pressure to needle sites or other sources of external bleeding -Monitor temperature at least once per shift
Apply prolonged pressure to needle sites or other sources of external bleeding For a client with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage. Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for infection.
Which term refers to a method of recording, in graphic form, the electrical activity of a muscle? -Electromyography -Electroencephalography -Electrocardiography -Electrogastrography
Electromyography
At 8:00 a.m. (0800), a nurse assesses a client who is scheduled for surgery at 10:00 a.m. (1000). During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What would the nurse do next? -Check to see that the client had a chest X-ray the previous day as ordered. -Check the client's serum electrolyte levels and complete blood count (CBC). -Immediately notify the health care provider of these findings. Sign the preoperative checklist for this client.
Immediately notify the health care provider of these findings. The nurse would notify the health care provider immediately because dyspnea, a nonproductive cough, and back pain may signal a change in the client's respiratory status. The nurse would then check the results of any ordered tests (such as a chest X-ray, serum electrolyte levels, and CBC) because this information may help explain the change in the client's condition. The nurse would sign the preoperative checklist after notifying the health care provider of the client's condition and learning whether the provider will proceed with the scheduled surgery.
The nurse is aware that sulfonamide therapy is used cautiously in older adults because of decreased function of what organ system? -Splenic -Renal -Hepatic -Pancreatic
Renal
Which medication taken by the client in the previous 24 hours would be of greatest concern to the nurse caring for a client undergoing a bone biopsy? -aspirin -furosemide -digoxin -NPH insulin
aspirin Aspirin has anti-clotting properties, and bone is a very vascular tissue. The client taking aspirin in close proximity to a bone biopsy is at increased risk for excessive bleeding.
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? -uterine atony -uterine prolapse -uterine subinvolution -uterine contraction
uterine atony Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally, the nurse assists the woman with perineal care and applying a new perineal pad.
The nurse recognizes which change of the GI system is an age-related change? -increased motility -hypertrophy of the small intestine -weakened gag reflex -increased mucus secretion
weakened gag reflex A weakened gag reflex is an age-related change of the GI system. There is decreased motility, atrophy of the small intestine, and decreased mucus secretion.
Which client(s) is showing manifestations of infection? Select all that apply. -75-year-old client with temperature 37.3°C (99.2°F), declining mental status, weakness and fatigue -50-year-old client with temperature 36.5°C (97.7°F), heart rate 65 beats/min, fatigue -25-year-old client with temperature 40°C (104°F), sweating, shivering, states generalized pain -5-year-old client with temperature 36.8°C (98.2°F), distracted and irritable -2-month-old client with temperature 38.3°C (100.4°F), lethargy, poor feeding, and cyanosis
-25-year-old client with temperature 40°C (104°F), sweating, shivering, states generalized pain -2-month-old client with temperature 38.3°C (100.4°F), lethargy, poor feeding, and cyanosis -75-year-old client with temperature 37.3°C (99.2°F), declining mental status, weakness and fatigue
Which client has the highest risk of ovarian cancer? -30-year-old woman taking hormonal contraceptives -36-year-old woman who had her first child at age 22 -40-year-old woman with three children -45-year-old woman who has never been pregnant
45-year-old woman who has never been pregnant The incidence of ovarian cancer increases in women who have never been pregnant, are older than age 40, are infertile, or have menstrual irregularities. Other risk factors include a family history of breast, bowel, or endometrial cancer. The risk of ovarian cancer is reduced in women who have taken hormonal contraceptives, have had multiple births, or have had a first child at a young age.
A woman wearing hospital scrubs comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." What will the nursery nurse do next? -Look at the woman's hospital identification badge. -Determine which hospital unit the woman works on. -Inform the woman she cannot transport the baby. -Ask if the client actually sent the woman.
Look at the woman's hospital identification badge. Each member of the hospital staff should have an identification badge clearly displayed. The nursery nurse should look at the badge of the woman who is offering to take Mrs. Smith's baby to her as this is the only way to ensure the nurse is allowing an appropriate person to transport the baby. Education and watchful vigilance are the keys to preventing infant abductions. Each facility that cares for newborns should have specific policies and procedures in place that address this problem. The nurse should review these policies and know the protocols for the facility in which the nurse will be working.
The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next? -Hold the feeding and recheck the residual in 4 hours. -Return the residual and begin the feeding. -Administer an amount of water equivalent to the feeding. -Discard the residual and subtract the residual amount from the feeding.
Return the residual and begin the feeding. The amount of residual is within normal limits, and the client should have the feeding started. The residual should be returned to help prevent electrolyte imbalances. The other options do not ensure adequate nutritional management for the client.
Twenty minutes after a transfusion of packed red blood cells is initiated, a client reports shivering, headache, and lower back pain. The vital signs show a normal temperature and increased pulse and respiratory rate. What should be the first nursing actions? -Stop the transfusion, continue with saline infusion, and notify the physician regarding a suspected hemolytic reaction. -Slow the transfusion, notify the physician regarding a possible febrile reaction, and follow the physician's orders. -Slow the transfusion, give an antihistamine as ordered, and notify the physician regarding a possible allergic reaction. -Stop the transfusion, check the oxygen saturation levels, and check the urine volume.
Stop the transfusion, continue with saline infusion, and notify the physician regarding a suspected hemolytic reaction. Hemolytic reaction is one of the most severe blood reactions, so prompt action to stop the transfusion is very important, followed by ensuring the I.V. access is preserved.
A female HIV-positive patient with a high CD4 count has been taking nevirapine (Viramune) for 9 weeks. What clinical manifestations indicate to the nurse that the patient is having complications from this medication? -Nausea and headache -Yellow sclera and hepatomegaly -Decreased urine output and thirst -Constipation and nausea
Yellow sclera and hepatomegaly Severe, life-threatening and in some cases fatal hepatotoxicity, particularly in the first 18 weeks, has been reported in patients treated with nevirapine. In some cases, patients presented with nonspecific prodromal signs or symptoms of hepatitis and progressed to hepatitis. Female gender and patients with higher CD4 counts at initiation of therapy are increased risk factors for this complication.
A client presented with signs and symptoms of hypothyroidism and subsequent diagnostic testing revealed low levels of thyrotropin-releasing hormone (TRH) and thyroid stimulating hormone. The care team should focus assessments and interventions on the client's: -hypothalamus. -limbic region. -reticular activating system (RAS). -cranial nerves.
hypothalamus The hypothalamus coordinates and initiates many endocrine functions, including thyroid function by the release of TRH. The limbic region primarily regulates emotion and the RAS regulates sleep-wake cycles. The cranial nerves contribute to the special senses and certain motor and sensory functions in the face and neck.
The nurse working in a skilled nursing home is evaluating a client that has completed a 10-day course of antibiotics three days ago for pneumonia. What assessments will the nurse need to notify the healthcare provider about? Select all that apply. -cough with phlegm -clear breath sounds -pulse oximetry reading of 96% -change in level of consciousness -tympanic temperature 98.2°F (36.8°C)
-cough with phlegm -change in level of consciousness A change in the level of consciousness and a cough with phlegm are abnormal assessments related to pneumonia. Clear breath sounds, pulse oximetry reading of 96%, and tympanic temperature 98.2°F (36.8°) are normal assessments indicating that the antibiotic may have helped manage the pneumonia symptoms.
The nurse is caring for a client with a central venous catheter. Suddenly, the client reports chest and shoulder pain and is having difficulty breathing. The nurse suspects the client is having an air embolism. The nurse would implement which interventions? Select all that apply. -Elevate the head of bed -Place client on left side in Trendelenburg position -Notify the health care provider -Closely monitor vital signs -Place in high Fowler's position
-Place client on left side in Trendelenburg position -Notify the health care provider -Closely monitor vital signs The following interventions are appropriate for care of a client suspected of having an air embolism. Place on left side in Trendelenburg position, notify the health care provider, and monitor vital signs closely.
A neonate is to receive a hepatitis B vaccine within a few hours after birth. What is the best approach for the nurse to take when giving this medication? -Administer the medication in the neonate's vastus lateralis with a 25-gauge needle. -Administer the medication in the vastus lateralis with a 20-gauge needle. -Administer the medication in the dorsogluteal with a 25-gauge needle. -Administer the medication in the deltoid muscle with a 20-gauge needle.
Administer the medication in the neonate's vastus lateralis with a 25-gauge needle. The vastus lateralis site is a safe choice for intramuscular (IM) injections in a neonate. A 22- to 25-gauge needle is recommended for neonates, but the nurse must assess the neonate's size before determining needle size to use. The 25-gauge needle is recommended for neonates. The dorsogluteal site should not be used until school age. Neither the deltoid muscle nor the dorsogluteal muscle are recommended IM sites for neonates. These muscles should not be used until toddler age or older. The volume of the medication should not exceed 0.5 ml per injection until the child is preschool age.
Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They demonstrate understanding of the information when they state which of the following as the form of the genetic viral material? -Deoxyribonucleic acid (DNA) -Ribonucleic acid (RNA) -Viral core -Glycoprotein envelope
Ribonucleic acid (RNA) HIV is a retrovirus that carries its genetic material in the form of RNA rather than DNA. HIV consists of a viral core containing the viral RNA, surrounded by an envelope consisting of protruding glycoproteins.
