NUR310 Final Exam

To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices? A. They help the venous blood return to the heart. B. They will not cause discomfort, but gently massage the legs. C. They are used instead of anticoagulant therapy. D. They must be worn until the first time the client gets out of bed.

ANS: A DVT is a potential complication of any surgery lasting longer than 30 minutes. The purpose of pneumatic compression devices is to venous return. In addition to the pneumatic compression devices, a mechanical form of DVT prophylaxis, a pharmaceutical prophylaxis is often required. Pneumatic compression devices are continued until the client is up ambulating frequently throughout the day.

A child with a history of asthma is brought to the emergency department experiencing an acute exacerbation of asthma. Which nursing assessment findings support this conclusion? Select all that apply. A. Fever B. Stridor C. Wheezing D. Tachycardia E. Hypotension

ANS: C, D Bronchial constriction with mucus production causes wheezing. With the decrease in arterial oxygenation associated with asthma, the heart rate will increase. Stridor is due to foreign body obstruction, not asthma. Hypertension, not hypotension, may occur with asthma.

While working in a neuromuscular clinic the nurse monitors infants for symptoms of cerebral palsy. Which statements by infants' mothers indicate the need for further evaluation for cerebral palsy? Select all that apply. A. "My baby doesn't make eye contact." B. "My baby seems to have a voracious appetite." C. "My baby was able to turn from front to back by 2 months of age." D. "I've noticed that this baby clings to me more than other children of the same age." E. "All my other children were sitting alone by this age. This baby doesn't seem to be anywhere near sitting alone."

ANS: C, E An infant that turns from front to back at an early age will often be found to have spastic cerebral palsy; it is the spasticity that causes an unintentional turn from front to back. Cerebral palsy is a neurologic problem and is commonly recognized when the child fails to meet developmental norms.

A 3-year-old boy in respiratory distress is treated in the emergency department. A diagnosis of acute spasmodic laryngitis (spasmodic croup) is made. At the time of discharge, the mother asks how to handle another attack at home. What should the nurse recommend? A. Placing him near a cool-mist humidifier B. Bringing him to the ED C. Giving him an OTC cough syrup D. Offering him warm tea sweetened honey

ANS: A During a spasmodic croup attack, cool humidified air to decrease inflammation is a fast home remedy. An attempt should be made to interrupt the attack at home first rather than going to the ED.

The nurse considers that a 70-year-old female client can best limit further progression of osteoporosis by doing what? A. Taking supplemental calcium and vitamin D B. Increasing the consumption of eggs and cheese C. Taking supplemental magnesium and vitamin E D. Increasing the consumption of milk and milk products

ANS: A Research demonstrates that women past menopause need at least 1500 mg of calcium a day, which is almost impossible to obtain through dietary sources; because the average daily consumption of calcium is 300 to 500 mg. Vitamin D promotes the deposition of calcium into bones.

A nurse is teaching skin and basic care to the mother of a 6-month-old infant with eczema. Which statement indicates that the mother needs further teaching? A. "I'll have to be careful not to cut my baby's nails short." B. "I gave all of my baby's woolen blankets to my nephew." C. "The baby can't have foods made with whole milk anymore." D. "I'll need to buy a whole new wardrobe of cotton clothing for the baby."

ANS: A The baby's nails should be cut very short to minimize injury from scratching. Woolen and synthetic fabrics tend to irritate the eczematous rash. Nonhuman milk can exacerbate eczema. Cotton clothing seems to be tolerated the best by infants with eczema.

A client sustains a complex comminuted fracture of the tibia with soft tissue injuries after being hit by a car while riding a bicycle. Surgical placement of an external fixator is performed to maintain the bone in alignment. Postoperatively it is most essential for the nurse to do what? A. Cleanse the pin sites with alcohol several times a day. B. Perform a neurovascular assessment of both lower extremities. C. Ambulate the client with partial weight bearing on the affected leg. D. Maintain placement of an abduction pillow between the client's legs.

ANS: B A neurovascular assessment identifies early signs and symptoms of compartment syndrome. Compartment syndrome is increased pressure within a closed fascial space caused by a fracture or soft tissue damage that compresses circulatory vessels, nerves, and tissues, compromising viability of the limb. The nurse should monitor for the six Ps: unrelenting pain, pallor, paresthesia, pressure, pulselessness, and paralysis. In addition, the circumference of the extremity will increase, and the leg will feel hard and firm on palpation. Both legs are assessed for asymmetry .

A mother arrives in the emergency department with her severely dehydrated infant. After being treated aggressively, the infant is rehydrated and ready to be discharged. What is the priority concern that the nurse should include in the discharge teaching plan for the mother? A. Importance of a well-balanced diet B. Signs of dehydration in infants C. The need for cleanliness of feeding utensils. D. Effect of antibiotics on viral gastroenteritis.

ANS: B It is most important for the mother to learn that immediate treatment is necessary for an infant with vomiting or diarrhea. Because infants have a greater proportion of body fluid to tissue than adults, they cannot maintain fluid balance in the event of a large loss of fluid through vomiting or diarrhea.

A client is admitted to the hospital with a diagnosis of Crohn disease. What is most important for the nurse to include in the teaching plan for this client? A. Controlling constipation B. Meeting nutritional needs C. Preventing increased weakness D. Anticipating a sexual alteration

ANS: B To avoid GI pain and diarrhea, these clients often reuse to eat and become malnourished. The consumption of a high-calorie, high-protein diet is advised. Diarrhea, not constipation, is a problem with Crohn disease. Preventing an increase in weakness is a secondary concern that results from malnutrition; correcting the malnutrition will increase strength.

An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant? Select all that apply. A. Limiting fluid intake B. Instilling saline nose drops C. Maintaining contact precautions D. Suctioning mucus with a bulb syringe E. Administering warm humidified oxygen

ANS: B, C, D Saline nose drops help clear the nasal passage, which improves breathing and aids the intake of fluids. RSV Is contagious; infants with RSV should be isolated from other children, and the number of people visiting or caring for the infant should be limited. Infants with RSV produce copious amounts of mucus, which hinders breathing and feeding; suctioning before meals and at naptime and bedtime provides relief. Fluid intake should be increased; adequate hydration is essential to counter fluid loss.

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism? A. An obese client with leg trauma B. A pregnant client with acute asthma C. A client with diabetes who has cholecystitis D. A client with pneumonia who is immunocompromised

ANS: A An obese client with leg trauma has two risk factors for development of pulmonary embolism: obesity and leg trauma.

A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? A. A 59-year-old who had a knee replacement B. A 60-year-old who has bacterial pneumonia C. A 68-year-old who had emergency dental surgery D. A 76-year-old who has a history of thrombocytopenia

ANS: A Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation.

The parents of a 3-year-old child who has recurrent attacks of acute spasmodic laryngitis (spasmodic croup) ask the nurse why this happens to their child. What is the best rationale for the nurse to convey why this is a disorder of young children? A. They have small airways. B. They are mouth breathers C. They have immature immune systems. D. They are prone to upper respiratory infections.

ANS: A Swelling and edema in airways with small diameters lead to the signs and symptoms of croup.

A woman fractured her left tibia and fibula one week ago and has a cast in place. She is taking acetaminophen (Tylenol) with codeine for pain and an oral contraceptive. She began experiencing left calf pain 3 days ago and began having shortness of breath and chest pain 15 minutes ago. When the shortness of breath and chest pain increase, she calls the emergency department and communicates this information to the triage nurse. What is the triage nurse's best response? A. "Give me your name and address. I am sending an ambulance to your home. You need emergency care." B. "It sounds as if your cast may be constricting the blood flow in your leg. You probably need a new cast." C. "It sounds like you are having an allergic response to the medication. is there someone there who can drive you to the hospital?" D. "You are experiencing an interaction between your pain and oral contraceptive medications. You need to come to the emergency department now for care."

ANS: A The client's clinical manifestations, along with the history of a recent fracture, immobilization, and use of an oral contraceptive, suggest a pulmonary embolism. An ambulance will limit the woman's use of her leg, which may prevent further emboli. The client's findings are not indicative of compression syndrome.

A client was diagnosed with ulcerative colitis. Two months after the diagnosis, the client is readmitted for an exacerbation of the illness. The client is weak, thin, and irritable. The client states, "I am now ready for surgery to create an ileostomy." Which nursing intervention will best meet the client's priority need? A. Replace the client's fluids and electrolytes B. Help the client gain weight C. Teach the client how to use the ileostomy appliance D. Encourage client interaction with other clients who have an ileostomy

ANS: A When a client has an ulcerative colitis exacerbation, the client may have over 10 stools per day and the stools are bloody and full of mucus. The client can become dehydrated and loose vital electrolytes. Fluid and electrolyte replacement is a life-saving strategy; it must be done before surgery is performed.

A 2-year-old child is brought to the emergency department after the sudden onset of high fever, drooling, and respiratory distress. What nursing actions should the nurse perform? Select all that apply. A. Start an intravenous line B. Draw a blood sample for CBC and differential C. Examine the child's throat with a flashlight and tongue depressor for swelling D. Assess oxygen saturation of the blood and administer oxygen by mask if it is below 94% E. Ask the parents to remain in the waiting room during the examination and interventions F. Assess the child's temperature and administer an antipyretic if the rectal temperature is higher than 101 F.

ANS: A, B, C, E The child is presenting with signs of epiglottitis. An IV line will prevent dehydration and provide access for emergency medications if needed.

A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe? Select all that apply. A. Scaly lesions B. Pruritic pustules C. Reddened papules D. Multiple petechiae E. Erythematous macules

ANS: A, C Psoriasis is characterized by dry, scaly lesions that occur most frequently on the elbows, knees, scalp, and torso. Sharply defined reddened papules or plaques covered by scales occur because of dermal inflammation; the inflammation occurs because of an abnormal growth of epidermal cells related to an autoimmune reaction. Macules are erythematous flat spots on the skin, as in measles.

The nurse is caring for a client who has sustained blunt trauma to the forearm. The nurse assesses the client for which early sign of compartment syndrome? A. Warm skin at the site of injury B. Escalating pain in the fingers C. Rapid capillary refill in affected hand D. Bounding radial pulse in the injured arm

ANS: B Elevated tissue pressure restricts blood flow, causing increasing ischemia and increasing pain; it is the cardinal early symptom of compartment syndrome. The arm will feel cool, not warm, because of a decrease in circulation. Sluggish, not rapid, capillary refill is a sign of compartment syndrome. The pulse will be diminished, not bounding; increasing edema impairs circulation.

A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) infection is made, and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care? A. Place in a warm, dry environment B. Maintain standard and contact precautions C. Administer prescribed antibiotic immediately. D. Allow parents and siblings to room in with the infant.

ANS: B RSV is highly contagious. The infant should be isolated or placed with other infants with RSV. Standard and contact precautions are instituted to limit the spread of pathogens to others. The infant should receive cool, humidified oxygen by nasal cannula or mask or in a croup tent.

What strategy should the nurse employ to be effective when using play therapy with a 6-year-old child with autism? A. Play music and dance with the child. B. Use mechanical and inanimate objects for play. C. Employing positive reinforcements such as hugging. D. provide brightly colored toys and blocks that can be held.

ANS: B Self-isolation and disinterest in the interpersonal relationships lead the autistic child to find security in nonthreatening, impersonal objects. These children do not respond to brightly colored toys and blocks as other children do unless movement is involved.

A nurse in the pediatric clinic is taking the health history of a toddler with an exacerbation of eczema. What are the nurse's priority assessments of the child? Select all that apply. A. Increase in appetite B. Wearing cotton clothes C. Tolerance of new foods D. Exposure to a viral infection E. Recent contact with someone with eczema

ANS: B, C Eczema is a common manifestation of allergies in the young child and is often related to foods and clothing. Wearing cotton clothing indicates the parents understanding and are trying to minimize their child's allergic reaction. Tolerance of new foods is a positive sign that the child is outgrowing some food allergies.