PASSPOINT QUIZ (endocrine&metabolic, neurosensory, respiratory disorder)

the client will control the amount of pain medication administered. Explanation: Studies have supported that one reason patient-controlled analgesia is effective is because the client has control over the opioid administration.Morphine is the most commonly used opioid in patient-controlled analgesia.Only one opioid is administered at a time.Nursing assessments and actions remain basically the same for the client using patient-controlled analgesia.

Apply ice compresses. Explanation: The most effective way to decrease discomfort is to decrease local edema. Cold application, such as an ice compress or ice bag, is effective. Heat dilates local vessels and increases local congestion. Semi-Fowler's position helps decrease edema and prevents aspiration. Nose blowing should be avoided for at least 48 hours after the nasal packing is removed because it can disrupt the surgical site and lead to bleeding.

A client on mechanical ventilation is receiving pancuronium I.V. as needed. Which assessment finding indicates that the client needs another pancuronium dose?

fighting the ventilator Explanation: Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting endotracheal intubation and paralyzing the client so the client breathes in synchrony with the ventilator. Fighting the ventilator is a sign that the client needs another pancuronium dose. The nurse should administer a dose I.V. every 20 to 60 minutes. Movement of the legs, fingers, or lips has no effect on the ventilator and therefore isn't used to determine the need for another dose.

The nurse teaches a client with type 2 diabetes mellitus about diabetic retinopathy. Which statement if made by the client would indicate to the nurse that teaching was effective?

"Tight control of blood sugar and blood pressure can prevent damage to my eye." Explanation: The major cause of blindness in people with diabetes mellitus is diabetic retinopathy. Corneal problems, cataracts, refractive changes, glaucoma, and extraocular muscle changes are also noted, but retinopathy is the most common problem. The risk of retinopathy is not associated with a family history of cataracts, but retinopathy risk does increase with poor glycemic, lipid, and blood pressure control. Type 1 and type 2 diabetics are at risk for retinopathy, and the risk does not increase if the client is on insulin therapy.

A nurse on a neurologic unit is working on performance improvement with a stroke-management team. The nurse identifies a gap between the time a client enters the emergency department (ED) and the time that client is admitted to the intensive care unit (ICU) for aggressive treatment. The nurse's meeting with the team to develop a change strategy using indicators. Which statement by a team member indicates a need for further teaching regarding performance management?

"We can discipline the ED staff for not getting the clients to the ICU fast enough." Explanation: Using statistics and other indicators, such as ED staffing information, to develop a change strategy is part of performance management. Disciplining staff doesn't reflect a strategy based on indicators. Collaborating with staff from other areas results in performance improvement, not performance management.

A client is admitted with a diagnosis of diabetic ketoacidosis. An insulin drip is initiated with 50 units of insulin in 100 ml of normal saline solution administered via an infusion pump set at 10 ml/hour. The nurse determines that the client is receiving how many units of insulin each hour? Record your answer using a whole number.

5 Explanation: To determine the number of insulin units the client is receiving per hour, the nurse must first determine the number of units in each milliliter of fluid (50 units ÷ 100 ml = 0.5 units/ml). Next, multiply the units per milliliter by the rate of milliliters per hour (0.5 units × 10 ml/hr = 5 units).

Which family member exposed to tuberculosis would be at highest risk for contracting the disease?

76-year-old grandmother Explanation: Elderly persons are believed to be at higher risk for contracting tuberculosis because of decreased immunocompetence. Other high-risk populations in the United States and Canada include the urban poor, clients with acquired immunodeficiency syndrome, and minority groups.

What should a nurse do when administering pilocarpine?

Apply pressure on the inner canthus to prevent systemic absorption. Explanation: When administering pilocarpine, the nurse should apply pressure on the inner canthus to prevent systemic absorption of the drug. Pilocarpine doesn't cause night blindness. The outer canthus doesn't absorb eyedrops, so applying pressure there won't be helpful. Flushing the client's eye with normal saline solution after administering pilocarpine is contraindicated because it will wash the drug out of the eye, rendering treatment ineffective.

A nurse is preparing to palpate a client's thyroid gland. Which action by the nurse is appropriate?

Encircle the client's neck with both hands, have the client slightly extend their neck, and ask them to swallow. Explanation: When palpating the thyroid gland, the nurse should encircle the client's neck with both hands, have the client slightly extend their neck, and ask them to swallow. As the client swallows, the gland is palpated for enlargement as the tissue rises and falls. Having the client flex their neck wouldn't allow for palpation. Massaging the area or checking during inhalation doesn't allow for the movement of tissue that swallowing provides.

Which goal is a priority for a client who has undergone surgery for retinal detachment?

Prevent an increase in intraocular pressure. Explanation: After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal. Control of pain with analgesics is a secondary goal. The client should avoid getting soap and water in the eye when bathing. Maintaining a darkened environment is not necessary for this client.

After 5 days of hospitalization, a client who is receiving morphine sulfate for pain control asks for pain medication with increasing frequency and exhibits increased anxiety and restlessness. The vital signs are within normal ranges. What is a possible cause of this behavior?

The client has developed tolerance to the dose of morphine. Explanation: Tolerance to a regular opioid dose can develop with frequent use. The client experiences increased discomfort, asks for medication more frequently, and exhibits anxious and restless behavior, actions which are often misinterpreted as indicative of developing dependence or addiction. The client's symptoms do not suggest that the dosage is too high. Addiction is a psychological condition in which a client takes drugs for nontherapeutic reasons. This client is receiving morphine for pain control. There are no data given about the client's coping mechanisms.

Which action will be most helpful to the nurse when determining the need for oxygen therapy in a client with chronic obstructive pulmonary disease?

Use a pulse oximeter to determine oxygen saturation. Explanation: A pulse oximeter, which measures oxygen saturation, is the most effective noninvasive way to determine a client's need for oxygen therapy. Although the client may feel the need for oxygen during periods of dyspnea, this is not a reliable way of determining the client's need. Fatigue may be due to other factors besides oxygenation levels. Evaluating the client's hemoglobin level can provide an indication that the client may have less oxygen-carrying capacity but is not a reliable indicator of oxygen need.

A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; Pco2 48 mm Hg (6.4 kPa); Po2 58 mm Hg (7.7 kPa); HCO3 26 mEq/L (26 mmol/L). Which prescription should the nurse implement first?

albuterol nebulizer Explanation: The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest X-ray and sputum sample can be obtained once the client is stable.

A client who has been treated for chronic open-angle glaucoma for 5 years asks the nurse, "How does glaucoma damage my eyesight?" What should the nurse tell the client?

causes increased intraocular pressure." Explanation: In COAG, there is an obstruction to the outflow of aqueous humor, leading to increased intraocular pressure. The increased intraocular pressure eventually causes destruction of the retina's nerve fibers. This nerve destruction causes painless vision loss. The exact cause of glaucoma is unknown. Glaucoma does not lead to retinal detachment.

A nurse notices that a client admitted for exacerbation of chronic obstructive pulmonary disease is short of breath. The client has signed an advance directive indicating that they don't want to be resuscitated. The nurse should

check the client's oxygen saturation. Explanation: The nurse should check the client's oxygen saturation before calling the physician. The fact that the client has signed an advance directive doesn't mean that the nurse shouldn't provide any care. There's no reason for the nurse to get the crash cart at this point.

To decrease intraocular pressure following cataract surgery, what should the nurse instruct the client to avoid?

coughing Explanation: Coughing is contraindicated after cataract extraction because it increases intraocular pressure. Other activities that are contraindicated because they increase intraocular pressure include turning to the operative side, sneezing, crying, and straining. Lying supine, ambulating, and deep breathing do not affect intraocular pressure.

Which indicator is the best for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement?

daily weight Explanation: Measuring daily weight is a reliable, objective way to monitor fluid balance. Rapid variations in weight reflect changes in fluid volume, which suggests insufficient control of the disease and the need for more glucocorticoids in the client with Addison's disease. Nurses should instruct clients taking oral steroids to weigh themselves daily and to report any unusual weight loss or gain. Skin turgor testing does supply information about fluid status, but daily weight monitoring is more reliable. Temperature is not a direct measurement of fluid balance. Thirst is a nonspecific and very late sign of weight loss.

The nurse should teach clients that the most common route of transmitting tubercle bacilli from person to person is through contaminated:

droplet nuclei. Explanation: Tubercle bacilli are spread by airborne droplet nuclei. Droplet nuclei are the residue of evaporated droplets containing the bacilli, which remain suspended and are circulated in the air. Dust particles and water do not spread tubercle bacilli. Tuberculosis is not spread by eating utensils, dishes, or other fomites.

A client has low back pain. What should the nurse instruct the client to avoid doing?

exceeding the prescribed exercise program Explanation: The client with low back pain should not exceed the prescribed exercises even though they may think, "If this will make me well, double will make me well quicker." When exceeding prescribed exercise programs, the client's muscle may be unconditioned and easily tired, leading to injury and increased pain. To use proper body mechanics when lifting light objects, the client should bring the item close to the center of gravity, which occurs when the object is kept below the level of the elbows. Leaning forward while bending the knees allows for the muscles of the thigh to be used instead of those of the lower back. Sleeping on the side with the legs flexed is appropriate because the spine is kept in a neutral position without twisting or pulling on muscles.

A client with cirrhosis begins to develop ascites. Spironolactone is prescribed to treat the ascites. The nurse should monitor the client closely for which drug-related adverse effect?

hyperkalemia Explanation: Spironolactone is a potassium-sparing diuretic; therefore, clients should be monitored closely for hyperkalemia. Other common adverse effects include abdominal cramping, diarrhea, dizziness, headache, and rash. Constipation and dysuria are not common adverse effects of spironolactone. An irregular pulse is not an adverse effect of spironolactone but could develop if serum potassium levels are not closely monitored.

On admission, the client's arterial blood gas (ABG) values were: pH, 7.20; PaO2, 64 mm Hg (8.5 kPa); PaCO2, 60 mm Hg (8 kPa); and HCO3-, 22 mEq/L (22 mmol/L). A chest tube is inserted, and oxygen at 4 L/minute is started. Thirty minutes later, repeat blood gas values are: pH, 7.30; PaO2, 76 mm Hg (10.1 kPa); PaCO2, 50 mm Hg (6.7 kPa); and HCO3-, 22 mEq/L (22 mmol/L). This change would indicate:

improving respiratory status. Explanation: The ABG values after chest tube insertion are returning to normal, indicating that treatment is effective.Impending respiratory failure would be indicated by a decreasing PaO2 or an increasing PaCO2.The client is not alkalotic because the pH values are below 7.35.If the chest tubes were obstructed, the client's respiratory status would deteriorate.

A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which area indicates effective therapy?

muscle rigidity Explanation: Levodopa is prescribed to decrease severe muscle rigidity. Levodopa does not improve mood, appetite, or alertness in a client with Parkinson's disease.

A client appears flushed and has shallow respirations. The arterial blood gas report shows the following: pH, 7.24; partial pressure of arterial carbon dioxide (PaCO2), 49 mm Hg (6.5 kPa); bicarbonate (HCO3-), 24 mEq/L (24 mmol/L). These findings are indicative of which acid-base imbalance?

respiratory acidosis Explanation: The pH of 7.24 indicates that the client is acidotic. The PaCO2 value of 49 mm Hg is elevated. The HCO3- value of 24 mEq/L is normal. The client is in uncompensated respiratory acidosis. Hypoventilation and a flushed appearance are additional clinical manifestations of respiratory acidosis.

Which is an expected finding for a client who has been treated for bacterial pneumonia?

the ability to perform activities of daily living without dyspnea Explanation: An expected outcome for a client recovering from pneumonia would be the ability to perform activities of daily living without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/min indicates the client is experiencing tachypnea, which would not be expected on recovery. A weight loss of 5 to 10 lb (2 to 5 kg) is undesirable; the expected outcome would be to maintain normal weight. A client who is recovering from pneumonia should experience decreased or no chest pain.

When determining how to administer analgesics to a client who has been receiving opiates for pain relief administered by injection, the nurse should consider using patient-controlled analgesia since it is more effective because:

the client will control the amount of pain medication administered. Explanation: Studies have supported that one reason patient-controlled analgesia is effective is because the client has control over the opioid administration.Morphine is the most commonly used opioid in patient-controlled analgesia. Only one opioid is administered at a time. Nursing assessments and actions remain basically the same for the client using patient-controlled analgesia.

The nurse is to check a client's gag reflex. The most effective technique for testing the gag reflex is to:

touch the back of the client's throat with a tongue blade. Explanation: The best technique for assessing the gag reflex is to touch the back of the client's throat in the pharyngeal area with a tongue blade or cotton swab. The reflex is absent if the client does not gag. Reflexes are typically absent or sluggish in the presence of increased intracranial pressure. Swallowing does not indicate the presence of a gag reflex. It is dangerous to place liquids in the mouth of a client with an unconfirmed gag reflex because of the risk of aspiration. Endotracheal suctioning does not test the client's gag reflex.