PN1 Final Exam-NCLEX Exam 2 Elimination/Ethics/Surgery

Hand hygiene refers to: 1. Using plain soap and water 2. Using an antiseptic hand rub (e.g., alcohol, chlorhexidine, or iodine) 3. Using antimicrobial soap and water 4. All of the above

Answer 4. Rationale: All are methods of hand hygiene

Which is not usually worn as PPE when anticipating spatter of blood or body fluids? 1. Jacket with long sleeves 2. Gloves 3. Head covering 4. Protective eyewear or face shield 5. Face mask

Answer 1. Rationale: A jacket with long sleeves does not provide protection from blood splatter or body fluids.

What are the main steps in the emergency treat- ment of MH? 1. Activate the emergency medical code team 2. Stop triggering agents, hyperventilation with high O2 flow, dantrolene intravenously 3. Administer dantrolene subcutaneously 4. Begin cardiopulmonary resuscitation (CPR)

Answer 1. Rationale: Activation of the emergency medical code team is a main step in the emergency treatment of MH.

Which is within the sterile field? 1. Items above the level of the draped client 2. Items below the level of the draped client 3. The gowned and gloved provider's back 4. From the gowned and gloved provider's head to the chest

Answer 1. Rationale: Items above the level of the draped client are within the sterile field

Which is correct regarding surgical attire? 1. If sturdy footwear that completely covers the foot and that is worn only in the surgical area is available, shoe covers are not needed for infection prevention purposes. 2. Sterile surgical gloves are considered sterile if gloved hands drop below the level of the waist. 3. When removing surgical gloves, always remove the gloves simultaneously. 4. Caps and masks worn in the OR should be sterile.

Answer 1. Rationale: Shoe covers are needed for infection prevention purposes.

In thinking about the distinctions between spirituality and religious faith, identify the client statement that indicates a developing sense of spirituality in the hours before surgery. 1. I think my need to have cardiac surgery may be a sort of wake-up call. I may need to take more time to stop and smell the roses after this. 2. Will you pray with me? 3. When my minister shows up, tell him I'll be right back. 4. Will I have to stop eating and drinking tonight at midnight?

Answer 1. Rationale: Spirituality is the attempt to provide meaning within life's events. Religious faith has a slightly more specific definition.

What is the differential diagnosis of MH? 1. External heating, septicemia, thyrotoxicosis, pheochromocytoma, anaphylaxis, respiratory problems, pulmonary emboli, and myopathy 2. External heating only 3. Elevated blood pressure and pulse 4. Dizziness and blurred vision

Answer 1. Rationale: The differential diagnosis of MH includes: external heating, septicemia, thyrotoxicosis, pheochromocytoma, anaphylaxis, respiratory problems, pulmonary emboli, and myopathy.

Identify the correct statement about prevention of wrong site surgery: 1. Have the conscious client identify the correct site with a visible mark. 2. Because the surgical permit lists the correct site, no additional measures are necessary beyond careful permit review. 3. The nurse should verbally ask the alert client to state the area to be operated on and should document the client statement in the nursing notes. 4. Knowing that the surgeon has carefully pre- planned for the surgery, no additional checks are needed.

Answer 1. Rationale: To be absolutely sure that the surgical team is positive about the correct site or correct side of the body, the clients placing a mark is best. Lessons of the past indicate that reliance on documents or the surgeon's memory may lead to unfortunate client consequences.

From the list, identify surgeries that would be classified as major: 1. Laparoscopic cholecystectomy 2. Pneumonectomy 3. Incision and drainage of an axillary abscess 4. Coronary artery bypass graft 5. Total left hip replacement 6. Appendectomy

Answer 2, 4, 5. Rationale: Lung removal and CABG are major surgeries because the chest cage is usually opened. Disruption to the underlying tissues, extended length of time for completion of surgery, and the likelihood of intensive care stays indicate that these are not minor. Total hip replacement also involves major tissue disruption and mobility interruption.

In responding to a preoperative client's question about complementary therapy, which initial response by the nurse is most likely to be helpful? 1. None of those therapies have been shown to have scientific merit. 2. Tell me what you mean. Are you speaking about something like relaxation therapy or more along the lines of herbal remedies or something else? 3. There has been a renewed interest in such things as acupuncture lately. 4. Does your surgeon know of your interest?

Answer 2. Rationale: As an initial response, it always wise to seek clarification of complex questions, especially when the preoperative nurse is dealing with information that is likely not to have clear-cut answers. Clients may draw unusual conclusions during times that are stressful, such as the preoperative period

Which actions by a postoperative nurse reflect incomplete understanding of client confidentiality needs under HIPAA? 1. Sharing information with health care personnel on a need-to-know basis 2. Discussing client recovery times with an unidentified caller 3. Using a cover sheet on a clipboard 4. Stopping unidentified personnel from looking through a client's chart 5. Selecting family spokesperson to relay information to family and friends of the client

Answer 2. Rationale: Not knowing a caller's identity means that the RN may be discussing confidential information with an unauthorized individual.

Identify the incorrect statement related to emergency surgery: 1. The most common causes of emergency surgery include gunshot wounds, accidents, and combat injuries. 2. The highest priority in the emergency department is given to preservation of life. There are no exceptions. 3. The nurse will routinely perform physical assessment and lab draws as first priorities with the emergency client likely to need surgery, even if it means decreased time for communicating with the family. 4. In cases of emergency that involve life threat, formal consent procedures may be temporarily bypassed.

Answer 2. Rationale: There are exceptions to highest ER prioritization always centering on preservation of life. There will be instances in which the terminally ill client will report in to the ER for ease of access to other hospital services.

The suffixes, -ectomy and -ostomy/-otomy refer to: 1. Fusion and splinting 2. Removal and opening into 3. Stomach and gastrointestinal (GI) tract 4. Incision and drainage

Answer 2. Rationale: This is a recall test item. Refer to definitions within the chapter

Which is not true regarding gloves? 1. Certain hand lotions can affect the integrity of gloves. 2. Wearing gloves replaces the need for handwashing. 3. Sterile surgical gloves are recommended for surgical procedures. 4. Certain gloves are latex-free.

Answer 2. Rationale: Wearing gloves does not replace the need for hand washing.

Which statement regarding processing of contaminated instruments is false? 1. Instruments should be processed in an area separate from where clean instruments are stored. 2. Personnel should wear latex-free utility gloves. 3. Instruments need cleaning only if they have visible contamination. 4. Cleaning an instrument precedes all sterilization and disinfection processes.

Answer 3. Rationale: All instruments need cleaning even if they do not have visible contamination

The term laser is an acronym for: 1. Lateral accumulation of serial emission of radiation 2. Light accumulation of surface energy rays 3. Light amplification by the stimulated emission of radiation 4. Light amplification of supersonic electrical reams

Answer 3. Rationale: Light amplification by the stimulated emission of radiation (LASER)

Which task may not be delegated by the preoperative nurse to unlicensed assistive personnel? 1. Drawing blood for preoperative analysis 2. Performing a bedside blood glucose check 3. Performing initial physical assessment upon client entry into the hospital 4. Orienting the client to the hospital room

Answer 3. Rationale: Only the registered nurse is permitted to perform and document physical assessment of clients

The term used to denote self-donation of blood products prior to the day of surgery is: 1. Allogeneic 2. Autonomous 3. Autologous 4. Alopecic

Answer 3. Rationale: This is a recall test item. Refer to discussion in the chapter

Identify the case in which the preoperative nurse will notify the surgeon or surgical area and place a temporary hold on client transport to surgery. 1. The nurse inadvertently gave the client a preoperative IV dose of morphine a few minutes before the consent was signed. 2. The nurse assistant reports the client has a 39.2° C (102.5° F) oral temperature. 3. The client states he is having second thoughts about surgery. 4. All of the above.

Answer 4. Rationale: All are reasons to delay the client's arrival in the surgery holding area. Some may lead to cancellation of surgery because the client may not have been capable of informed consent, may not be stable physically, or may not want to go through with surgery at this time

Identify the most likely and most serious danger in the future use of implantable electronic chips for containing a client's health history: 1. The chip could be deactivated by such things as supermarket scanners. 2. The wrong client's records could be implanted. 3. Unnecessary pain. 4. Violation of confidentiality.

Answer 4. Rationale: Electronic record keeping will always hold the potential for client's private information to be captured by those without a need to know and without client consent.

What monitoring is used for a general anesthesia in an individual suspected to have MH? 1. ECG, blood pressure, CO2 monitoring, and pulse oximeter 2. Temperature, creatininase, electrolytes, and blood gas analysis 3. 2 only 4. 1 and 2 are correct

Answer 4. Rationale: Monitoring of the client suspected to have MH includes ECG, blood pressure, CO2 monitoring, pulse oximeter, temperature, creatininase, electrolytes, and blood gas analysis.

The nurse is instructing the preoperative client on what items to bring to the hospital for an anticipated two-day stay. Identify the client statement that indicates the need for additional teaching: 1. I think I'll leave my rings and watch at home. 2. Why don't I just copy my medication bottle labels onto a list and not bring in a bunch of medicine bottles for the nurses to check. 3. My spouse is checking out five or six library books and will be ready to bring in a favorite if I'm feeling good after surgery. 4. If I bring in my laptop computer, maybe I can catch up on some office work.

Answer 4. Rationale: On a two-day stay and noncomplex surgery, it might be unwise for the client to focus energy on work-related matter

Which statement is true regarding monitoring the correct functioning of a sterilizer? 1. A chemical indicator should be placed in a visible area of the package before sterilization processing. 2. A biological indicator spore test should be processed through a sterilizer cycle at least once a week. 3. A biological indicator control test matching the same lot of the spore test should be submitted with the sterilizer spore test. 4. Mechanical assessments of sterilizer cycle time and temperature should be monitored 5. All of the above

Answer 5. Rationale: All answers are true regarding monitoring the correct functioning of a sterilizer.

What are the early signs of MH? 1. Decreased core body temperature and decreased CO2 2. Bradycardia 3. Flushed skin tone 4. Tachycardia, arrhythmia, elevated CO2, and masseter spasm 5. All of the above

Answer 5. Rationale: All are early signs of MH

Which is true regarding standard infection control precautions? 1. Standard precautions are strategies used to reduce the risk of transmission of pathogens in the health care setting. 2. Standard precautions should be used in caring for all clients, regardless of their infectious status. 3. Expanded or transmission-based precautions are used beyond standard precautions to interrupt the spread of certain pathogens. 4. Standard precautions apply to exposure to blood, all body fluids and secretions (except sweat), non-intact skin, and mucous membranes. 5. All of the above

Answer 5. Rationale: All are true for standard infection-control precautions

Indications for handwashing include: 1. When gloves are removed and before leaving the OR 2. Before washing contaminated instruments 3. When hands are visibly soiled 4. Before client care 5. 1, 3, and 4 are correct. 6. All of the above

Answer 5. Rationale: Hand washing indications include: when gloves are removed and before leaving the operating room, when hands are visibly soiled, and before client care.

The nurse is taking a history from the mother of a child being admitted with flare-up of celiac disease. What piece of information would the nurse expect the mother to report? 1. Stools that are fatty 2. An increased appetite with no weight gain 3. Episodes of abdominal pain that are wavelike just before meals 4. Soft, formed stools

Answer: 1 Rationale: Acute episodes of celiac disease are characterized by bulky, frothy stools with fat. Anorexia would be expected rather than increased appetite. Pain does not occur in waves prior to mealtimes. Stools are not soft and formed.

A child has been admitted with acute glomerulonephritis (AGN). All of the following tests are positive for AGN. The nurse concludes that which laboratory test is most indicative of this disease? 1. Elevated antistreptinolysin O (ASO) titers 2. Elevated erythrocyte sedimentation rate (ESR) 3. Presence of hematuria according to urinalysis 4. Elevated creatinine concentrations

Answer: 1 Rationale: An elevated ASO titer indicates a recent streptococcal infection, which is a precursor to AGN. An elevated ESR indicates inflammation in the body and is associated with many diseases. Hematuria is simply blood in the urine, which has many possible causes. Creatinine concentrations reflect the functioning of the kidney.

The nurse caring for a client with hemolytic jaundice anticipates which findings on laboratory test results? 1. Elevated serum indirect bilirubin 2. Decreased serum protein 3. Elevated urine bilirubin 4. Decreased urine pH

Answer: 1 Rationale: Hemolytic jaundice is caused by excessive breakdown of red blood cells, and the amount of bilirubin produced exceeds the ability of the liver to conjugate it, so there is an increase in indirect bilirubin. Serum protein is not measured to detect hemolytic jaundice. Unconjugated bilirubin is insoluble in water and is not found in the urine. Urine pH is not decreased by hemolytic jaundice.

Which laboratory test would the nurse expect to be ordered for a child with dehydration caused by vomiting and diarrhea? Select all that apply. 1. Serum sodium 2. Urine specific gravity 3. Serum ammonia 4. Serum amylase 5. Blood urea nitrogen (BUN)

Answer: 1, 2, 5 Rationale: Serum sodium would be expected to increase in a client with dehydration because of hemoconcentration. Measuring urine specific gravity provides data about the concentration of urine and provides information regarding hydration. The BUN rises with dehydration and is therefore a general indicator of hydration status, although it also reflects kidney function. Serum ammonia could be elevated in liver disease. Serum amylase could be elevated in pancreatic disorders.

The client with diverticular disease is scheduled for a sigmoidoscopy and suddenly reports severe abdominal pain. On examination, the nurse notes a rigid abdomen with guarding. What action should the nurse take next? 1. Notify the physician. 2. Place the client in a more comfortable position. 3. Keep the client distracted until the procedure begins. 4. Tell the client that the test will show what is causing his problem.

Answer: 1 Rationale: Perforation of an obstructed diverticulum can cause abscess formation or generalized peritonitis. The manifestations of peritonitis are abdominal guarding and rigidity and pain. Because treatment of this complication is beyond the scope of independent nursing practice, the physician must be notified. Sigmoidoscopy is contraindicated in cases of perforation. Placing the client in a position of comfort could be attempted after notifying the physician of the complication.

The mother of a child at the renal clinic asks why a radiological evaluation is performed on all children who have had one documented urinary tract infection (UTI). What information would the nurse include as the best explanation for use of x-ray? 1. It rules out structural abnormalities. 2. It confirms the absence of bacterial colonies after antimicrobial therapy. 3. It determines which kidney was infected. 4. It determines the probability of the infection recurring.

Answer: 1 Rationale: Radiological evaluations done after a documented UTI in children reveal structural abnormalities in 1-2% of girls and 10% of boys. Radiological tests cannot confirm bacterial colonies, determine the site of an old infection, or help predict whether infection will reoccur

A client is being evaluated for possible duodenal ulcer. The nurse assesses the client for which manifestation that would support this diagnosis? 1. Epigastric pain relieved by food 2. History of chronic aspirin use 3. Distended abdomen 4. Positive fluid wave

Answer: 1 Rationale: The pain of a gastric ulcer is dull and aching, occurs after eating, and is not relieved by food as is the pain from duodenal ulcer. The pancreatic juices that are high in bicarbonate are released with food intake and relieve duodenal ulcer pain when the client eats. Chronic aspirin use is irritating to the stomach. Distended abdomen is a vague sign and is unrelated. A positive fluid wave is consistent with ascites and is unrelated.

An individual has a seizure while walking down the street. During the seizure, a nurse from a physician's office is noticed driving past without stopping to assist. The individual sues the nurse for negligence but fails to win a judgment for which reason? 1. The nurse had no duty to the individual. 2. The nurse did what most nurses would do in the same circumstance. 3. The nurse did not cause the client's injuries. 4. The nurse was off-duty at that time.

Answer: 1 Rationale: To be guilty of negligence, the nurse must have a relationship with the client that involves a duty to provide care. The relationship is usually a component of employment. The nurse did not necessarily do what others would do in this situation. Although the nurse did not cause the client's injuries, it does not prevent the nurse from assisting in this situation. Although the nurse was off-duty, the nurse could have assisted if motivated to do so.

The post-cholecystectomy client asks the nurse when the T-tube will be removed. Which response by the nurse would be appropriate? 1. "When your stool returns to a normal brown color, the tube can be removed." 2. "The tube will be removed at the same time as your staples." 3. "When the tube stops draining, it will be removed." 4. "The tube is usually removed the day after surgery."

Answer: 1 Rationale: When T-tube drainage subsides and stools return to a normal brown color, the tube can be clamped 1 to 2 hours before and after meals in preparation for tube removal. If the client tolerates clamping, the tube will then be removed. The tube is not removed at the same time as the incisional staples. It is not necessary for drainage to completely stop before tube removal. The client may not be ready for tube removal the day after surgery.

Which discharge instructions would the nurse give to a client who will receive an aminoglycoside antibiotic at home to address the risk of nephrotoxicity? Select all that apply. 1. Increase fluid intake to 2000-2500 mL fluid daily. 2. Report sudden weight gain or puffy eyes. 3. Don't be concerned with edema as a normal side effect. 4. Elevated blood pressure is an expected drug effect. 5. Eat a low protein diet while taking this antibiotic.

Answer: 1, 2 Rationale: The client should maintain a fluid intake of 2000 to 2500 mL per day to reduce the risk of nephrotoxicity. To detect nephrotoxicity early, the client should report signs of edema. Edema is not a normal side effect of the medication. To reduce the risk of nephrotoxicity, the client should report hypertension. It is unnecessary to eat a low protein diet while taking an aminoglycoside antibiotic.

Which statements by a female client indicate that instruction in ways to prevent urinary tract infection (UTI) was understood? Select all that apply. 1. "I should avoid tub baths and take showers instead." 2. "I should drink 8 to 10 glasses of fluid per day." 3. "I should only wear nylon underpants." 4. "I should void every 6 hours while I am awake." 5. "I should use powder or talc to aid in keeping the perineal skin dry."

Answer: 1, 2 Rationale: Tub baths can promote migration of bacteria in the lower urinary tract; the client should shower instead. Maintaining an intake of 8 to 10 glasses of fluid daily will help prevent UTI. Cotton underpants are best, and nylon should be avoided because synthetic fibers retain body moisture and irritate the perineal area, which can promote the growth of bacteria. Emptying the bladder every 2 to 4 hours while awake is recommended to prevent urinary stasis. Powder or talc can be irritating to perineal skin and should be avoided.

The nurse is admitting a child with a diagnosis of "rule out appendicitis." The nurse assesses this client for which manifestations? Select all that apply. 1. Generalized abdominal pain 2. Pain localizing in right lower quadrant 3. Fatty stools 4. Elevated white blood cell count 5. Indigestion

Answer: 1, 2, 4 Rationale: Manifestations of appendicitis often begin with generalized abdominal pain. As abdominal pain progressively worsens, it tends to localize in the right lower quadrant at McBurney's point. Elevated WBC count can elevate to 15,000 to 20,000 cells/mm3 because of the inflam- matory response. Fatty stools are not part of the clinical pic- ture. Indigestion is not typical, although the client may have nausea and vomiting, fever, chills, anorexia, diarrhea or acute constipation.

The nurse is educating the client with gastroesophageal reflux disease (GERD) about ways to minimize symptoms. Which information in the client's history should the nurse address as an indicator that needs to be changed? Select all that apply. 1. Lifting weights for exercise 2. Being a vegetarian 3. Having a body mass index of 26 4. Taking calcium carbonate tablets 5. Drinking 2-4 cups of coffee daily

Answer: 1, 3, 5 Rationale: Lifestyle modifications can minimize symptoms of GERD. Anything that increases intra- abdominal pressure should be avoided, such as lifting weights. Obesity or being overweight also aggravates symptoms, as indicated by a body mass index of 26. Coffee, cola, other sources of caffeine, and chocolate decrease lower esophageal sphincter tone and can increase symptoms of GERD. Being a vegetarian does not increase risk of GERD. Calcium carbonate tablets (Tums) often aid in symptom relief.

Which assessments made by the nurse could indicate the development of portal hypertension in a client with cirrhosis? Select all that apply. 1. Hemorrhoids 2. Bleeding gums 3. Muscle wasting 4. Splenomegaly 5. Ascites

Answer: 1, 4, 5 Rationale: Obstruction to portal blood flow causes a rise in portal venous pressure resulting in splenomegaly, ascites, and dilation of collateral venous channels predominantly in the paraumbilical and hemorrhoidal veins, the cardia of the stomach, and extending into the esophagus. Bleeding gums would indicate insufficient vitamin K production in the liver. Muscle wasting commonly accompanies the poor nutritional intake commonly seen in clients with cirrhosis.

The health care provider orders a medication in a dose that is considered toxic. The nurse administers the medication to the client, who later suffers a cardiac arrest and dies. What consequence can the nurse expect from this situation? Select all that apply. 1. The health care provider can be charged with negligence, being the person who ordered the dose. 2. As the employing agency, only the hospital can be charged with negligence. 3. The nurse and physician may be terminated from employment to prevent a charge of negligence to the hospital. 4. Negligence will not be charged, as this event could happen to any reasonable person. 5. The nurse can be charged with negligence for administering the toxic dose.

Answer: 1, 5 Rationale: Health care providers who prescribe incorrect dosages of medications are liable for their errors. The nurse is open to a charge of negligency for failing to verify and question the incorrect dose. The hospital can be sued as the responsible employing agency, but the health care provider and the nurse can also be charged with negligence. Terminating the health care provider and nurse from employment would not stop a lawsuit charging negligence for employee actions that have already taken place. Prescribing and administering incorrect doses are not considered events that routinely hap- pen to "reasonable person."

11 The nurse should evaluate results of which laboratory tests while caring for a client who has cirrhosis of the liver? Select all that apply. 1. Prothrombin time 2. Urinalysis 3. Serum lipase 4. Serum troponin 5. Serum albumin

Answer: 1, 5 Rationale: Many clotting factors are produced in the liver, including fibrinogen (factor I), prothrombin (factor II), factor V, serum prothrombin conversion accelerator (factor VII), factor IX, and factor X. The client's ability to form these factors may be impaired with cirrhosis, putting the client at risk for bleeding. The prothrombin time will evaluate blood clotting ability. Urinalysis is a general screening measure or can be used to diagnose problems with the urinary tract. Serum lipase is a useful indicator of disorders of the pan- creas. Serum troponin is a common laboratory test used to diagnose myocardial infarction. One function of the liver is to synthesize protein, which may be impaired with cirrhosis.

The client returning from a colonoscopy has been given a diagnosis of Crohn's disease. The oncoming shift nurse expects to note which manifestations in the client? Select all that apply. 1. Steatorrhea 2. Firm, rigid abdomen 3. Constipation 4. Enlarged hemorrhoids 5. Diarrhea

Answer: 1, 5 Rationale: Steatorrhea is often present in the client with Crohn's disease. Diarrhea is also key feature, but unlike ulcerative colitis, the loose stool usually does not contain blood and is usually less frequent in number of episodes. A firm rigid abdomen is not a manifestation of Crohn's disease. Constipation is not a manifestation of Crohn's disease. Hemorrhoids are not a manifestation of Crohn's disease.

The client who has ulcerative colitis is scheduled for an ileostomy. When the client asks the nurse what to expect related to bowel function and care after surgery, what response should the nurse make? 1. "You will be able to have some control over your bowel movements." 2. "The stoma will require that you wear a collection device all the time." 3. "After the stoma heals, you can irrigate your bowel so you will not have to wear a pouch." 4. "The drainage will gradually become semisolid and formed."

Answer: 2 Rationale: A client with an ileostomy has no control over bowel movements and must always wear a collection device. The drainage tends to be liquid but becomes paste- like with intake of specific foods.

A child has been admitted to the unit with nephrotic syndrome. In talking with the mother, she reports that a cousin had acute glomerulonephritis (AGN) last year. The mother asks how these two diseases compare, as they both affect the kidneys. The nurse's response would include which piece of information? 1. Both disorders produce smoky colored urine. 2. Both disorders cause greatly reduced urine output. 3. Both disorders have a genetic basis. 4. Both disorders require treatment with antibiotic therapy.

Answer: 2 Rationale: Both AGN and nephrotic syndrome are characterized by a reduction in urine output. AGN presents with smoky urine while the urine in nephrotic syndrome is clear and frothy. AGN is a postinfectious disease with no genetic basis. Antibiotics are not used in nephrotic syndrome.

Which laboratory data is the most accurate indicator that a client with acute renal failure has met the expected outcomes? 1. Decreasing blood urea nitrogen (BUN) levels 2. Decreasing serum creatinine 3. Decreasing neutrophil count 4. Decreasing lymphocyte count

Answer: 2 Rationale: Creatinine is the metabolic end product of creatine phosphate and is excreted via the kidneys in relatively constant amounts. BUN, a measurement of the nitrogen portion of urea, is also excreted in urine and is a good indicator of renal function. However, conditions that increase protein catabolism also cause a rise in BUN levels. Therefore, the serum creatinine levels are more appropriate to evaluate in determining the return of renal function. Neutrophils and lymphocytes are not used to monitor the return of renal function.

A nurse who floats to the infant and toddlers nursing unit asks the pediatric nurse about the notation "ESSR" on the care plan of a client. The nurse explains that this documentation refers to which item? 1. The feeding method for children with gastroesophageal reflux 2. The feeding method for children with cleft lip or palate 3. The procedure for repair of pyloric stenosis 4. The procedure for repair of Hirschsprung's disease

Answer: 2 Rationale: ESSR is the abbreviation for the four key steps in feeding the infant or child with cleft lip or palate. These steps are to Enlarge nipple; Stimulate suck reflex; Swallow fluid; Rest after each swallow. It does not refer to a treatment or feeding method used in gastroesophageal reflux, pyloric stenosis, or Hirschsprung's disease.

The client with a duodenal ulcer asks the nurse why an antibiotic is part of the treatment regimen. Which information should the nurse include in the response? 1. Antibiotics decrease the likelihood of a secondary infection. 2. Many duodenal ulcers are caused by the Helicobacter pylori organism. 3. Antibiotics are used in an attempt to sterilize the stomach. 4. Many people have Clostridium difficile, which can lead to ulcer formation.

Answer: 2 Rationale: Helicobacter pylori infection is a major cause of peptic ulcers so treatment includes antibiotic therapy to eradicate the microorganisms. Antibiotics do not reduce the likelihood of a secondary infection; they treat the primary infection. Antibiotics are not used to sterilize the bowel, which would upset the normal flora of the GI tract. Clostridium difficile is a contagious microorganism that can lead to severe diarrhea.

A nurse forgets to administer a client's diuretic and the client experiences an episode of pulmonary edema. The charge nurse would consider the medication error to constitute negligence because the situation contains which element? 1. Purposeful failure to perform a health care procedure 2. Unintentional failure to perform a health care procedure 3. Act of substituting a different medication for the one ordered 4. Failure to follow a direct order by a physician

Answer: 2 Rationale: Negligence is the unintentional failure of an individual to perform or not perform an act that a reason- able person would or would not do in the same or similar circumstances. A purposeful failure to perform a procedure would be the opposite of negligence, which is unintentional. Substituting a different medication does not fit the description of the situation in the question. Failure to follow a direct order does not fit the description in the situation in the question.

The nurse caring for a client with uncomplicated choleli- thiasis anticipates that the client's laboratory test results will show an elevation in which of the following? 1. Serum amylase 2. Alkaline phosphatase 3. Mean corpuscular hemoglobin concentration (MCHC) 4. Indirect bilirubin

Answer: 2 Rationale: Obstructive biliary disease causes a significant elevation in alkaline phosphatase. Serum amylase would increase in pancreatic disorders. MCHC is one type of red blood cell index used to differentiate among different types of anemia. Obstruction in the biliary tract causes an elevation in direct bilirubin, not indirect bilirubin.

The mother of a child undergoing an emergency appendectomy tells the nurse, "If I had brought him in yesterday when he complained of an upset stomach, this wouldn't have happened." What is the best response by the nurse? 1. "It's okay; you got him here just in time before it ruptured." 2. "It is often difficult to predict when a simple complaint will become more serious." 3. "Next time he seems sick, you should bring him in immediately." 4. "Sometimes parents can make a mistake without meaning to do so."

Answer: 2 Rationale: Parents often react to a child's illness with feelings of guilt for not recognizing the severity of the condition sooner. A response that provides emotional support and reduces parental anxiety encourages parents to feel confident in their abilities as caregiver. Telling the parent "it's OK" ignores the parent's feelings. Directing the parent to seek care immediately next time adds to the parent's stress. Using the word "mistake" adds to the parent's perceived guilt.

In a child with acute renal failure, the nurse would help to prevent hyperkalemia by limiting which foods in the child's diet? 1. Grains, cheese, and citrus fruits 2. Potatoes, tomatoes, and oranges 3. Cereals, processed sugars, and wheat 4. Rice, leafy green vegetables, and carbonated beverages

Answer: 2 Rationale: Potatoes, tomatoes, and oranges have a high level of potassium content. The others have less potassium in them.

A client with urinary tract infection (UTI) is prescribed phenazopyridine (Pyridium). Which instruction would the nurse give the client? 1. "This drug will take care of the infection causing your symptoms." 2. "Your urine may turn reddish orange and may cause staining of your clothes." 3. "Take the drug before meals to minimize GI symptoms." 4. "Always keep this drug and use it at the first symptom of a UTI."

Answer: 2 Rationale: The drug makes the urine reddish orange in color, and the client should be advised that this might stain the underwear and other clothing. The client should also be reassured that it should not be confused with blood in the urine. Phenazopyridine does not target the cause of the infection. Taking the drug after meals minimizes GI symptoms associated with the use of this drug. Indiscriminate use of a urinary analgesic can mask symptoms and delay initiation of treatment.

Which statements made by a client who has received a renal transplant indicates that the desired outcome of discharge teaching has been met? Select all that apply. 1. "I will double my prednisone dose if my urine output is less than 300 mL/day." 2. "I will need to avoid crowds and prevent infection." 3. "Now I can eat whatever I want as long as I watch how much salt I use." 4. "Since I have not yet rejected the transplant, I never have to worry about rejection anymore." 5. "I should check my temperature and report increases to the physician."

Answer: 2, 5 Rationale: Clients with renal transplant need to be on long-term immunosuppressive drugs that predispose them to infection. The client must verbalize factors that potentially expose him to infection. Self-monitoring of temperature helps the client detect signs of rejection early that can be reported to the physician. The client must adhere to medication doses prescribed by the physician. Dietary restrictions for sodium must be discussed with the physician and the dietician. The success of transplantation is not guaranteed and the client could experience signs of rejection after discharge.

An adult female ambulatory care client receiving an oral anticoagulant is given aspirin for a headache while visiting a neighbor, who is a nurse. The client subsequently has a bleeding episode because of a drug interaction. The legal nurse consultant interprets that which necessary ele- ments of malpractice are missing from this case? Select all that apply. 1. Breech of duty 2. Duty owed 3. Injury experienced 4. Causation between nurse's action and injury 5. Intent to cause harm or injury

Answer: 2, 5 Rationale: There was no nurse-client relationship because the nurse was acting as a neighbor and not in an employment capacity. Thus, there can be no duty owed. Intent is not a necessary element of malpractice, because malpractice can occur because of unintended actions as well. There was no breach of duty because there was no official nurse-client relationship, which accompanies an employment situation. There was injury experienced because of this event. The bleeding was caused by the interaction of the aspirin with the anticoagulant.

Which statement made by a client with polycystic kidney disease indicates that the desired outcome has been met? 1. "I know these drugs will make the cysts disappear." 2. "The development of renal failure with this disease is very rare." 3. "I will have my family seek genetic counseling and screening." 4. "I sure am glad that hemodialysis will shrink the cysts."

Answer: 3 Rationale: Adult polycystic kidney disease is an autosomal-dominant disorder, and the client should be advised to have family members screened for the disease. The cysts will not disappear. Eventually, clients with this disease require dialysis or transplantation because of renal failure. The management of clients with polycystic kidney disease is mainly supportive and not curative.

A client with chronic renal failure asks the nurse why he is anemic. What response by the nurse is best? 1. "The increased metabolic waste products in your body depress the bone marrow." 2. "We will need to review your dietary intake of iron-rich foods." 3. "There is a decreased production by the kidneys of the hormone erythropoietin." 4. "It is most likely that you have hereditary traits for the development of anemia."

Answer: 3 Rationale: Anemia is common in clients with renal failure because of decreased production of erythropoietin by the kidneys and shortened RBC life. Erythropoietin is involved in the stimulation of the bone marrow to produce RBCs. Metabolic wastes do not depress the bone marrow. Anemia is common in clients with renal failure but is not caused by iron deficiency. Heredity does not play a role in anemia associated with renal failure.

A client is referred to a surgeon by the general practitio- ner. After meeting the surgeon, the client decides to find a different surgeon to continue treatment. The nurse sup- ports the client's action, utilizing which ethical principle? 1. Beneficence 2. Veracity 3. Autonomy 4. Privacy

Answer: 3 Rationale: Autonomy is the right of individuals to take action for themselves. Beneficence is an ethical princi- ple to do good and applies when the nurse has a duty to help others by doing what is best for them. Veracity refers to truthfulness. Privacy is the nondisclosure of information by the health care team.

A client with cancer has decided to discontinue further treatment. Although the nurse would like the client to continue treatment, the nurse recognizes the client is competent and supports the client's decision using which ethical principle? 1. Justice 2. Fidelity 3. Autonomy 4. Confidentiality

Answer: 3 Rationale: Autonomy refers to the right to make one's own decisions, which is the principle supported in this situation. Justice refers to fairness. Fidelity refers to trust and loyalty. Confidentiality refers to the right to privacy of personal health information. C

A client with diverticular disease undergoes a colonoscopy. During an abdominal assessment, the nurse looks for which sign to indicate a possible complication of the procedure? 1. Diarrhea 2. Nausea and vomiting 3. Guarding and rebound tenderness 4. Redness and warmth of the abdominal skin

Answer: 3 Rationale: Bowel perforation is a possible result of colonoscopy if the colonoscope accidentally pierces the bowel wall. Perforation could lead to symptoms of peritonitis, such as guarding and rebound tenderness. The other options are incorrect, because diarrhea, nausea and vomiting as signs of obstruction, and redness and warmth of abdominal skin are not of concern.

A client with renal calculi is advised to restrict calcium in the diet. The nurse determines that the client understands the restriction when the client states to avoid which types of foods? 1. Chicken, beef, and salmon 2. Green vegetables, fruit, and legumes 3. Chocolate, smoked fish, and low-fat milk 4. Eggs, meat, and poultry

Answer: 3 Rationale: Chocolate, smoked fish, milk products, beans, lentils, and dried fruits are high in calcium. In calcium phosphate and calcium oxalate calculi, dietary management includes an acid-ash diet and limiting foods high in calcium and oxalate. The other foods listed may be consumed as desired.

A client with end-stage renal disease (ESRD) is to be admitted to the hospital because of shortness of breath. The serum potassium level is 7.0 mEq/L. What appropriate hospital unit should this client be admitted to? 1. A semiprivate room in a medical surgical unit 2. A private room in a medical surgical unit 3. A nursing unit with continuous cardiac monitoring 4. A nursing unit for ventilator-assisted clients

Answer: 3 Rationale: Clients with potassium levels of 6.5 and greater are predisposed to develop cardiac arrhythmias, muscle cramps, and gastrointestinal symptoms. The client should be admitted to a nursing unit with telemetry or cardiac monitoring capabilities because of the risk of developing life-threatening cardiac dysrhythmias. Typical ECG abnormalities associated with hyperkalemia are prolonged PR interval; wide QRS; tall, tented T-wave; and ST segment depression. Major cardiac dysrhythmias common in clients with highly elevated potassium levels include heart block, ventricular standstill, and ventricular fibrillation. A semi-private room may not necessarily have cardiac monitoring. A private room is not necessary. The client does not need to be admitted to a unit with ventilated clients.

A client with chronic renal failure has fluid volume excess. The laboratory report indicates the sodium level to be 120 mEq/L. The nurse interprets this as which of the following? 1. An elevated sodium level that must be reported immediately to the physician 2. An error in the laboratory analysis 3. A possible hemodilution effect secondary to excessive water retention 4. An expected reduced number of sodium ions in clients with chronic renal failure

Answer: 3 Rationale: Clients with renal failure retain sodium, and any decrease in the serum level (normal 135-145 mEq/L) will most likely be caused by hemodilution from the excessive fluid retention. A sodium level of 120 mEq/L is significantly lower than normal. There is no reason to conclude there is a laboratory error. Clients with renal failure retain sodium, and the number of sodium ions would be expected to increase if there was not a corresponding increase in fluid retention.

The nurse is teaching home feeding guidelines to the mother of a child with nonorganic failure to thrive. Essential information for the nurse to include would be the importance of which item? 1. Restricting eating except at mealtimes 2. Allowing the child to eat alone to minimize distraction 3. Allowing the child to snack on finger foods, such as circular oat cereal and bananas 4. A relaxed mealtime with few limits on behavior

Answer: 3 Rationale: Finger foods are helpful in encouraging children with failure to thrive to increase food intake. The parent should be taught to encourage increased food intake, including between meal snacks. The child does not need to eat alone; instead mealtimes should be structured family events. Although a relaxed atmosphere is good, there can be limits on behavior during mealtimes to provide structure.

The nurse is caring for a child with a history of severe diarrhea. Which notation about acid-base imbalance would the nurse expect to find in the medical record? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

Answer: 3 Rationale: In severe diarrhea, excess bicarbonate (base) is lost, which predisposes to metabolic acidosis. There is also carbohydrate malabsorption and depletion of glycogen stores, resulting in fat metabolism. Ketoacids are the by-products of fat metabolism, which adds to the metabolic acidosis. Diarrhea is not a respiratory proble

A mother arrives at the pediatric clinic with her 6-month- old infant. While the nurse assesses the child, the mother points to the umbilicus and says: "What am I going to do about this? When he cries, it looks like it's going to burst." What is the best response by the nurse? 1. "It's best if you don't let him cry." 2. "It probably won't rupture unless he gets excessively upset. I wouldn't worry about it at this time." 3. "I know it looks frightening, but it really won't burst." 4. "Put a binder around it, and that will keep it from bursting when he gets upset."

Answer: 3 Rationale: It is a common finding that when the infant with an umbilical hernia cries, the hernia protrudes but will not rupture. It is unnecessary to try to prevent the infant from crying. An umbilical hernia will not rupture because the infant gets upset and this response does not reassure the par- ent. The family is instructed not to apply tape, straps, or coins to the umbilicus to reduce the hernia.

A child with Hirschsprung's disease is being discharged after Soave endorectal pull-through procedure for colostomy closure. Which item should the nurse include in the discharge teaching plan? 1. Stools may be infrequent and uncomfortable for the first few weeks. 2. It will be necessary to perform weekly rectal irrigations for approximately 6 weeks. 3. Report fever, increasing pain or discomfort, or redness of the incision to the surgeon. 4. Stools will be fatty for a week or so and then gradually return to normal.

Answer: 3 Rationale: It is important that any signs of infection be reported at once. After the Soave procedure, normal bowel function is expected. No rectal irrigations are necessary. Stools are not fatty for a week or so following the Soave procedure.

A 9-year-old male client with severe esophagitis is 12 hours status/post-Nissen fundoplication for gastroesophageal reflux. What action by the nurse would be appropriate while providing nursing care? 1. Encourage him to take small amounts of clear liquids every 4 hours. 2. Administer nasogstric or gastrostomy feedings every 4 hours. 3. Ask him to choose a face on the Wong FACES pain rating scale. 4. Insert a pH probe to monitor esophageal acidity.

Answer: 3 Rationale: Pain management is a high priority following gastric surgery, and the nurse should use age- appropriate tools to assess for pain, such as the Wong FACES rating scale. A gastrostomy tube or nasogastric tube placed during surgery is kept in place to maintain gastric decompression so drinking is not allowed. The child is kept NPO until bowel function returns. The use of a pH probe to measure gastric acidity is not necessary.

A client in the intensive care unit develops prerenal failure following surgery. Which of the following causes should the nurse suspect? 1. Vascular disease 2. Urethral obstruction 3. Hypovolemia 4. Glomerulonephritis

Answer: 3 Rationale: Prerenal failure is caused by factors such as hypovolemia and decreased cardiac output that reduce renal blood flow and perfusion. Vascular disease may be a factor in the development of intrarenal failure. Urethral obstruction can cause postrenal failure. Glomerulonephritis may be a factor in the development of intrarenal failure

The nurse is caring for a client who has ascites, and the health care provider prescribes spironolactone (Aldactone). The client asks why this drug is being used. What is the best response by the nurse? 1. "This drug will help increase the level of protein in your blood." 2. "The drug will cause an increase in the amount of the hormone aldosterone your body produces." 3. "This medication is a diuretic but does not make the kidneys excrete potassium." 4. "This will help you excrete larger amounts of ammonia."

Answer: 3 Rationale: Spironolactone is used in clients with ascites who show no improvement with bedrest and fluid restriction. It inhibits sodium reabsorption in the distal tubule and promotes potassium retention by inhibiting aldosterone. Spironolactone does not increase protein levels in the blood. Spironolactone does not increase production of aldosterone. Spironolactone does not aid in excreting ammonia, although lactulose (Cephulac) will do this.

In caring for a client 4 days post-cholecystectomy, the nurse notices that drainage from the T-tube is 600 mL in 24 hours. Which is the most appropriate action by the nurse? 1. Clamp the tube q 2 hours for 30 minutes 2. Place the patient in a supine position 3. Assess drainage characteristics and notify the physician 4. Encourage an increased fluid intake

Answer: 3 Rationale: The T-tube may drain up to 500 mL in the first 24 hours and decreases steadily thereafter. If there is excessive drainage, the nurse should further assess the drain- age to be able to describe it accurately and notify the physi- cian immediately. Clamping the T-tube after the first 24 hours would be contraindicated as it is too soon to do this. Placing the client in a supine position will not alter the flow of T-tube drainage. While increased fluids in general would offset fluid loss from the T-tube, this does not address the significance of the excessive drainage.

A client has a total gastrectomy. The nurse explains to the client the need for long-term injections of which vitamin? 1. Thiamine 2. Folic acid 3. Cyanocobalamin 4. Niacin

Answer: 3 Rationale: The loss of parietal cells that secrete intrinsic factor results in vitamin B12 (cyanocobalamin) defi- ciency postgastrectomy, because intrinsic factor is needed for absorption of vitamin B12. For this reason, clients require vitamin B12 injections for life. The other options identify other B-complex vitamins.

The nurse is explaining the process of peritoneal dialysis to a client who recently developed renal failure. Which statement would the nurse include in a discussion with the client? 1. "The solutes in the dialysate will enter the bloodstream through the peritoneum." 2. "The peritoneum is more permeable because of the presence of excess metabolites." 3. "The peritoneum acts as a semipermeable membrane through which wastes move by diffusion and osmosis." 4. "The metabolites will move from the interstitial space to the bloodstream mainly through diffusion and ultrafiltration."

Answer: 3 Rationale: The peritoneum acts as a semipermeable membrane, allowing substances to move from an area of high concentration (the blood) to an area of lower concentration (the dialysate). Metabolic waste products and excess water can be eliminated through osmosis and diffusion utilizing the peritoneum as the semipermeable membrane.

A male client who presents to the emergency department with coffee-colored urine and edema states he had a bad sore throat a few weeks ago. His blood pressure is elevated, and urinalysis shows blood and protein in the urine. The nurse interprets that this clinical picture is consistent with which developing health problem? 1. Urinary tract infection 2. Urinary calculi 3. Acute glomerulonephritis 4. Acute prostatitis

Answer: 3 Rationale: The symptoms are typical of acute glomerulonephritis. Hematuria and proteinuria are caused by a damaged glomerular capillary membrane, which allows blood cells and proteins to escape into the renal filtrate. A urinary tract infection usually manifests with signs of infection including fever, malodorous urine, frequency, and urgency. Clients with urinary calculi usually present with renal colic. Prostatitis, or inflammation of the prostate gland, has presenting symptoms similar to a urinary tract infection.

A nurse and teacher are discussing legal issues related to the practice of their professions. The teacher asks what the functions are of the Nurse Practice Act (NPA) in that state. The nurse would include which thoughts in a response? Select all that apply. 1. Accredit schools of nursing 2. Enforce ethical standards of behavior 3. Protect the public 4. Define the scope of nursing practice 5. Determine liability insurance rates

Answer: 3, 4 Rationale: A state's NPA serves to protect the public by setting minimum qualifications for nursing in rela- tion to skills and competencies. One way it fulfills responsi- bility to protect the public is by defining the scope of nursing practice in that state. The state board of nursing approves schools to operate but does not accredit them. The state board of nursing does not enforce ethical standards. A state NPA has no role in setting liability insurance rates for nurses.

The nurse is conducting dietary teaching with a client who has dumping syndrome. The nurse encourages the client to avoid which foods that the client usually enjoys? Select all that apply. 1. Eggs 2. Cheese 3. Fruit 4. Pork 5. Cookies

Answer: 3, 5 Rationale: Dumping syndrome, in which gastric contents rapidly enter the bowel, can occur following gastrectomy. Dietary fats and proteins are increased, and carbohydrates, especially simple carbohydrates such as fruits and desserts, are reduced. This helps slow the GI transit time and reduce the GI cramping, diarrhea, and vasomotor symptoms associated with dumping syndrome.

A client with a urinary diversion device has the nursing diagnosis Risk for Impaired Skin Integrity. Which interventions will the nurse use with this client? Select all that apply. 1. Change urine collection device every other day. 2. Teach self-catheterization technique. 3. Empty the bag reservoir every 2 hours. 4. Monitor for foul-smelling urine. 5. Ensure appliance wafer is not more than 1/8 inch larger than stoma.

Answer: 3, 5 Rationale: Emptying the reservoir bag every 2 hours prevents overfilling and possible leakage of urine into the skin surface. Ensuring that opening is not more than 1/8 inch larger than stoma reduces the risk of skin irritation and breakdown from urine on the skin. The urine collection device should be changed as needed to maintain integrity of the system. Self- catheterization is not appropriate for this nursing diagnosis. Monitoring for foul-smelling urine and monitoring for signs of infection are more appropriate interventions for the diagnosis risk for infection.

The nurse working in an acute care environment would utilize which strategies to reduce the risk of malpractice litigation? Select all that apply. 1. Discuss any errors with the client and family in detail. 2. Keep incident reports on file. 3. Maintain expertise in practice. 4. Offer opinions to clients when the situation warrants. 5. Report unsafe staffing levels to supervisor.

Answer: 3, 5 Rationale: Maintaining expertise in practice by keeping up to date in knowledge and skills aids in reducing the risk of malpractice claims by fostering continued competence in practice. Unsafe staffing levels can result in a higher incidence rate of errors, which could later lead to charges of malpractice. Thus, reporting such situations so they can be prevented should be beneficial. Discussing errors in detail with the client and family does not reduce the risk of a mal- practice claim. Incident reports should be kept on file but do not decrease the risk of malpractice litigation. The nurse should not offer opinions at any time as this is not part of therapeutic communication.

The nurse is caring for a client with a history of alcoholism. Which findings would indicate that the client has possibly developed chronic pancreatitis? Select all that apply. 1. Steady weight gain 2. Flank pain on left side only 3. Fatty stools 4. Excessive hunger 5. Constipation and flatulence

Answer: 3, 5 Rationale: Steatorrhea (fatty stools) result from a decrease in pancreatic enzyme secretion with pancreatitis. The client with chronic pancreatitis is likely to experience bouts of constipation and flatulence. The client with chronic pancreatitis is likely to experience weight loss rather than weight gain. The pain of pancreatitis is felt in the abdomen and is not limited to the left flank. Manifestations of chronic pancreatitis include nausea and vomiting rather than excessive hunger.

The nurse is caring for an adult client with poor urine output. The nurse would report to the health care provider if the client had a urine output less than how many milliliters (mL) per hour for 2 consecutive hours? Provide a numerical answer.

Answer: 30 Rationale: The minimal urine output by the kidneys per hour is 30 mL. It is prudent for the nurse to report a drop below this amount if it persists for 2 hours or longer so that corrective treatment can be undertaken.

When caring for a client who has cirrhosis, the nurse notices flapping tremors of the wrist and fingers. How should the nurse chart this finding? 1. "Trousseau's sign noted." 2. "Caput medusa noted." 3. "Fetor hepaticus noted." 4. "Asterixis noted."

Answer: 4 Rationale: Asterixis, also called liver flap, is the flapping tremor of the hands when the arms are extended. Trousseau's sign reflects hypocalcemia. Caput medusa refers to spiderlike abdominal veins that are also commonly found in clients with cirrhosis who have portal hypertension as a complication. Fetor hepaticus is a specific odor noted in liver failure.

A 10-month-old female infant with biliary atresia is being discharged after a Kasai procedure. Which statement, if made by the parents, indicates that teaching with regard to prognosis has been understood? 1. "We are glad this problem was found so early; now everything will be fine." 2. "We will stop her liver medicine now that she is being discharged." 3. "We are happy to be able to stop that special formula and many of those vitamins." 4. "We know that even though surgery is over, she will likely need a liver transplant."

Answer: 4 Rationale: Because the Kasai procedure is palliative, a liver transplant is required in 80 to 90% of cases. The Kasai procedure is not curative, and prognosis is best if performed before 10 weeks of age. Its purpose is to achieve biliary drainage and avoid early liver failure. Medications need to be continued after discharge as prescribed. Formula vitamins need to be continued after the procedure.

A staff nurse concerned about maintaining client confidentiality would take which action while carrying out assigned duties? 1. Read the records of clients not assigned to the nurse to become more familiar with disease processes. 2. Share information about a client with nurses from the unit to which the client may eventually be transferred. 3. Allow the client's family to review the medical record to obtain answers to their questions. 4. Share information about the client with those involved in planning nursing care.

Answer: 4 Rationale: Client confidentiality is maintained when the nurse shares client information only with those currently involved in the plan of care. Staff should only access information about clients currently assigned to their care and should not access information about other clients on the unit not assigned to them. Client information should not be shared with nurses who are not currently working with the client. Family members would need approval from the client and the health care provider prior to reviewing a medical record

A client asks why a diagnostic test has been ordered and the nurse replies, "I'm unsure but will find out for you." When the nurse later returns and provides an explanation, the nurse is acting under which principle? 1. Nonmaleficence 2. Veracity 3. Beneficence 4. Fidelity

Answer: 4 Rationale: Fidelity means being faithful to agreements and promises. This nurse is acting on the client's behalf to obtain needed information and report it back to the client. Nonmaleficence is the duty to do no harm. Veracity refers to telling the truth for example, not lying to a client about a serious prognosis. Beneficence means doing good, such as by implementing actions (e.g., keeping a salt shaker out of sight) that benefit a client (heart condition requiring sodium- restricted diet).

The nurse caring for a client undergoing a hemodialysis procedure places high priority on evaluating the client frequently for what common complication during the treatment? 1. Hyperglycemia 2. Infection and fever 3. Dialysis dementia 4. Hypotension

Answer: 4 Rationale: Hypotension is the most common complication during hemodialysis and is related to several factors, including changes in serum osmolality and rapid removal of fluid from the intravascular compartment. Hyperglycemia could occur in peritoneal dialysis because of the glucose composition of the dialysate. Infection and fever should be an ongoing assessment, not just when the client is undergoing hemodialysis. Dialysis dementia is a progressive, long-term complication.

A client is scheduled for a fecal fat exam. In planning client education, the nurse includes that which dietary modification is necessary before the test? 1. Eat a fat-free diet the day before the exam. 2. Eat a high-fat meal right before the exam. 3. Eat a diet containing 35 grams of fat for 36 hours before the test. 4. Eat at least 100 grams of fat for 3 days before and during the test.

Answer: 4 Rationale: It is suggested that adults consume at least 100 grams of fat per day for 3 days before the test and throughout specimen collection. The other responses pro- vide incorrect information.

Which statement made by a client with chronic renal failure and who is on hemodialysis indicates the need for further teaching? 1. "I will report any increase in my weight of 5 pounds in a 2-day period." 2. "I take my prescribed antihypertensive drugs daily." 3. "I am careful to take precautions in the arm with the AV fistula." 4. "I comply with salt restrictions in my diet by using salt substitutes."

Answer: 4 Rationale: Many salt substitutes use potassium chloride. Potassium intake is carefully regulated in clients with renal failure, and the use of salt substitutes will worsen hyperkalemia. Increases in weight do need to be reported to the health care provider as a possible indication of fluid volume excess. The control of hypertension is essential in the management of a client with renal failure. An AV fistula does need to be protected from injury that could be caused by constricting clothing, venipunctures, and other items

A client was admitted to the hospital with cholelithiasis the previous day. Which new assessment finding indicates to the nurse that the stone has probably obstructed the common bile duct? 1. Nausea 2. Elevated cholesterol level 3. Right upper quadrant (RUQ) pain 4. Jaundice

Answer: 4 Rationale: Nausea and RUQ pain occur in cholelithiasis, but obstruction of the common bile duct results in reflux of bile into the liver, which produces jaundice. Alkaline phosphatase increases with biliary obstruction but cholesterol level does not increase

A child is being treated for nephrotic syndrome. The nurse has told the mother that it is important to keep the child's skin clean and dry. When the mother asks why, what rationale would the nurse include in a response? 1. The skin is fragile secondary to electrolyte deficiency. 2. Frequent urination may leave moisture on the skin that predisposes to breakdown. 3. Dietary restrictions make fighting infection hard. 4. The condition causes a reduction of gamma globulin in the body.

Answer: 4 Rationale: Nephrotic syndrome involves the loss of protein in the urine. Gamma globulins, which help the body fight infections, are proteins. There is no electrolyte deficiency. The child is oliguric and therefore does not urinate frequently. The only restrictions on the child's intake are fluid and perhaps sodium.

What type of renal failure would the nurse expect to see in a client who overdosed accidentally on tobramycin (Nebcin)? 1. Prerenal failure 2. Postrenal failure 3. Extrarenal failure 4. Intrarenal failure

Answer: 4 Rationale: Nephrotoxic drugs, such as aminoglycoside antibiotics (tobramycin), can damage the nephrons and cause intrarenal (within the kidneys) failure. Prerenal causes of renal failure include any condition that reduces the blood flow to the kidney, such as heart failure, shock, and other conditions. Postrenal failure can be caused by conditions that obstruct urine outflow in the lower urinary system. There is no condition called extrarenal failure.

In conducting client teaching with a client who will undergo peritoneal dialysis at home, the nurse includes discussion of what common and significant complication of peritoneal dialysis? 1. Pulmonary embolism 2. Hypotension 3. Dyspnea 4. Peritonitis

Answer: 4 Rationale: Peritonitis is a grave complication of peritoneal dialysis, caused by bacteria that may enter through the catheter or dialysate solution. Hypotension is a common complication of hemodialysis but not peritoneal dialysis. Pulmonary embolism and dyspnea are not common complications of peritoneal dialysis.

A client is scheduled for a partial nephrectomy. In teaching the client about postoperative care, the nurse uses which rationale to explain why aggressive measures are needed to prevent atelectasis and pneumonia? 1. Nephrectomy involves paralyzing the intercostal muscles. 2. Intraoperative surgical contamination of the pulmonary structures is unavoidable. 3. The client must be maintained in a flat position for 24 hours. 4. The surgery involves an upper abdominal or flank incision.

Answer: 4 Rationale: The proximity of the incision to the muscles involved in breathing and coughing makes the client breathe shallowly and avoid coughing because of the fear of pain. This can lead to atelectasis and pneumonia. The intercostal muscles are not paralyzed by nephrectomy. Pulmonary structures are not contaminated during surgery. The client should be turned and repositioned to reduce the risk of atelectasis and pneumonia. There is no need to lie flat for 24 hours.

The nurse is preparing to admit a client with urge incontinence. In writing the nursing care plan, the nurse writes interventions that target which manifestation? 1. Involuntary loss of urine without warning or stimulus 2. Loss of urine when coughing or sneezing 3. Inability to empty bladder 4. Inability to inhibit urine flow long enough to reach the toilet

Answer: 4 Rationale: Urge incontinence is the unpredictable passage of urine soon after a strong urge to void is felt. Total incontinence is involuntary loss of urine without warning or stimulus. Stress incontinence is loss of urine when intra-abdominal pressure rises, such as with coughing or sneezing. Urinary retention is an inability to empty the bladder.

Which clients are at the greatest risk for instability during the time of surgery (select all that apply): 1. The 96-year-old retired person who will have repair of a right foot bunion. 2. A 30-year-old cancer client who is mildly immunosuppressed following a recent round of chemotherapy 3. The 61-year-old client with a history of hypertension that is well controlled with medication 4. The 56-year-old client with a 10-year history of emphysema 5. A 23-year-old who is 5′ 6′′ tall and weighs 125 pounds

Answers 1, 2, 4. Rationale: Age, immunosuppression (even if mild at the time of surgery), and long-term respiratory compromise will increase the general risks for anesthesia and surgery.

Contemporary Med-Surg

Chapter 20

Med-surg

Chapter 21

Section 9

Chapter 59

Section 9

Chapter 60

Section 2

NCLEX chapter 5

Med surg

chapt 22