Prep U Questions Exam 2

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity? -"Drink 8 ounces of water three times daily and once at bedtime to remain hydrated." -"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer." Explanation: Wrinkling and poor skin turgor results from loss of elastic fibers and collagen changes in the dermal connective tissue. As such, clients should be taught to avoid soaps with artificial ingredients or fragrances, as these may be harsher on the skin. It is good to be clean; however, advice of taking at least two showers per day is excessive and may dry the skin. Moisturizer should be applied to the skin following bathing to prevent dryness of the skin. Drinking water is important to remain hydrated; however, the nurse should recommend drinking 1,500 to 2,000 mL of water daily. Drinking 8 ounces three times a day is 720 mL.

The nurse working at the blood bank is speaking with a potential blood donor client. The client has been living in South America where there was a Zika outbreak. Which statement by the nurse is most appropriate? -"Because you lived in South America for more than 3 months, there is risk of transmitting the Zika virus through blood transfusions." -"To prevent the spread of microorganisms, anyone who has lived out of the country for over 6 months is unable to donate blood."

"Because you lived in South America for more than 3 months, there is risk of transmitting the Zika virus through blood transfusions." Explanation: In February 2016, the U.S. Food and Drug Administration (FDA) issued recommendations to reduce the risk of transmission of the Zika virus through blood transfusion. The FDA recommends deferral of people from donating blood if they have been to areas with active Zika virus transmission, potentially have been exposed to the virus, or have had a confirmed Zika virus infection (FDA, 2016).

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? -"Fluid in the tissue space between and around cells." -"Fluid inside cells."

"Fluid in the tissue space between and around cells." Explanation: Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).

The nurse is caring for a client who is taking nitroglycerin. Which client statement requires immediate nursing intervention? -"I am taking tadalafil in addition to nitroglycerin." -"I will wear gloves when applying this."

"I am taking tadalafil in addition to nitroglycerin."

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response? -"You will need to use a bedpan while the chest tube is in position." -"I can assist you to the bathroom and back to bed."

"I can assist you to the bathroom and back to bed." Explanation: The client can move in bed, and ambulate while carrying the drainage system, as long as he or she has orders to do so. The nurse should supervise ambulation to the bathroom and back to bed while the client has the drain inserted to make sure it stays intact and to monitor for safety. Other answers are incorrect.

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? -"I should drink 1,500 mL/day of fluid." -"I should drink 2,500 mL/day of fluid."

"I should drink 2,500 mL/day of fluid." Explanation: In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss.

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response? -"Necrotic tissue is devitalized tissue that must be removed to promote healing." -"That is called slough, and it will usually fall off."

"Necrotic tissue is devitalized tissue that must be removed to promote healing." Explanation: The tissue the client is inquiring about is not normal. Dry brown or black tissue is necrotic. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge.

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response? -"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." -"The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage."

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action? -"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." -"Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin."

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." Explanation: The nurse should apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensuring that the product stays confined to the wound and does not impact on intact surrounding tissue/skin. Applying the medicated gel with an applicator allows for better control over the application, thus minimizing any additional trauma to wound. The procedure should be preformed using sterile technique, but clean technique can be used when proving care to chronic or pressure injury wounds. To manage contamination risk, cleansing of a wound should be done from top to center to outside.

A client has been admitted for fluid volume excess related to right sided heart failure. Which assessment data would the nurse expect related to the fluid volume excess? Select all that apply: -blood pressure 100/48 -crackles in the lungs -distended neck veins -poor skin turgor -excessive urination

-crackles in the lungs -distended neck veins

The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, in which temperature range will the nurse set the pad? -100°F to 104°F (37.7°C to 40°C) -105°F to 109°F (40.5°C to 43°C)

105°F to 109°F (40.5°C to 43°C)

A client's intake and output is being measured and recorded each shift. The client has had the following intake: Calculate the amount, in milliliters, the nurse documents as fluid on the intake sheet. Record your answer using a whole number. 3 oz apple juice 4 oz tea 5 oz pureed chicken 2 oz mashed potatoes 4 oz orange gelatin 2 oz vanilla ice cream -390 -600

390 Explanation: Intake measurements include all oral and parenteral fluids. Oral fluids include any liquids ingested or any foods that become liquid at room temperature. Gelatin and ice cream are examples of solid foods to include. Pureed foods is not considered fluid intake nor is mashed potatoes. Based on the measurements, the client consumed 13 oz of fluid. One ounce is equal to 30 ml, so 13 oz of fluid is equal to 390 mL.

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing? -60 drops/mL -30 drops/mL

60 drops/mL Explanation: Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL).

A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first? -Apply oxygen as prescribed -Raise the head of the bed

Apply oxygen as prescribed Explanation: The nurse should first apply oxygen, which will help to improve oxygen saturation and health status. The client may not require intubation, once oxygen is provided. Although the client may require education on incentive spirometry, the immediate priority intervention is to stabilize the client's oxygen saturation. Similarly, raising the head of the bed may help with the client's comfort but may not have sufficient effect on oxygen saturation.

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation? -Arterial blood gas -Hemoglobin levels

Arterial blood gas Explanation: Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? -Administer the prescribed analgesic. -Assess the client's wound and vital signs.

Assess the client's wound and vital signs.

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? -Use regular gum and hard candy. -Avoid salty or excessively sweet fluids.

Avoid salty or excessively sweet fluids. Explanation: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect.

A nurse is administering medication to a client with a gastrointestinal tube. Which intervention is a recommended guideline for medication administration using this route? - Crush medications to a fine powder and mix with 15 to 30 mL of water. - Follow medication administration with a 30- to 60-mL water flush between medication doses.

Crush medications to a fine powder and mix with 15 to 30 mL of water.

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? -Dehiscence of the wound -Herniation of the wound

Dehiscence of the wound

While receiving a medication IV piggyback, the client reports discomfort at the IV site. Upon assessment, the site is cool to the touch and slightly swollen. What is the best action by the nurse? -Discontinue the IV site and restart IV in a new location. -Monitor the site closely for any signs of complications.

Discontinue the IV site and restart IV in a new location.

The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that resulted in a pneumothorax. What nursing action is appropriate when constant bubbling is noted in the suction control chamber? -Contact the Rapid Response Team. -Document the finding.

Document the finding. Explanation: Constant bubbling in the suction control chamber is normal and should be documented. Other actions are inappropriate.

The nurse is preparing to change the IV tubing of a client receiving a peripheral venous IV infusion 5% dextrose and water based on the understanding that IV tubing is generally changed at which interval? -Every 96 hours. -Every 24 hours.

Every 96 hours. Explanation: Generally, IV tubing is changed every 72 to 96 hours. Changing the tubing helps to prevent contamination and bacterial growth.

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? -Green beans -Fish

Fish

The nurse is teaching a client how to take medications upon discharge. The client is alert and oriented but unable to articulate the teaching back to the nurse. What is the appropriate nursing action? -Give written instructions to the client and caregivers. -Arrange for home health to see the client.

Give written instructions to the client and caregivers.

Which situation accurately describes a recommended guideline when administering oral medications to clients? -If a client vomits immediately after receiving oral medications, readminister the medication. -If a child refuses to take medication, crush the medication, if allowable, and add to a small amount of food.

If a child refuses to take medication, crush the medication, if allowable, and add to a small amount of food.

The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate? You Selected: -it measures how much oxygen you receive -It decreases dry mucous membranes by delivering small water droplets.

It decreases dry mucous membranes by delivering small water droplets. Explanation: The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flow meter is a gauge used to regulate the amount of oxygen that a client receives. The health care provider prescribes concentration.

The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response? -Maintain the client's oxygenation and alert the health care provider immediately. -Page the respiratory therapist STAT.

Maintain the client's oxygenation and alert the health care provider immediately. Explanation: If the tracheostomy becomes dislodged and is not easily replaced, the nurse should notify the primary care provider immediately, cover the tracheostomy stoma, and assess client's respiratory status.

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? -Metabolic alkalosis -Metabolic acidosis

Metabolic alkalosis Explanation: Metabolic alkalosis is associated with an excess of HCO3, a decrease in H+ ions, or both, in the extracellular fluid (ECF). This may be the result of excessive acid losses or increased base ingestion or retention. Loss of stomach acid may result in this condition. Metabolic acidosis is a proportionate deficit of bicarbonate in ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate such as in diarrhea. Respiratory acidosis is when the carbon dioxide level is high and the ph is low. Respiratory alkalosis is when the carbon dioxide level is low and the ph is high.

The nurse is caring for a client with a yeast infection. Which medication does the nurse anticipate will be prescribed? -bisacodyl -Miconazole

Miconazole

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? -Do not attempt to remove the sutures because the wound needs more time to heal. -Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert? -Muscle weakness, fatigue, and dysrhythmias -Nausea, vomiting, and constipation

Muscle weakness, fatigue, and dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? -Have a loved one tell the client to drink more. -Offer small amounts of preferred beverage frequently.

Offer small amounts of preferred beverage frequently. Explanation: Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.

Which statement accurately describes a general consideration when performing CPR on a client? -Perform hands-only CPR for victims of drowning, trauma, and airway obstruction. -Perform CPR on an obese client the same as on a non-obese client.

Perform CPR on an obese client the same as on a non-obese client. Explanation: Perform CPR in the same manner if the client is obese. If the nurse is unsure whether the client has a pulse, CPR should be initiated anyhow. Hands-only CPR is not recommended for victims of drowning, trauma, airway obstruction, and acute respiratory distress. If available, use a one-way valve mask over a child's nose and mouth when performing CPR.

A nurse is caring for a client who is not able to take food orally for 1 week to 10 days. Which type of nutrition is the client likely receive? -Total parenteral nutrition -Peripheral parenteral nutrition

Peripheral parenteral nutrition Explanation: The client requires peripheral parenteral nutrition. Peripheral parenteral nutrition provides temporary nutritional support of approximately 2000 to 2500 calories daily. It can meet a client's metabolic needs when oral intake is interrupted for 7 to 10 days, or it can be used as a supplement during a transitional period as a client begins to resume eating. Total parenteral nutrition (TPN) is preferred for clients who are severely malnourished or may not be able to consume food or liquids for a long period. Metabolizing nutrition is a way to replenish and supply water to the body. A nasogastric feed is administered through narrow tubing that is inserted through the client's nose into the stomach; it is better suited for short-term nutrition.

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect? -Phlebitis -Infiltration

Phlebitis Explanation: Phlebitis is an inflammation of a vein caused by mechanical trauma from a needle or catheter. It is characterized by local acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Infiltration, the escape of fluid into the subcutaneous tissue, is caused by a dislodged needle or penetrated vessel wall. It is characterized by swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Sepsis, or infection, is caused by invasion of microorganisms. It is characterized by erythema, edema, induration, drainage at the insertion site, fever, malaise, chills, and other vital sign changes. Air embolism is air in the circulatory system caused by a break in the IV system above the heart level. It is characterized by respiratory distress, increased heart rate, cyanosis, decreased blood pressure, and a change in level of consciousness.

In preparing to administer a drug to a client, the nurse has pierced a multi-use vial of medication. What is the appropriate nursing action? -Place the date on the vial and retain for future use. -Send the vial with the remaining drug back to the pharmacy.

Place the date on the vial and retain for future use.

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing -Poor tissue perfusion -Congestive heart failure

Poor tissue perfusion Explanation: Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition.

The nurse is preparing to administer an intramuscular (IM) injection into a client. Which procedure should the nurse use to administer the injection? -Pull skin and subcutaneous tissue 1 to 1.5 in (2.5 to 3.75 cm) to one side of the injection site while injecting. -Pull the skin taut between two fingers while injecting.

Pull skin and subcutaneous tissue 1 to 1.5 in (2.5 to 3.75 cm) to one side of the injection site while injecting.

During a skin assessment, the nurse recognizes the first indication that a pressure injury may be developing when the skin is which color during the application of light pressure? -White -Red

Red Explanation: Nonblanching erythema is one of the earliest signs of impending skin breakdown. Blue-greyish color is pallor. Yellow is jaundice and related to liver issues. White skin is associated with no blood supply.

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? -Slow the rate of IV fluids. -Remove the IV.

Remove the IV. Explanation: The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order? -Residual Volume (RV) -Total lung capacity (TLC)

Residual Volume (RV) Explanation: During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds.

A nurse brings a client the prescribed dose of medication and finds that the client is not in the unit. What should the nurse do in this case? -Inform the head nurse about the client's absence. -Return the medication to the medication cart or medication room.

Return the medication to the medication cart or medication room.

The nurse is preparing to administer a bolus of furosemide 0.8 mg to a client with congestive heart failure and kidney disease. Which right of drug administration would the nurse question and confirm in this client? -Right client -Right time -Right drug -Right amount

Right drug

The nurse is determining a site for an IV infusion. What guideline should the nurse consider? -Antecubital veins should be used for long-term infusions. -Scalp veins should be selected for infants because of their accessibility.

Scalp veins should be selected for infants because of their accessibility. Explanation: Potential sites for neonates and children include: veins of the scalp (neonates under 6 months) because of the accessibility, and dorsal veins of the foot (toddlers). The antecubital veins are not a good choice for infusion because flexion of the client's arm can displace the IV catheter. The veins in the leg of an adult should not be used, unless other sites are inaccessible, because of the danger of stagnation of peripheral circulation and possible serious complications, such as deep vein thrombosis. Veins in surgical areas are not recommended and would not increase the potency of medication.

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action? -Stop removing staples and apply an abdominal pad over the incision. -Stop removing staples and inform the surgeon

Stop removing staples and inform the surgeon Explanation: If there are signs of dehiscence, the nurse should stop removing staples and inform the surgeon. The surgeon may or may not order further staple removal. An occlusive dressing or ABD pad will not adequately prevent further dehiscence.

The nurse is preparing to administer a transdermal medication. How should this be accomplished? - The nurse should inject the medication just below the dermis of the skin. - The nurse should apply the medication directly to the skin

The nurse should apply the medication directly to the skin

A nurse is preparing to re-site a client's IV during the client's hospital stay following a mastectomy. What accurately describes an assessment that should be made before starting the infusion? -The nurse should assess the preferred site, ideally the dorsal and ventral surfaces of the upper extremities. -The nurse should assess the arms and hands for a potential site, preferably in the antecubital vein.

The nurse should assess the preferred site, ideally the dorsal and ventral surfaces of the upper extremities. Explanation: The nurse should initiate venipuncture on the dorsal or ventral surface of the upper extremities. The IV should not be located in the antecubital vein because this site is vulnerable to displacement. The nondominant arm should be used for convenience, and extremities compromised from a previous condition should be avoided.

The nurse has begun caring for a surgical client who has been ordered preoperative antibiotics prior to bowel surgery. While the nurse will adhere to all the principles of safe medication administration, which domain will the nurse pay particular attention toroute in this situation? -Route -Documentation -Time -Place -Dosage

Time

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? -To splint the area when engaging in activity -To ambulate using a cane or walker

To splint the area when engaging in activity Explanation: To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating. Teaching the client to ambulate using a cane or walker may be necessary but is not done to support the underlying tissues or to decrease discomfort. It is done to ensure the client can use the ambulatory devices correctly. There is no indication that the client needs to stay in bed; in fact, ambulation should be encouraged. Teaching the client to turn the head away while coughing is done to aid in prevention of infection.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? -Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. -Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm.

Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. Explanation: Guidelines to determine suction catheter depth include the following: Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm past the length of the endotracheal tube. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the client, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm.

A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action? -Place the probe on the client's earlobe. -Warm the client's hands and try again.

Warm the client's hands and try again. Explanation: Finding an absent or weak signal, the nurse should check vital signs and client condition. If satisfactory, warming the extremity may facilitate a stronger reading. This should be attempted prior to resorting to using the client's earlobe. Bright light can interfere with the operation of light sensors and cause an unreliable report. A blood pressure cuff will compromise venous blood flow to the site leading to inaccurate readings.

Which client would most likely require placement of an implantable port? - a 58-year-old woman with stage 3 breast cancer requiring weekly chemotherapy - an 18-year-old man s/p gunshot wound in the ICU requiring multiple blood transfusions

a 58-year-old woman with stage 3 breast cancer requiring weekly chemotherapy

To which client would the nurse be most likely to administer a PRN medication? -a client who is reporting pain near the surgical site -a client whose asthma is treated with inhaled corticosteroids

a client who is reporting pain near the surgical site

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately? -a sterile, flexible applicator moistened with saline -a small plastic ruler

a sterile, flexible applicator moistened with saline

The nurse is caring for a client who has a heavily exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound? -an alginate dressing -an antimicrobial dressing

an alginate dressing

The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as: -apnea. -dyspnea.

apnea. Explanation: The newborn's breathing pattern is characterized by occasional pauses of several seconds between breaths. This periodic breathing is normal during the first 3 months of life, but frequent or prolonged periods of apnea (cessation of breathing 20 seconds or longer) are abnormal. Dyspnea refers to shortness of breath. Orthopnea refers to difficulty breathing when lying flat. An elevation of carbon dioxide levels in the blood is termed hypercapnia.

The nurse in the postanesthesia care unit (PACU) is assessing a new client who has just undergone abdominal exploratory laparotomy. Which response should the nurse prioritize after noting the SaO2 is 95% (0.95), blood pressure is 128/80 mm Hg, cardiac monitor is showing rare premature atrial contractions (PAC), and drainage on abdominal dressing is approximately 5 cm × 3 cm of pinkish drainage along the lower edge of the dressing? -record full electrocardiogram (ECG) and notify health care provider -apply additional dressing, especially over the lower edge where drainage is occurring

apply additional dressing, especially over the lower edge where drainage is occurring

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? -potassium and chloride -calcium and phosphorus

calcium and phosphorus Explanation: The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances. Sodium, chloride, and potassium are regulated by the kidneys and affected by fluid balance.

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for: -dehiscence. -herniation.

dehiscence.

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? -nausea and vomiting -distended neck veins

distended neck veins Explanation: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication? -hemorrhage -evisceration

evisceration Explanation: Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude.

The nurse observes a client practice pursed-lip breathing in preparation for discharge. Which action should the nurse point out needs correcting? -holds lips as though to whistle -exhales to a count of 4

exhales to a count of 4 Explanation: Expiration should be two to three times longer than inspiration, so it should be to the count of 6 or more. This will help remove more carbon dioxide from the lungs. The other actions demonstrate correctly performed pursed-lip breathing.

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? -febrile reaction: fever develops during infusion -hemolytic transfusion reaction: incompatibility of blood product

hemolytic transfusion reaction: incompatibility of blood product Explanation: The listed symptoms occur when a blood product is incompatible. Hives, itching, and anaphylaxis occur in allergic reactions; fever, chills, headache, and malaise occur in febrile reactions. In a bacterial reaction, fever; hypertension; dry, flushed skin; and abdominal pain occur.

The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis? -high respiratory rate -low blood pressure

high respiratory rate Explanation: A client diagnosed with Impaired Gas Exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.

The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate? -hypotonic -hypertonic

hypertonic Explanation: Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink. Because of a lower osmolarity, a hypotonic solution in the intravascular space moves out of the intravascular space and into intracellular fluid, causing cells to swell and possibly burst. An isotonic fluid remains in the intravascular compartment. Plasma is an isotonic solution.

The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers as well as showing signs of tetany. Which imbalance does the nurse suspect? -hypocalcemia -hypermagnesemia

hypocalcemia Explanation: The parathyroid gland regulates calcium levels, and partial removal can cause hypocalcemia. Hypocalcemia is manifested by numbness and tingling as well as tetany. The signs and symptoms do not relate to altered magnesium or potassium levels. Calcium and phosphorus have an inverse relationship, so with low calcium, the nurse will expect a high, not a low, phosphorus level.

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: -hypokalemia. -hypocalcemia.

hypokalemia. Explanation: The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has prescribed fly larvae to debride the wound. Which type of debridement does the nurse understand has been prescribed? -mechanical debridement -autolytic debridement

mechanical debridement Explanation: The use of fly larvae (maggot therapy) is a form of mechanical debridement, because their mandibles and rough body surface scratch the necrotic tissue. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed. Surgical (sharp) debridement is the removal of necrotic tissue from the healthy areas of a wound with sterile scissors, forceps, or other instruments.

The nurse is caring for a bedridden client who is at risk for the development of pressure injuries. In which position can the nurse place the client to relieve pressure on the trochanter area? -Trendelenburg -Oblique

oblique

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? -palpating the veins on the nondominant hand -placing the tourniquet on the upper arm for 2 minutes

placing the tourniquet on the upper arm for 2 minutes Explanation: The tourniquet should not be applied for longer than 1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client. Other options are correct techniques when preparing for venipuncture.

The nurse is caring for a client who has excess levels of carbon dioxide in the blood, and chronic hypoxemia. Which intervention will the nurse recommend? -diaphragmatic breathing -pursed-lip breathing

pursed-lip breathing Explanation: Pursed-lip breathing is most helpful for clients who have excessive levels of carbon dioxide in the blood and chronic hypoxemia. Other choices do not eliminate as much carbon dioxide from the blood.

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document? -serosanguineous -sanguineous

serosanguineous Explanation: Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink or pink-yellow. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors, such as green or yellow; this drainage indicates infection.

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present? -stage II -stage I

stage II

A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which stage should the nurse document for this wound? -unstageable wound -suspected deep tissue injury

suspected deep tissue injury

A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur? -trauma to the tracheal mucosa -prevention of suctioning

trauma to the tracheal mucosa Explanation: Occluding the Y-port on the suction tubing is what creates the suction. While suctioning would be difficult but possible, suctioning while advancing the tube would damage the tracheal mucosa and remove excessive amounts of oxygen, not carbon dioxide, from the respiratory tract. Suctioning during insertion of the catheter would not compromise sterility.

The nurse is caring for a confused client who requires a transdermal patch application. Which location will the nurse choose to apply the patch? -upper arm -upper back

upper back

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? -place a foot board on the bed -use pillows to maintain a side-lying position as needed

use pillows to maintain a side-lying position as needed Explanation: Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury.