Qbank #5
The nurse receives several telephone messages when performing triage. Which client will the nurse direct to come to the health care facility immediately? 1. Multipara client at four weeks gestation and reporting unilateral, dull abdominal pain. 2. Primigravida client at five weeks gestation and having vaginal spotting and some cramping. 3. Multigravida client at six weeks gestation reporting frank, red vaginal bleeding with moderate cramps. 4. Primipara client at seven weeks gestation and reporting an increase in whitish vaginal secretions.
ANSWER: 1 - The client reporting unilateral dull abdominal pain needs to be evaluated immediately for an ectopic pregnancy. Why 2 is wrong: the client having vaginal spotting and cramping is describing symptoms of a threatened abortion and should be instructed to decrease activity. Why 3 is wrong: the client having frank red vaginal bleeding with moderate cramps is describing symptoms of a spontaneous abortion and should be instructed to save and count the pads. Why 4 is wrong: whitish vaginal secretions is expected during the first trimester of pregnancy.
The nurse provides care for a postoperative client reporting pain. The nurse removes an opioid medication from the electronic medication dispensing system. Prior to administering the medication, the nurse notices that another nurse medicated the client with the same medication 5 minutes earlier. Which action is appropriate for the nurse to take? SATA. 1. Return the medication to the electronic medication dispensing system. 2. Document the near miss medication error in the client's record. 3. Notify the nursing supervisor. 4. Notify the client of the near miss. 5. Notify the HCP. 6. Measure the client's vital signs.
ANSWER: 1 - The unused medication in the original packaging should be returned to the electronic medication dispensing system. If the medication was removed from the original packaging, two nurses must witness the discarding and the wasting being recording in the system. All other actions are not necessary because the client did not receive the double dose.
The nurse provides care for clients on a cruise ship. The nurse interviews several clients who are experiencing severe vertigo unrelieved by dimenhydrinate. Which client does the nurse assign to see the HCP first? 1. A client with a temperature of 100 degrees and who reports hearing loss in the right ear. 2. A client who reports seeing objects that seem to be moving around. 3. A client who has a full feeling in the ear with a crackling and popping sounds. 4. A client who reports ringing in the ears and occasional vertigo.
ANSWER: 1 - This client has an elevated temperature and a decrease in hearing, both of which are symptoms that indicate infection. Why 2 is wrong: this client is experiencing symptoms of vertigo, which is uncomfortable for the client but not life-threatening. Why 3 is wrong: this client is experiencing symptoms of serous otitis media related to eustachian tube obstruction. This condition can occur due to flying or scuba-diving and does not require treatment. Why 4 is wrong: This client is experiencing tinnitus, which is uncomfortable for the client but not life threatening.
The nurse provides care for a client who is one day postpartum. The client voids large amounts of urine frequently. Which action does the nurse implement? 1. Assure the client that this is expected after delivery. 2. Ask the client if the urine is cloudy. 3. Check the specific gravity of the urine. 4. Notify the HCP.
ANSWER: 1 - Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during pregnancy. A urine output of 3,000 mL or more each day during the first 2-3 days is expected.
The healthcare provider informs a client that she is pregnant. The client voices concern to the nurse that this pregnancy is not well-timed. Which action should the nurse take first? 1. Explain that ambivalence is a normal finding at this time. 2. Ask the client is she would like to have counseling about her options. 3. Determine if the client was utilizing oral contraceptives. 4. Assess the client's support system.
ANSWER: 1 - most women have conflicting feelings about being pregnant (ambivalence) during the early weeks of pregnancy. They have wanted to wait longer to achieve career or educational goals or to have longer spacing between children. Even women who have planned their pregnancies or worked hard to overcome infertility often experience ambivalence. It is important for the nurse to first normalize the client's experience).
The nurse provides care to an older adult client diagnosed with metastatic colon cancer. Which difference in pain tolerance because of the client's age will the nurse expect to assess? 1. Decreased. 2. Unchanged. 3. Increased. 4. No effect.
ANSWER: 1 (aging lowers pain tolerance because of diminished adaptive capacity).
The nurse provides care for a newborn who passed meconium stool in utero. The newborn's respiratory rate is 32 breaths/min, heart rate is 114/min, and good muscle tone is present immediately after delivery. Which action is most important for the nurse to take? 1. Suction newborn's mouth and nose with a bulb syringe. 2. Assist the newborn's respiratory effort with a resuscitation bag. 3. Dry and wrap the newborn in warm blankets. 4. Request the HCP suction the newborn's trachea.
ANSWER: 1 (maintaining a patent airway is a priority for the newborn with potential for aspiration). - When the fetus experiences stress in utero, it may pass the first stool (meconium) before delivery. Should this occur, the fecal material can easily be aspirated by the fetus. Upon delivery, the primary action is to ensure the patency of the newborn's airway by suctioning all material from the nose and mouth.
The nurse provides care for a client in the first trimester of pregnancy and diagnosed with hyperemesis gravidarum. The client presents with decrease in weight, poor skin turgor, and electrolyte disturbances. Which action will the nurse implement first? 1. Start an intravenous fluid 2. Complete an intake and output record every 4 hours. 3. Provide oral fluids every hour 4. Perform a weight check every morning
ANSWER: 1 (parenteral hydration is the best way to rehydrate the client who is suffering hyperemesis gravidarum).
The nurse reviews a prescription for glimepiride for a client diagnosed with type 2 diabetes. Which entry in the client's medication record causes the nurse to question the glimepiride prescription? SATA. 1. Propranolol 2. Gemfibrozil 3. Ginkgo biloba 4. Ginseng 5. Ibuprofen 6. Valerian
ANSWER: 1, 2, 4, 5 - Beta-adrenergic blocking agents may mask symptoms of hypoglycemia, which is a primary adverse affect of oral anti-diabetic agents. - Gemfibrozil increases the hypoglycemic effect of sulfonylureas. - Ginseng increases the hypoglycemic effect of sulfonylureas. - Ibuprofen increased the hypoglycemic effect of oral anti-diabetic medications. Gingko: does not interact with oral anti-diabetic agents, but does interact with anticoagulants. Valerian: does not interact with oral anti-diabetic agents, but interacts with sedative-type medications.
The nurse assesses a newborn immediately after birth using the Apgar scoring system. Which sign for the nurse assess for when using this scoring system? SATA. 1. Heart rate 2. Respiratory effort 3. Core temperature 4. Muscle tone 5. Reflex irritability
ANSWER: 1, 2, 4, 5 Apgar score: heart rate, respiratory effort, muscle tone, reflex response, and color
While making hourly rounds, the nurse notices a fire in a trash can in a client's room. Upon inspection, the client is not in the room. Which action does the nurse take initially to manage the fire? SATA 1. Activate the fire alarm. 2. Use blankets and pillows to extinguish the fire. 3. Close the door to the room. 4. Locate the client to determine how the fire started. 5. Evacuate all clients from the unit.
ANSWER: 1, 3 - Since the client is not in the room, the nurse needs to activate the nearest alarm. - Closing the door to the room will decrease oxygen flow available to fuel the fire and slow its growth. Why 2 is wrong: this may cause the fire to grow. Why 4 is wrong: The nurse needs to focus on extinguishing and containing the first first. After the fire is extinguished, the nurse should locate the client. Why 5 is wrong: evacuation of clients who are in immediate danger should occur first. however, evacuation of the entire unit is the last resort and is done only if efforts to contain the fire fail.
The nurse teaches an adult female client with a family history of hypertension. Which recommendation does the nurse include in client education? SATA. 1. Limit sodium intake to 2 grams or less daily. 2. Exercise at least twice weekly. 3. Avoid use of tobacco products. 4. Limit alcohol consumption to one serving per day. 5. Limit coffee consumption to two servings daily.
ANSWER: 1, 3, 4 - Excessive sodium intake (greater than 2 grams daily) increases the risk for hypertension. - Smoking or the use of other tobacco products increases the risk for hypertension. - Excessive alcohol intake is linked to hypertension. For adult females, no more than one serving of alcohol per day is recommended. Why 2 is wrong: A sedentary lifestyle increases the risk for hypertension. The american heart association recommends moderate activity for at least 30 minutes daily, 5 days per week. Why 5 is wrong: Although caffeine may cause a spike (not a sustained increase) in the blood pressure of some people, coffee is not a recognized risk factor for hypertension.
The nurse provides care to an intrapartum client on the labor and delivery unit. Which observation requires follow up? SATA. 1. The partner answers questions that are directed toward the client. 2. The client screams and uses obscenities during the delivery. 3. The partner refuses to leave the client's side when asked to do so. 4. The client reports excitement about the birth experience. 5. Fetal heart rate varies from 130-150 bpm 6. Each contraction lasts longer than 90 seconds.
ANSWER: 1, 3, 6 - Indicators of intimate partner violence include when one partner speaks on behalf of the other partner. The issue should be privately and tactfully explored with the client. - A partner's refusal to allow the other partner privacy may be an indicator of IPV. The issue should be privately and tactfully explored with the client. - Uterine contractions of greater than 90 seconds should be reported, as prolonged uterine contraction may cause fetal distress or lead to uterine rupture. Why 2 is wrong: especially during the transition phase of labor, maternal behaviors such are screaming and swearing are not uncommon. Why 4 is wrong: excitement about birth is normal Why 5 is wrong: the healthy fetal HR ranges from 120-160bpm.
While working on the inpatient hospital unit, the nurse observes a visitor approach the nurses' station. The visitor stands close to the nurse and makes aggressive verbal threats. Which action by the nurse is appropriate? SATA. 1. Remain calm and acknowledge that the visitor is upset and frustrated. 2. Back up slowly toward the corner of the room. 3. Place a hand on the visitor's chest to keep distance between the visitor and the nurse. 4. Call for security staff to assist with the individual. 5. Ask the visitor to return to the client's room. 6. Empathize with the visitor and state that the frustration is warranted.
ANSWER: 1, 4 - This is a priority action. Staying calm and verbalizing how the visitor is feeling can help diffuse the situation. - If the visitor has made violent or threatening statements toward him/herself or others, it is appropriate to notify security for assistance. Why 2 is wrong: When confronted with a potentially violent individual, the safety of the nurse and staff is priority. Backing into a corner or placing the threatening individual between the nurse and the exit route is unsafe. Why 3 is wrong: it is unsafe for the nurse physically to touch a potentially violent individual. Why 5 is wrong: The visitor should not be alone with either the nurse or the client in the current threatening state. Why 6 is wrong: the visitor's behavior is inappropriate and unsafe and should not be condoned or excused.
At 1200, the nurse admits a client with shortness of breath related to heart failure. At 1900, the nurse provides a hand-off report. Which information is most important for the nurse to communicate? 1. The client reaches 240 mL on incentive spirometer. 2. Urinary output since admission has been 110 mL. 3. The client's admission weight is 194 lb. 4. Brain natriuretic peptide (BNP) is elevated.
ANSWER: 2 - Expected urinary output is at least 30 mL per hour. The client's decreased UO is concerning, especially considering the client has likely received diuretic therapy to treat HF).
The nurse provides care for clients in an acute care facility. The nurse would seek collaboration from other members of the health care team for which client first? 1. A client newly diagnosed with type 1 diabetes requiring diabetic nurse educator teaching regarding insulin administration. 2. A referral to the social worker for a pediatric client with impetigo who has multiple unexplained burn marks across the torso. 3. A client requiring a dressing change by a wound care specialist for a diabetic foot ulcer. 4. A client with heart failure who requires evaluation by physical therapy to determine physical strength and endurance before discharging to home.
ANSWER: 2 - Injuries that cannot be explained by the caregiver of a pediatric client may indicate physical abuse and require referral to a social worker for follow up. The nurse should prioritize collaboration with the social worker first to protect the physical safety of the child. A nurse is required by law, to report any case of suspected abuse. All other clients are not immediate needs
The nurse counsels a client who is trying to conceive on how to best prevent neural tube defects. Which water-soluble vitamin is important for preventing neural tube defects? 1. Riboflavin (vitamin B12) 2. Folic acid (vitamin B9) 3. Ascorbic acid (vitamin C) 4. Thiamine (vitamin B1)
ANSWER: 2 - Maternal folic acid deficiency is a risk factor for the development of neural tube defects (spina bifida). A daily consumption of 0.4 mg of folic acid is recommended for women of childbearing age).
The nurse provides care for a client with total parental nutrition (TPN) running through a PICC line. The client is diaphoretic and reports a headache and feeling weak. When assessing the client, the nurse notices that the TPN has been stopped. Which action does the nurse take first when managing the situation? 1. Provide juice and crackers to the client. 2. Check the client's blood glucose. 3. Change the TPN tubing and obtain a new bag. 4. Notify the HCP.
ANSWER: 2 - Rebound hypoglycemia can occur when the TPN is stopped abruptly. The nurse should first check the client's blood glucose.
The nurse provides care for a client 24 hours after admission. The client's spouse reports that the client drinks a fifth of vodka daily. The nurse notifies the HCP that the client is restless, agitated, and irritable. The HCP prescribes chlorpromazine 25 mg intramuscularly. Which action does the nurse take first? 1. Administer the medication as prescribed. 2. Contact the HCP. 3. Continue to monitor the client. 4. Ensure that the lights are on in the client's room.
ANSWER: 2 - The client has symptoms of alcohol withdrawal. Chlorpromazine is not appropriate for the client. The nurse should contact the HCP for a benzodiazepine to sedate the client and calm the neurological irritability. Why 1 is wrong: Chlorpromazine is an antipsychotic/antiemetic but is not the correct medication for a client with symptoms of alcohol withdrawal. Why 3 is wrong: The nurse should address the incorrect prescription for the client first. this is a "do nothing" response. Why 4 is wrong: This is an appropriate action for a client in alcohol withdrawal but the first priority should be to address the incorrect prescription with the HCP.
The nurse teaches a client who is breastfeeding about the stool that the newborn will eliminate. Which information will the nurse include? 1. Several soft-formed, brown stools daily are normal. 2. Expect 3-6 small, soft, orange-yellow stools each day. 3. Anticipate one well-formed yellow stool daily. 4. Frequent, loose, green stools will occur each day.
ANSWER: 2 - The stool of a breastfed infant is orange-yellow, soft, and small with an even consistency. The client should expect up at 6 stools a day. The number of stools decreases with age. The color will change with the introduction of solid foods. Why 1 is wrong: the stool of breastfed infants are softer than those of bottle-fed infants. The color varies from yellow to brown depending on the formula. Why 3 is wrong: the stools of a breastfed infant are soft, not well-formed, and occur 3-6 times per day. Why 4 is wrong: greenish stools commonly occur in first week of life during the transition period from meconium to breastfed stools. Frequent, loose, green stools are abnormal.
The nurse prepares a solution of parenteral nutrition (PN) to infuse through a client's central line. Which piece of equipment does the nurse obtain before starting the infusion? 1. Glucose monitor 2. Electronic infusion pump 3. Pulse oximeter 4. Urine glucose strips
ANSWER: 2 (because of the high glucose content, use of an infusion pump is necessary to ensure that the solution does not infuse too rapidly or slowly). Why 1 is wrong: a blood glucose meter will also be needed, but is not the most essential item needed before starting the infusion. Why 3 is wrong: There is no need for a pulse oximeter related to the PN infusion. Why 4 is wrong: Urine glucose strips are not needed because blood glucose monitoring is standard practice with PN.
The nurse provides care for a client experiencing alcohol withdrawal delirium. The client tells the nurse that bugs are crawling on the walls in the room. Which action by the nurse is appropriate? 1. Place a can of insecticide within the client's field of vision. 2. Turn on the lights and remain with the client. 3. Distract the client with simple activities. 4. Dim the lights, and encourage the client to rest
ANSWER: 2 (the client diagnosed with alcohol withdrawal delirium may experience delusions and hallucinations. Place the client is a quiet, well-lighted room and stay with the client if possible to interpret the environment
The nurse is preparing to transport a client diagnosed with tuberculosis to the radiology department. Which action does the nurse take to prevent transmission of the disease? SATA. 1. Wear sterile gloves when assisting the client to a wheelchair. 2. Notify personnel in radiology about the client's diagnosis. 3. Have the client wear a surgical mask during transport. 4. Instruct personnel to keep a 3 feet (1 meter) distance from the client. 5. Wear an N95 respirator mask when preparing for transport.
ANSWER: 2, 3, 5 - It is appropriate for the nurse to notify the personnel in radiology about the client's diagnosis so appropriate precautions can be implemented. - It is appropriate for the nurse to have the client wear a surgical mask during transport to prevent the spread of infection throughout the hospital. - A client diagnosed with tuberculosis should be in airborne precautions. The nurse needs to wear a N95 respirator mask to prevent transmission of the disease. Why 4 is wrong: personnel without a mask should keep 3 feet distance from a client who is in DROPLET precautions. A client diagnosed with TB is in airborne precautions which requires a mask at all times when working with this client.
The nurse notices a client's family gathering outside the client's room to take a group picture. The client seems to be in agreement with the picture. Which action by the nurse is appropriate? SATA. 1. Take the picture for the family to be sure the privacy of all clients in the unit is protected. 2. Politely instruct the family to take the picture inside the client's room. 3. Call security to ask the family to leave because they have broken confidentiality and privacy regulations. 4. Escort the family to a common area of the hospital outside the unit to take a picture. 5. Take no action if other clients are not outside of their room when the picture is taken.
ANSWER: 2, 4
During a home visit, the nurse evaluates the care provided to a client diagnosed with protein-calorie malnutrition (PCM). Which outcome indicates to the nurse that care has been effective? SATA 1. Moist oral mucous membranes. 2. Weight gain of 4lb in 2 weeks. 3. Dry skin on both arms and legs. 4. Report of bowel movement every 3 days. 5. Supply of high-protein supplements on the kitchen counter.
ANSWER: 2, 5
The nurse provides care for a 7-year old client during a wellness exam. Which factor in the child's history alerts the nurse that hyperlipidemia screening is necessary? 1. Maternal history of obesity. 2. Paternal history of DM. 3. Sibling history of stroke. 4. Grandparent history of HTN.
ANSWER: 3 - If the child has a sibling with a history of stroke, screening for hyperlipidemia is recommended in children ages 2-8 years. Why 1 is wrong: Hyperlipidemia screening is warranted in this age group if the child, not the mother, has a history of obesity. Why 2 is wrong: Hyperlipidemia screening is recommended if the child themselves has DM, not the parent. Why 4 is wrong: Hyperlipidemia screening is recommended if the child is diagnosed with HTN, not the grandparents.
The nurse prepares to complete a health history with a client in a community clinic. Which action will the nurse take first? 1. Measure vital signs. 2. Determine major health problems. 3. Provide for physical and psychological comfort. 4. Develop the genogram.
ANSWER: 3 - If the client is not physically and psychologically comfortable, the health assessment will not go as well as it could. This is the priority. All other actions can be completed once physical and psychological comfort is established.
The nurse provides care for a client who is having an anaphylactic reaction. The client is hypotensive and in respiratory distress. The nurse notes the client has swollen lips and tongue. Which intervention should the nurse perform first? 1. Be prepared to administer intravenous (IV) epinephrine. 2. Start an IV immediately and infuse normal saline. 3. Apply oxygen using a high-flow, non-rebreather mask. 4. Ensure that intubation and tracheotomy equipment is ready
ANSWER: 3 - When a client is having an anaphylactic reaction, oxygen should immediately be applied to ensure there is adequate oxygenation helping to prevent hypoxia, dysrhythmia, shock, and cardiopulmonary arrest. The rest of the tasks will be completed after applying oxygen using a high-flow, non-rebreather mask.
A nurse performs developmental age assessments on several pediatric clients. The nurse determines which finding is priority for further assessment? 1. The 6-month old who sits alone to play. 2. The 3-month old who has a strong grasp reflex. 3. The 13-month old who cannot place cereal in mouth. 4. The 10-month old who cannot pull to stand up.
ANSWER: 3 - bringing objects to the mouth usually occurs between 4-6 months with finger eating occurring between 10-12 months. The ability to grasp cereal between the thumb and index finger should occur around 9 months. This child is experiencing a developmental delay that requires assessment.
The nurse provides discharge teaching to a client recently diagnosed with asthma. Which prescribed medication should the nurse instruct the client to use during an acute asthma episode? 1. Fluticasone 2. Guaifenesin 3. Theophylline 4. Albuterol
ANSWER: 4 - Albuterol is a fast-acting bronchodilator used for treatment of acute asthma episodes. Albuterol may be administered by using a metered-dose inhaler or nebulizer. Fluticasone: an inhaled corticosteroid. used for long-term maintenance to manage asthma. does not provide immediate bronchodilation. Guaifenesin: used to thin and liquefy secretions, does not promote bronchodilation. Theophylline: promotres bronchodilation, but is not fast-acting.
The nurse provides care for clients in the ED. A newly married women is brought to the ED by her parents, who relate that their son-in-law was killed 3 days ago in a boating accident. The parents report that their daughter has been uncontrollably screaming and crying since the accident. Which action does the nurse take first? 1. Administer diazepam. 2. Ask the parents to leave the room. 3. Refer the client and her parents to family therapy. 4. Silently sit with the client maintaining eye contact.
ANSWER: 4 - It is important that the nurse convey warmth, caring, and empathy with the client. The nurse should structure the environment so the client can express feelings about her loss. It is important to allow the client to share painful feelings while the nurse is silent. Maintaining eye contact is healing and conveys concern. Why the rest are wrong: may be appropriate at some point, but it is more important for the nurse to convey to the client she is present and the client can be open to talk about her feelings.
An explosion occurs inside the parking deck of a local hospital. The ED staff dispatches to triage, but the integrity of the building structure is questionable. Applying the principles of mass casualty, in which order does the nurse perform the actions when preparing to care for clients who are easily accessible? 1. Provide care to an unresponsive adult client with a severed femur and no spontaneous respirations. 2. Provide care to an older adult client with a bleeding head injury. 3. Provide care to a crying adult client who denies injury. 4. Provide care to a school-age client with a deformed, closed forearm. 5. Provide care to an unresponsive young adult client with asymmetrical chest expansion, respirations 26/min, and cyanotic nail beds. 6. Quickly assess and triage accessible clients.
ANSWER: 6, 5, 2, 4, 3, 1 During a mass casualty, initial evaluation of all accessible clients should be done quickly in order to triage and prioritize care using a tag system. Systems in use include: 1. Red injuries: life threatening but survivable with intervention. 2. Yellow injuries: significant but can wait hours without jeopardizing life or limb. 3. Green injuries: minor and can wait hours to days 4. Black injuries: extensive, and survival is unlikely even with care.
