Question bank

The nurse is teaching a group of women in a community clinic about prevention of osteoporosis. Which over-the-counter medication should the nurse recognize as having the most elemental calcium per tablet?

Calcium carbonate contains 400 mg of elemental calcium in 1 gram of calcium carbonate. Calcium carbonate is inexpensive and convenient; it is found in many over-the-counter antacid products, including Tums and Rolaids.

A nurse is working in an OB-GYN clinic. A 40 year-old woman in the first trimester of an unplanned pregnancy provides a health history to the nurse. Which information should receive priority attention?

A report by the client that she has been taking medications in the first trimester of pregnancy should be followed up immediately. ACE inhibitors, commonly used to control high blood pressure, are pregnancy category X, as they can cause teratogenic effects on the developing fetus, increasing the risk of birth defects. Women who are taking medications and who are planning a pregnancy should be switched to medications that are not harmful to the developing fetus before they begin trying to get pregnant.

An 88 year-old client is admitted to the telemetry unit following a minor surgical procedure. The client's history includes insulin dependent diabetes and a previous myocardial infarction. The nurse responds to the client's ECG alarm and finds the client's rhythm shows asystole and the client obtunded but responsive. Prioritize the actions of the nurse (with 1 being the top priority). Assess respirations and pulse Initiate emergency response system if indicated Look at a different ECG lead to confirm rhythm Check a blood glucose level

After checking responsiveness, establishing a patent airway and then assessing breathing and circulation are the next priorities (ABCs). This assessment would provide information to decide whether the emergency response team is needed. Because the client is responsive, the monitor rhythm is not correct, as a client with asystole would be unresponsive. Asystole on a rhythm strip may simply be a loose lead; a quick way to check this is to select another lead. The client's obtunded state indicates that ion is needed, so assessment of a central pulse and blood pressure is indicated to determine whether cardiovascular compromise is responsible for this condition. If no evidence of an immediate cardiac event is present, the blood glucose should be checked. Stress and changes in food or fluid consumption secondary to surgery increase the risk of glucose imbalance in the person with diabetes.

During the well-baby checkup, the parents respond to questions about their newborn. Which of these parents' comments would reveal an initial finding that's associated with pyloric stenosis?

All babies spit up. But forceful (projectile) vomiting is the hallmark finding of pyloric stenosis in most children. The infant is often hungry after vomiting and wants to feed again, but many breastfed babies have periods when all they want to do is nurse. Babies with pyloric stenosis may have a olive-shaped mass in their upper belly, but a "little lump" above the belly button is not specific to pyloric stenosis.

A nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which approach demonstrates appropriate teaching by the nurse?

All three stages of the chickenpox lesions will be present on the child's body at the same time. Children should not be medicated with aspirin due the possibility of developing Reye's syndrome. A person with chickenpox is contagious one to two days before their blisters appear and remain contagious until all the blisters have crusted over. Antiviral medications are not usually prescribed to otherwise healthy children. Over-the-counter hydrocortisone creams can help relieve itchy skin.

The nurse is teaching the client with chronic renal failure (CRF) about medications. The client questions the purpose of taking aluminum hydroxide. What is the best explanation for the nurse to give the client about the therapeutic effects of this medication?

Aluminum binds phosphates that tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidney. Antacids such as Amphojel are commonly used to decrease serum phosphate.

A client who is newly diagnosed with hypertension is prescribed benazepril. What is the most important point to make when teaching the client about this medication?

Benazepril (Lotensin) is an angiotensin converting enzyme (ACE) inhibitor. Even if you don't know this drug, remember that the spelling of ACE inhibitors usually end with "pril." One of the side effects of ACE inhibitors is a dry cough; sometimes the cough is severe enough to require discontinuation of the drug. But the most important point to make is that if the client's voice changes or "sounds funny" or there is any swelling of the lips, tongue or throat, the client should contact the health care provider because this could indicate angioedema, a potentially fatal condition

The client with cancer is being treated with a biological response modifier. Which of the following side effects does the nurse anticipate with biologic therapy?

Biological response modifier cancer therapy agents (for example, interferons and interleukins) are drugs that stimulate the body's own defense mechanisms to fight cancer cells. Flu-like findings such as chills, fever and nausea, are common side effects of this type of therapy. The other assessment findings are not what you would expect when the body is fighting pathogens.

At a well-child checkup, the nurse is assessing a 1 year-old who was born prematurely and is being evaluated for cerebral palsy (CP). Which information provided by the parents would support this diagnosis?

Cerebral palsy refers to a group of conditions that affect movement, balance and posture. Prematurity, infections during pregnancy, and asphyxia during labor and delivery are risk factors for CP. Some children with CP may have delays in learning to roll over, sit, crawl or walk. Because this child was born prematurely, it would be expected that he would be smaller than other babies. At this age, most children can say a few words (like "mama"), but they are not talking, and mealtime can get pretty messy.

An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident (CVA) has had a blood pressure of 160/100 to 180/110 over the past two hours. The nurse has also noted increased lethargy since admission. Which of the following new findings should the nurse report immediately to the provider?

Changes in speech patterns and level of conscious are indicators of potential continued intracranial bleeding or extensions of a stroke. Further diagnostic testing may be indicated. Recall the word "FAST" with stroke findings: "F" is for changes in the face such as drooping of corner of the eye or mouth, "A" is for a drifting down of one arm when the arms are raised to shoulder height, "S" is for slurred speech and "T" is to telephone 911.

The nurse is caring for a 2 month-old infant with a congenital heart defect pre-operatively. How does the nurse best promote adequate nutrition while meeting the child's health needs?

Children with congenital heart defects have increased nutritional needs and tend to tire quickly during feeding. Breastmilk offers optimal nutrition and the work of breast-feeding is less than the work of bottle-feeding, which is why the nurse should support the mother's efforts to breast-feed. Infants with congenital heart disease usually do better when fed more often and on a demand schedule; usually 8 to 12 times a day is fine. The infant should not be given water since there are no calories in water. Medications should never be mixed with milk or formula.

The client is being treated for tuberculosis (TB). Which assessment would indicate that the client is having a possible adverse response to isoniazid?

Clients who are being treated with isoniazid are at risk for developing drug-induced hepatitis. The appearance of jaundice may indicate an elevation of the client's serum bilirubin levels; liver enzymes (AST and ALT) will also be elevated. A small number of adults taking isoniazid develop severe hepatitis that may progress to liver failure and even death unless the drug is stopped immediately.

The nurse is caring for a child who is diagnosed with coarctation of the aorta. Which finding would the nurse expect when assessing the child?

Coarctation of the aorta, which is a narrowing or constriction of the descending aorta, causes increased blood flow to the upper extremities, resulting in a bounding pulse in the arms. Cardinal signs include resting systolic hypertension, absent or diminished femoral and pedal pulses, and a widened pulse pressure.

The 17 year-old female is diagnosed with bulimia nervosa. Which lab result does the nurse anticipate?

Common findings of bulimia include electrolyte imbalances, such as hypokalemia, hypocalcemia, hypochloremia, and hyponatremia; BUN is increased. Metabolic acidosis is expected with laxative abuse; metabolic alkalosis is due to vomiting.

The client is prescribed dexamethasone by mouth every other day and asks the nurse for more information about the medication. What information would the nurse want to share with the client? (Select all that apply)

Dexamethasone is a glucocorticosteroid used for its anti-inflammatory properties. It is best to take the medication in the morning, before 9:00 am, with food or milk to avoid stomach upset. A low-sodium diet is usually prescribed because the drug can cause an elevation in blood pressure, salt and water retention, and increased potassium loss. Dexamethasone also causes calcium loss; the client should increase calcium in the diet and take a calcium supplement. Because the medication affects the immune system, it could make vaccinations ineffective and/or lead to serious infections. It's always a good idea for clients to keep track of medication administration, particularly when they are not taking the medication every day.

The nurse receives report on the following client assignments. Which client should the nurse assess first?

Dizziness with PUD may indicate hemorrhaging. The findings in the other options are either expected and are not life-threatening: clients may feel lightheaded when they are not drinking enough fluids after a gastrectomy; difficulty swallowing can be a symptom of GERD; gastrointestinal symptoms are the most common side effects of NSAIDs.

The client is a new admission diagnosed with Alzheimer's disease (AD). The nurse reviews all drugs (including complementary & integrated health therapies) routinely taken at home with a family member. Which of the following treatments would be a concern for the nurse?

Donepezil, rivastigmine and galantamine are most commonly used in the treatment of AD. Complementary and integrative therapies used to treat AD include ginkgo biloba (a plant extract) and omega-3 fatty acids. While there really isn't enough research to support using these treatments, continued use won't necessarily be harmful. However, coconut oil, (which is a source of caprylic acid) is a concern. While there has been limited research on Katasyn (an experimental drug containing caprylic acid), there's no scientific evidence that coconut oil is safe and effective or prevents cognitive decline.

Lifting

During any client-transferring task, if any caregiver is required to lift a client who weighs more than 35 lbs (15.9 kg), then the client should be considered to be fully dependent, and assistive devices should be used for the transfer.

A nurse and a client are talking about the client's progress towards understanding the client's behaviors during stressful situations. This is typical of which phase in a therapeutic relationship?

During the working phase, alternative behaviors and techniques are explored mutually with a nurse and a client. A discussion of the meaning behind behaviors is one of many approaches during the working phase.

The nurse is reviewing the list of medications for a client who is scheduled for electroconvulsive therapy (ECT). Which medication does the nurse recognize as the one that will promote skeletal muscle relaxation?

ECT is performed under full general anesthesia and muscle relaxation. The sequence of administration is to give the anesthetic induction agent first, followed by the muscle relaxant. Two of the most commonly used anesthetics for this procedure are propofol and methohexital. These drugs are all well-suited for short procedures, such as ECT (which typically takes less than 10 minutes). Succinylcholine is the drug of choice for skeletal muscle relaxation in ECT, due to its brief duration of action. Atropine is an anticholinergic drug and may be used for ECT to help reduce the risk of arrhythmias and to minimize oral or other secretions and to prevent bronchial constriction.

A 35 year-old female client talks to the nurse in her health care provider's office about her new diagnosis of uterine fibroids. What statement by the woman is incorrect and indicates that more teaching is needed?

Fibroids that cause no findings may require only "watchful waiting." The client may just need pelvic exams or ultrasounds every once in a while to monitor the fibroid's growth. Treatment for the symptoms of fibroids (such as painful menses and heavy periods) may include oral contraceptives, IUDs, iron supplements to prevent or treat anemia (due to heavy periods), NSAIDs for cramps or pain or even short-term hormonal therapy to help shrink the fibroids. Surgical removal using myomectomy or hysterectomy is usually reserved as a final alternative after other treatment options have failed to provide adequate relief. In addition, concerns about loss of fertility with this diagnosis and its treatment may be important to this client who is still in her childbearing years.

A child is treated with succimer for lead poisoning. Which of these assessments should the nurse perform first?

Succimer (Chemet) is used in the management of lead or other heavy metal poisoning. Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia. Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ.

A child is sent to the school nurse by a teacher who has a written note that fifth disease is suspected. Which of the following should the nurse expect to find if the child has this condition?

Fifth disease is also referred to as parvovirus infection or erythema infectiosum. Some people may call it slapped-cheek disease because of the face rash that develops resembling slap marks. It is also commonly called fifth disease because it was fifth of a group of once-common childhood diseases that all have similar rashes. The other four diseases are measles, rubella, scarlet fever, and Dukes' disease. People will not know that a child has parvovirus infection until the rash appears, and by that time the child is no longer contagious.

There is an order to administer intravenous gentamicin three times a day. What diagnostic finding indicates the client may be more likely to experience a toxic side effect of this medication?

Gentamicin is excreted unmodified by the kidneys. If there is any reduced renal function, toxicity can result. An elevated serum creatinine indicates reduced renal function and this puts the client at greater risk for toxicity. Reduced renal function will delay the excretion of many medications.

The nurse is caring for a client who received tenecteplase to open an occluded coronary artery following an acute myocardial infarction. Which finding should cause the greatest concern for the nurse?

Hemorrhage, or bleeding, is the most common risk associated with any thrombolytic. Tenecteplase (TNKase) is currently indicated for the management of acute myocardial infarction (AMI). Minor bleeding from the gums or nose can occur in about 25% of people who receive these drugs. Remember that the spelling of many of the generic thrombolytic agents end with "ase."

A newborn who is delivered at home and without a birth attendant is admitted to the hospital for observation. The initial temperature is 95 F (35 C) axillary. The nurse should recognize that cold stress may lead to what complication?

Hypothermia and cold stress cause a variety of physiologic stresses including increased oxygen consumption, metabolic acidosis, hypoglycemia, tachypnea and decreased cardiac output. The baby delivered in such circumstances needs careful monitoring. In this situation, the newborn must be warmed immediately to increase its temperature to at least 97 F (36 C). Normal core body temperature for newborns is 97.7 F to 99.3 F (36.5 C to 37.3 C).

The nurse discovers that a chest tube has become disconnected from the main connection site of a closed chest drainage unit (CDU). What immediate action should be taken by the nurse?

If the tube becomes disconnected from the main connection site of a CDU, the nurse should place the end of the chest tube in a bottle of sterile water (or saline solution) while someone else prepares a new CDU setup. The health care provider should be called (the nurse should expect an order for a chest X-ray.) To prevent the chest tube from coming apart, it's important to spiral-tape the main connection site and not to let loops of tubing hang down the side of the bed. If there is an air leak from the chest, do not clamp the chest tube as this will cause air to accumulate in the pleural cavity, potentially leading to a collapsed lung or tension pneumothorax. Only if the chest tube becomes dislodged from the client does the nurse need to cover the insertion site with a sterile gauze dressing.

A group of nurses on a unit are discussing stoma care for clients who have had a stoma made for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown?

Ileostomy output, which is from the small intestine, is of continuous, liquid nature. This high pH, alkaline output contains gastric and enzymatic agents that when present on skin can denude skin in a few hours. Because of the caustic nature of this stoma output, adequate peristomal skin protection must be delivered to prevent skin breakdown. With a transverse colostomy the stool is of a somewhat mushy and soft nature. With a sigmoid colostomy the output is formed with an intermittent output. An ileal conduit is a urinary diversion with the ureters being brought out to the abdominal wall.

The client is admitted to the emergency department with hypertensive crisis. Which finding requires immediate action by a nurse?

In a client who has uncontrolled hypertension, weakness in the extremities is a sign of cerebral involvement with the risk for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining three choices indicate mild fluid overload, which may be associated with heart failure due to hypertensive crisis, but they are not medical emergencies. Crackles throughout the lung fields with acute onset of dyspnea and orthopnea would indicate acute pulmonary edema, which would also be considered a medical emergency requiring immediate action.

Which finding should the nurse identify as the most characteristic of an acute episode of reactive airway disease?

In an acute episode of reactive airway disease, breathing is likely to be characterized by wheezing on expiration. This sound is made as air is forced through the narrowed passages and often can be heard by the naked ear without a stethoscope. Remember, reactive airway disease is a general term that does not indicate a specific diagnosis - it simply means there is wheezing due to airway reactivity to a trigger. The trigger can be an allergy, virus, cold air, humidity, exercise or any number of other respiratory triggers.

A client is admitted to the emergency department during an acute asthma attack. Which assessment finding would support this diagnosis?

In asthma, two situations are of concern. First, the airways are narrowed making it difficult to get air into the lungs, resulting in wheezing. An auditory wheeze is one that is heard with normal hearing of the ear without a stethoscope. This is an emergency situation. The second concern is thick, tenacious secretions. A forced expiratory volume (FEV1) is very concerning if it is 50% of predicted. Fever and chills are not consistent with asthma attacks.

A client has a chest tube inserted immediately after surgery for a left lower lobectomy. During the repositioning of the client during the first postop check, the nurse notices 75 mL of a dark, red fluid flowing into the collection chamber of the chest drain system. What is the appropriate nursing action?

It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position this soon after surgery. The dark color of the blood indicates it is not active bleeding inside of the chest. Sanguinous drainage should be expected within the initial 24 hours postop, progressing to serosanguinous and then to a serous type. If the drainage exceeds 100 mL/hr, the nurse should call the surgeon.

The nurse is caring for a child diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis). The nursing care plan should be based on the knowledge that this child is at risk for developing what complication?

Kawasaki disease affects the mucus membranes, lymph nodes, walls of the blood vessels and the heart. It can cause inflammation of the arteries, especially the coronary arteries of the heart, which can lead to aneurysms and possible heart attack in the child.

A young child is receiving treatment for lead poisoning. Which of the following is the most serious effect of long-term exposure to lead?

Lead toxicity can affect every organ system but it is especially dangerous for the brain. Lead can even alter the structure of the blood vessels in the brain and can lead to bleeding and brain swelling. In children, lead exposure is associated with lower IQ scores, learning disabilities, hyperactive behavior, and impaired hearing; higher levels of exposure can cause seizures and death. Neurological effects may persist into adulthood, despite treatment. Anemia (and fatigue), damage to the kidneys and abdominal pain (also called lead colic) are potentially reversible with treatment.

The client, who is receiving chemotherapy through a central venous access device (CVAD) at home, is admitted to the intensive care unity (ICU) with a diagnosis of sepsis. Which of the following nursing interventions is the priority?

Many cases of sepsis occur in immunocompromised clients and clients with chronic and debilitating diseases. Since it's likely the existing CVAD is the source of the infection, it should be cultured and removed. A new central line (usually an internal jugular or subclavian) needs to be inserted since large amounts of IV fluids are needed to restore perfusion. The new central line will also allow venous access for labs, medications and measuring central venous pressure. Together with central venous pressure monitoring, an indwelling urinary catheter will help guide fluid volume replacement. Many hospitals have restrictions on visitors with known or recent infections to help protect all clients.

The nurse is providing care for a client diagnosed with sickle cell crisis. Which medication ordered for pain control should be questioned by the nurse?

Meperidine (Demerol) is not recommended in clients with sickle cell disease. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Clients with sickle cell disease are particularly at risk for normeperidine-induced seizures.

The nurse is caring for a 4 year-old who will have surgery for tetralogy of Fallot tomorrow. Which laboratory report must receive priority attention by the nurse?

Tetralogy of Fallot is a cyanotic heart defect, which can manifest in polycythemia due to release of erythropoietin. Hemoglobin values of up to 20 and hematocrit's of 60 or higher may be seen. These must be noted and reported to the health care provider.

A nurse is caring for a client with schizophrenia who has been treated with quetiapine for one month. Today the client is increasingly agitated and reports having muscle stiffness. Which of these additional findings should be reported to the health care provider?

Neuroleptic malignant syndrome (NMS) is a rare disorder that can occur as a side effect of antipsychotic medications. It is characterized by muscular rigidity, tachycardia, hyperthermia, sweating, altered consciousness, autonomic dysfunction, and increased creatine phosphokinase (CPK). This is a life-threatening complication that can occur anytime during therapy with antipsychotic medications.

A nurse notes sudden onset confusion in an 83 year-old client. Which recently ordered medication would have most likely contributed to this change?

Older adults are more susceptible to the side effect of anticholinergic drugs, such as antihistamines. Antihistamines often cause confusion in the older adult, especially at higher doses. The Beers Criteria lists this and other potentially inappropriate medications for the elderly (65 and older).

The client underwent a total hip arthroplasty 48 hours ago. The client has been up in a chair and is prescribed physical therapy twice daily. What type of nursing care is needed for this client? (Select all that apply.)

On the first post-operative day following a total hip arthroplasty, the client will be up in a chair. The client should bend the affected leg at the knee when sitting in a chair - not keep it straight. Two days after surgery, the client will be walking in the hallway. When in bed, the client should continue to perform leg exercises and use a pillow or foam wedge between his or her legs (to keep the legs abducted.) The drain is usually removed the second day after surgery; there should be little-to-no drainage on the second post-op day. The client can eat a regular diet after surgery.

The nurse needs to accurately assess gastric placement of a nasogastric tube prior to the administration of an enteral feeding. What is the priority action the nurse should take before starting the infusion?

Once the initial placement of the tube has been confirmed by x-ray, the nurse will check the pH of the aspirate before administering medications or enteral feeding solutions. Current practice recommendations include assessing the feeding tube placement by testing the pH of aspirates, measuring the external portion of the tube, and observing for changes in the volume and appearance of feeding tube aspirates. If tube placement is in doubt, an x-ray should be obtained. The other methods are older approaches that are no longer recommended.

The nurse is assessing a client with a history of hypertension. Which of these questions is a priority for the nurse to ask?

Over-the-counter medications (OTC), especially those that contain cold preparations, can increase the blood pressure to the point of aggravation of the hypertension. The nurse would ask the other questions, but the answers to these questions don't have as great a risk for the client as the question about OTC medications.

A client taking isoniazid for tuberculosis (TB) asks the nurse about the side effects of this medication. The client should be instructed to report which of these findings?

Peripheral neuropathy is a common side effect of isoniazid and other antitubercular medications and should be reported to the health care provider. Daily doses of pyridoxine (vitamin B6) may lessen or even reverse peripheral neuropathy due to isoniazid use.

The nurse is providing information to a client about a prescribed medication. Which one of these statements, if made by a client, indicates that teaching about propranolol (Inderal) has been effective?

Propranolol is commonly used to treat hypertension, abnormal heart rhythms, heart disease and certain types of tremor. It is in a class of medications called beta blockers. Suddenly discontinuing a beta blocker can cause angina, hypertension, arrhythmias, or even a heart attack.

A client reports taking lithium as prescribed. Which of these findings indicate early signs of lithium toxicity?

Serum lithium levels should be between 0.8 - 1.2 mEq/L (remember, the exact numbers may vary slightly depending on the lab). Diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination may be early signs of lithium toxicity. Toxicity increases with increasing serum lithium levels, but clients may exhibit toxic finding at lithium levels below 2.0 mEq/L. Dehydration, other medications and other conditions can interfere with lithium levels.

Which nursing practice best reduces the chance of communication errors that might otherwise lead to negative client outcomes?

Standardized forms improve information for communication between caregivers. Most problems/poor outcomes involve some element of poor communication. The options of keeping good working relationships and using a professional tone of voice on the phone is good practice but not as useful for minimizing the chance of errors. Documenting at the end of the shift is incorrect practice and may lead to poor communication, as critical findings may be forgotten and not recorded.

The nurse is using the Glasgow Coma Scale (GCS) to assess a client who experienced a head injury. During the last assessment, the client scored a 14. Now the client opens eyes to verbal command (GCS 3), has purposeful movement to painful stimulus (GCS 5) and is using inappropriate words (GCS 3). Which intervention by the nurse should be implemented first?

The GCS measures the client's highest motor response, verbal response, and eye response (scores range from 3 to 15). The GCS can be used to help measure progress and predict a client's outcome or prognosis. A decreased score of 2 or more indicates "neuroworsening" and a need for urgent intervention. It's possible the change is due to increased intracranial pressure (ICP), but this needs to be determined first before other actions are taken.

A client has had a positive reaction to purified protein derivative (PPD). When the client asks, "What does this mean?" the nurse should respond with which statement?

The PPD skin test is used to determine the presence of tuberculosis antibodies. In an otherwise healthy person, an induration greater than or equal to 15 mm is considered a positive skin test. This indicates that the client has been exposed to the organism Mycobacterium tuberculosis. Additional tests such as a chest x-ray and sputum culture will be needed to determine if active tuberculosis is present. The sputum cytology test is the only definitive test to confirm a diagnosis of active TB.

The adult client is alert and cooperative. The client has a short leg cast and can only partially bear weight on the casted leg. Which technique can be safely used to transfer the client from the bed into a chair?

The algorithm for safe client handling and transferring an alert and cooperative client to a chair states: one caregiver applies a gait/transfer belt, uses the stand-and-pivot technique and transfers the client toward the strong side. A friction-reducing device is placed under the client to assist in turning or moving the person in bed, not transferring to a chair. A two person lift is unsafe.

A nurse is completing the initial assessment for a child immediately after a surgical correction of a ventricular septal defect. Which nursing assessment should be a priority during the process?

The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening that involves this electrical circuit.

The nurse is instructing a client with moderate persistent asthma on the proper method for using metered-dose inhalers (MDIs) and various types of medications. Which medication should the nurse advise the client to administer first?

The beta-agonist drugs are bronchodilators that relieve bronchospasm by relaxing the smooth muscle of the airway. These drugs should be taken first so that other medications can more deeply and effectively penetrate the lungs.

Following an alert of an internal disaster and the need for beds, the charge nurse is asked to list the clients who can potentially be discharged. Which one of these clients should the charge nurse select?

The client with type 1 diabetes is the only one with a chronic condition who has been treated for more than a day and whose condition is the most stable. The other clients' conditions are either unstable and/or more acute. Tylenol intoxication requires at least three to four days of intensive observation for the risk of hepatic failure. Because acute bacterial meningitis can lead to permanent brain damage or death, treatment must be started as soon as possible. It is considered a medical emergency for someone with an ICD who experiences multiple shocks.

A nurse is caring for a client two hours after a right lower lobectomy. During the assessment of the chest drainage unit (CDU), the nurse notes bubbling in the water-seal chamber. What is the first action the nurse should take?

The first action the nurse should take is to thoroughly check the dressing, tubing and drainage system. Usually intermittent bubbling in the water-seal chamber right after surgery indicates an air leak from the pleural space; this is a common finding and should resolve as the lung re-expands. Continuous bubbling usually means a leak in the CDU, such as a loose connection or a leak around the insertion site. Other nursing actions will include assessing the color and amount of the drainage and assessing the lungs. After the initial post-operative period, the nurse will assist the client to change positions and cough and deep breath to help re-expand the lung and promote fluid drainage.

A clinic nurse is discussing health promotion with a group of parents when a mother expresses concern about Reye's syndrome and asks about prevention. Which comment demonstrates appropriate teaching by the nurse?

The link between aspirin use and Reye's syndrome has not been confirmed. However, evidence suggests that the risk is sufficiently grave to include the warning on aspirin products. A study by Belay et al., (1999) concluded that Reye's syndrome, a severe neurologic disease that causes death or long-term neurologic sequelae in about one-third of patients, was shown to be epidemiologically associated with the ingestion of aspirin, a widely used analgesic and antipyretic agent.

A community health nurse has been caring for a 16 year-old who is 22-weeks pregnant with a history of morbid obesity, asthma and hypertension. Which of these lab reports need to be communicated to the health care provider as soon as possible?

The magnesium is low and the creatinine is high, indicating acute renal failure - this is the highest priority. With the history of hypertension, the findings may indicate preeclampsia. The rest of client's lab values are all abnormal except for the platelets. The client needs to be referred for immediate follow-up with a health care provider.

The nurse is performing the initial assessment of a client with asthma at the beginning of the shift. The client has oxygen running at 2 liters per minute per nasal cannula. Which assessment finding would the nurse be most concerned about?

The most common symptoms of asthma include tightness in the chest, labored breathing, coughing and wheezing. Rapid and shallow respirations associated with labored breathing indicate the client is losing the strength required to breathe. The intermittent wheezes indicate increased narrowing of the small airways and a worsening condition. This client requires prompt and aggressive respiratory intervention to avoid respiratory failure, including bronchodilators (such as nebulized albuterol), increased oxygen supplementation to maintain a SpO2 of at least 92%, and anti-inflammatory medications (such as IV corticosteroids). The increased mucus in the airways stimulates coughing and can cause coarse crackles; the anti-inflammatory medication and bronchodilator will make breathing and mucus removal easier.

A 3 year-old has just returned from surgery for application of a hip spica cast. What nursing action will be the priority?

The most important aspects of caring for the cast is to keep it clean and dry. Shortly after returning from surgery, waterproof plastic tape will be applied around the genital area to prevent soiling. The child should be turned every two hours to help facilitate drying, from side to side and front to back, with the head elevated at all times. If a crossbar is used to stabilize the legs, it should not be used to turn the child (it may break off). After the cast has completely dried and it becomes damp, it can be either exposed to air or a hair dryer (set to cool) may be used to help dry the cast.

A client with chronic kidney disease (CKD) is scheduled for hemodialysis at 9 am. It is now 6:30 am and the client is eating breakfast. How should the nurse help the client to prepare for hemodialysis? (Select all that apply.)

The nurse should administer a phosphate binder, such as sevelamer, with breakfast. Vitamin D may be prescribed with the phosphate binder to help control both serum calcium and phosphate levels. Some medications will be withheld; dialyzable meds and meds that lower blood pressure are held until after the procedure. The client should eat an easily digestible meal at least 2 hours before treatment begins, avoiding foods high in fiber or protein. The nurse should assess the patency of the access site (for presence of bruit, palpable thrill, distal pulses, and circulation), weigh the client, and measure vital signs.

The nurse is caring for a client who is experiencing a hypertensive crisis. The priority assessment in the first hour of care after admission to the critical care unit should focus on which factor?

The organ most susceptible to damage in hypertensive crisis is the brain, due to rupture of the cerebral blood vessels. Neurologic findings must be closely monitored.

The respiratory technician arrives to draw blood for arterial blood gas (ABG) analysis. What should the nurse understand about the procedure?

The radial artery is preferred; the second choice is the brachial artery and then the femoral artery. If a client is receiving oxygen, it should not be turned off unless ordered. After drawing the sample, it's very important to press a gauze pad firmly over the puncture site until bleeding stops or at least five minutes. Do not ask the client to hold the pad because if insufficient pressure is used, a large painful hematoma may form. The sample of arterial blood must be kept cold, preferably on ice to minimize chemical reactions in the blood.

The nurse is caring for a client diagnosed with acute angina. The client is receiving an intravenous infusion of nitroglycerin. What is the priority assessment during this treatment?

The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15 minutes until stable, and then every 30 minutes to every hour thereafter. Clients receiving IV nitroglycerin also require continuous ECG monitoring.

The nurse is providing discharge teaching to a client who has had a total hip prosthesis implanted. During teaching, the nurse should include which content in the instructions for home care?

These clients should avoid the bringing of the knees together. Clients are to use a pillow between their legs when lying down and can lie on the back or side. Crossing the legs or bringing the knees together results in a strain on the hip joint. This increases the risk of a malfunction of the prosthesis where the ball may pop out. A walker or crutches may be used as assistive devices. These and other precautions are minimally followed for six weeks postoperative and sometimes longer as indicated.

A 48-year old female with metastatic breast cancer is scheduled to receive her first dose of a trastuzumab (Herceptin). Which of the following results would prompt the nurse to hold the prescribed treatment and discuss the assessment with the ordering health care provider?

Trastuzumab is a monoclonal antibody used as anticancer therapy for women with HER2-positive breast cancer. The main concern in administering trastuzumab is cardiotoxicity and it is used with caution in any client who has a pre-existing heart condition. An ejection fraction is obtained as a baseline before treatment and may be monitored every few months while the client is receiving this medication. Although the blood glucose result is high-normal, it would have no impact on the administration of this drug.

A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness would the nurse recognize as increasing the risk of developing Reye's syndrome?

Varicella (chickenpox) and influenza are viral illnesses that have been identified as increasing the risk for Reye's syndrome. Use of aspirin with viral infections is contraindicated in children (from birth to 19 years of age) as it increases the risk of developing Reye's syndrome.

The nurse is performing an assessment on an infant with severe airway obstruction. Which assessment finding would the nurse anticipate?

When the trachea or bronchioles become partially blocked, air flow is restricted. Nasal flaring is an exaggerated opening and closing of the nostrils with breathing, and is considered a subtle but important sign of acute respiratory distress in an infant. This is an emergency and requires rapid medical intervention.

The nurse is examining a 2 year-old child with a tentative diagnosis of Wilm's tumor. The nurse would be most concerned about which statement by the mother?

Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction; therefore, a recent decrease in urinary output should be investigated further as it may be a sign of renal dysfunction. Increasing abdominal girth is a common finding in Wilm's tumor, but does not require immediate intervention by the nurse.

The nurse cares for a newborn with tracheoesophageal fistula (TEF) and esophageal atresia (EA.) Which nursing diagnosis is the highest priority?

With TEF, there's an abnormal opening between the trachea and esophagus; fluids are easily aspirated into the trachea and lungs. With EA, the esophagus ends in a blind pouch and doesn't attach to the stomach, so food can't get from the esophagus into the stomach. The 3 C's of TEF are choking, coughing and cyanosis; symptoms of EA include vomiting and drooling. The priority is to prevent aspiration and maintain an open airway. TEA with EA is a clinical and surgical emergency.

Nationally notifiable diseases

• Cholera • Cryptosporidiosis • Cyclosporiasis • Giardiasis • Hepatitis A • Legionellosis • Malaria* • Salmonellosis • Shigellosis • Typhoid fever • Vibriosis • Yellow Fever*