Seminar Questions (1873 Exam 3)

The nurse receives a call from a client concerned about eliminating brown-colored urine after taking nitrofurantoin for a urinary tract infection. The nurse should make which appropriate response? a) "Continue taking the medication; the brown urine occurs and is not harmful." b) "Take magnesium hydroxide with your medication to lighten the urine color." c) "Discontinue taking the medication and make an appointment for a urine culture." d) "Decrease your medication to half the dose, because your urine is too concentrated."

a) "Continue taking the medication; the brown urine occurs and is not harmful." -rationale: Nitrofurantoin imparts a harmless brown color to the urine and the medication should not be discontinued until the prescribed dose is completed. Magnesium hydroxide will not affect urine color. In addition, antacids should be avoided because they interfere with medication effectiveness.

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? a) "I should take hot baths because they are relaxing." b) "I should sit whenever possible to conserve my energy." c) "I should avoid long periods of rest because it causes joint stiffness." d) "I should do some exercises, such as walking, when I am not fatigued."

a) "I should take hot baths because they are relaxing." -rationale" To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

A new nursing graduate is caring for a client who is attached to a cardiac monitor. While assisting the client with bathing, the nurse observes the sudden development of ventricular tachycardia (VT), but the client remains alert and oriented and has a pulse. Which interventions would the nurse take? Select all that apply. a) Administer oxygen. b) Defibrillate the client. c) Obtain an electrocardiogram (ECG). d) Contact the health care provider (HCP). e) Assess circulation, airway, and breathing. f) Initiate cardiopulmonary resuscitation (CPR).

a) Administer oxygen. c) Obtain an electrocardiogram (ECG). d) Contact the health care provider (HCP). e) Assess circulation, airway, and breathing. -rationale: With VT in a stable client, the nurse assesses circulation, airway, and breathing; administers oxygen; and confirms the rhythm via a 12-lead ECG. The HCP is contacted, and antidysrhythmics may be prescribed. With pulseless VT, the HCP or a specially trained nurse must immediately defibrillate the client or initiate CPR followed by defibrillation as soon as possible.

A client is at risk for vasovagal attacks that cause bradydysrhythmias. The nurse would tell the client to avoid which actions to prevent this occurrence? Select all that apply. a) Applying pressure on the eyes b) Raising the arms above the head c) Taking stool softeners on a daily basis d) Bearing down during a bowel movement e) Simulating a gag reflex when brushing the teeth

a) Applying pressure on the eyes b) Raising the arms above the head d) Bearing down during a bowel movement e) Simulating a gag reflex when brushing the teeth -rationale:Vasovagal attacks or syncope occurs when the client faints because the body overreacts to certain triggers. The vasovagal syncope trigger causes your heart rate and blood pressure to drop suddenly. That leads to reduced blood flow to the brain, causing the client to briefly lose consciousness. The client at risk should be taught to avoid actions that stimulate the vagus nerve. Actions to avoid include raising the arms above the head, applying pressure over the carotid artery, applying pressure over the eyes, stimulating a gag reflex when brushing the teeth or putting objects into the mouth, and bearing down or straining during a bowel movement. Taking stool softeners is an important measure to prevent the bearing down and straining during a bowel movement.

The nurse is assessing the renal function of a client at risk for acute kidney injury. After noting the amount of urine output and urine characteristics, the nurse proceeds to assess which as the best indirect indicator of renal status? a) Blood pressure b) Apical heart rate c) Jugular vein distention d) Level of consciousness

a) Blood pressure -rationale: The kidneys normally receive 20% to 25% of the cardiac output, even under conditions of rest. For kidney function to be optimal, adequate renal perfusion is necessary. Perfusion can best be estimated by the blood pressure, which is an indirect reflection of the adequacy of cardiac output. The heart rate affects the cardiac output but can be altered by factors unrelated to kidney function. Jugular vein distention and level of consciousness are unrelated items.

The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected hepatitis. Which laboratory finding is most associated with hepatitis, requiring the nurse to contact the health care provider? a) Elevated serum bilirubin level b) Below normal hemoglobin concentration c) Elevated blood urea nitrogen (BUN) level d) Elevated erythrocyte sedimentation rate (ESR)

a) Elevated serum bilirubin level -rationale: Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and ESR. However, ESR is a nonspecific test that indicates the presence of inflammation somewhere in the body. The hemoglobin concentration is unrelated to this diagnosis. An elevated BUN level may indicate renal dysfunction.

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse should recognize that which are early clinical manifestations of this disorder? Select all that apply. a) Fatigue b) Anorexia c) High fever d) Weight loss e) Generalized weakness

a) Fatigue b) Anorexia e) Generalized weakness -rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. Early manifestations of RA include fatigue, anorexia, generalized weakness, low-grade fever, paresthesias. Weight loss is one of the late manifestations.

A woman has just been told by the health care provider that she has breast cancer. The woman responds, "Oh, no! Does this mean I'm going to die?" The nurse interprets the woman's initial reaction as which response? a) Fear b) Rage c) Denial d) Anxiety

a) Fear -rationale: The woman's reaction is one of fear. The woman has verbalized the object of fear (dying), which makes anxiety incorrect. There is no evidence of rage or denial in the woman's statement.

The nurse is reviewing the record of a client admitted to the hospital with a diagnosis of Hodgkin's disease. Which assessment findings noted in the client's record are associated with this diagnosis? Select all that apply. a) Fever b) Weight loss c) Night sweats d) Visual changes e) Enlarged, painless lymph nodes

a) Fever b) Weight loss c) Night sweats e) Enlarged, painless lymph nodes -rationale: Assessment of a client with Hodgkin's disease most often reveals enlarged, painless lymph nodes along with fever, malaise, and night sweats. Weight loss may be a feature in metastatic disease. Visual changes are not specifically associated with Hodgkin's disease.

The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions should be included in the care plan for this client? Select all that apply. a) Monitor daily weight. b) Measure abdominal girth. c) Monitor respiratory status. d) Place the client in a supine position. e) Assist the client with care as needed.

a) Monitor daily weight. b) Measure abdominal girth. c) Monitor respiratory status. e) Assist the client with care as needed. -rationale: Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the client's breathing patterns. The client should be placed in a semi-Fowler's position with the arms supported on a pillow to allow for free diaphragm movement. The correct options identify appropriate nursing interventions to be included in the plan of care for the client with ascites.

The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis? a) "I have had unprotected sex with multiple partners." b) "I ate shellfish about 2 weeks ago at a local restaurant." c) "I was an intravenous drug abuser in the past and shared needles." d) "I had a blood transfusion 30 years ago after major abdominal surgery."

b) "I ate shellfish about 2 weeks ago at a local restaurant." -rationale: Hepatitis A is transmitted by the fecal-oral route via contaminated water or food (improperly cooked shellfish), or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids, such as in the cases of intravenous drug abuse, history of blood transfusion, or unprotected sex with multiple partners.

The new registered nurse (RN) is reviewing cardiac rhythms with a mentor. Which statement by the new RN indicates that teaching about ventricular fibrillation has been effective? a) "Ventricular fibrillation appears as irregular beats within a rhythm." b) "Ventricular fibrillation does not have P waves or QRS complexes." c) "Ventricular fibrillation is a regular pattern of wide QRS complexes." d) "Ventricular fibrillation has recognizable P waves, QRS complexes, and T waves."

b) "Ventricular fibrillation does not have P waves or QRS complexes." -rationale: Ventricular fibrillation is characterized by the absence of P waves and QRS complexes. The rhythm is instantly recognizable by the presence of coarse or fine fibrillatory waves on the cardiac monitoring screen. Premature ventricular contractions (PVCs) appear as irregular beats within a rhythm. Ventricular tachycardia is a regular pattern of wide QRS complexes. Sinus tachycardia has a recognizable P wave, QRS complex, and T wave. Each of the incorrect options has a recognizable complex that appears on the monitoring screen.

The nurse is caring for a client with leukemia. In assessing the client for signs of leukemia, the nurse determines that what should be obtained? a) Platelet count b) Bone marrow biopsy c) White blood cell count d) Complete blood cell count

b) Bone marrow biopsy -rationale: Bone marrow aspiration or biopsy allows examination of blast cells and other hypercellular activity. Blood studies will not provide a definitive diagnosis of leukemia.

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? a) Peritonitis b) Hyperglycemia c) Hyperphosphatemia d) Disequilibrium syndrome

b) Hyperglycemia -rationale: An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis. Peritonitis is a risk associated with breaks in aseptic technique. Hyperphosphatemia is an electrolyte imbalance that occurs with renal dysfunction. Disequilibrium syndrome is a complication associated with hemodialysis.

The nurse is assessing a client with liver disease for signs and symptoms of low albumin. Which sign or symptom should the nurse expect to note? a) Weight loss b) Peripheral edema c) Capillary refill of 5 seconds d) Bleeding from previous puncture sites

b) Peripheral edema -rationale: Albumin is responsible for maintaining the osmolality of the blood. When the albumin level is low, osmotic pressure is decreased, which in turn can lead to peripheral edema. Weight loss is not a sign or symptom for hypoalbuminemia. Capillary refill of 5 seconds is a delayed filling time but is not associated with decreased albumin levels. Clotting factors produced by the liver (not albumin) are responsible for coagulation, and lack of clotting factors can result in bleeding from old puncture sites. The total protein level may decrease if the albumin level is low.

The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy? a) Restlessness b) Presence of asterixis c) Complaints of fatigue d) Decreased serum ammonia levels

b) Presence of asterixis -rationale: Asterixis is a flapping tremor of the hand that is an early sign of hepatic encephalopathy. The exact cause of this disorder is not known, but abnormal ammonia metabolism may be implicated. Increased serum ammonia levels are thought to interfere with normal cerebral metabolism. Tremors and drowsiness also would be noted.

The nursing student is assigned to care for a client with a diagnosis of acute kidney injury (AKI), diuretic phase. The nursing instructor asks the student about the primary goal of the treatment plan for this client. Which goal, if stated by the nursing student, indicates an adequate understanding of the treatment plan for this client? a) Prevent fluid overload. b) Prevent loss of electrolytes. c) Promote the excretion of wastes. d) Reduce the urine specific gravity.

b) Prevent loss of electrolytes. -rationale: In the diuretic phase, fluids and electrolytes are lost in the urine. As a result, the plan of care focuses on fluid and electrolyte replacement and monitoring. Options 1, 3, and 4 are not the primary concerns in this phase of AKI.

The nurse is reviewing the laboratory test results for a client receiving chemotherapy. The nurse notes that the white blood cell count is extremely low and places the client on neutropenic precautions. Which interventions are components of these types of precautions? Select all that apply. a) Allowing only fresh fruits in the client's room b) Removing fresh-cut flowers from the client's room c) Encouraging the client to eat any types of fresh vegetables d) Instructing family members on the proper technique for hand washing e) Instructing family members to wear a mask when entering the client's room

b) Removing fresh-cut flowers from the client's room d) Instructing family members on the proper technique for hand washing e) Instructing family members to wear a mask when entering the client's room -rationale: In the immunocompromised client, a low-bacteria diet is necessary. This includes avoiding the intake of fresh fruits and vegetables. Thorough cooking of all food also is required. Cut flowers and any standing water are removed from the room because both tend to harbor bacteria. Anyone who enters the client's room should perform strict and thorough hand washing and wear a mask.

A client with a diagnosis of question of rheumatoid arthritis (RA) is admitted to the unit. What blood tests would the nurse expect to be prescribed to confirm the diagnosis? Select all that apply. a) Cardiac enzymes b) Rheumatic factor c) Fasting blood glucose d) Antinuclear antibody (ANA) e) Erythrocyte sedimentation rate (ESR) f) Anticyclic citrullinated peptide antibody (anti-CCP)

b) Rheumatic factor d) Antinuclear antibody (ANA) e) Erythrocyte sedimentation rate (ESR) f) Anticyclic citrullinated peptide antibody (anti-CCP) -rationale: Blood tests commonly used to confirm the diagnosis of RA include ANA, rheumatic factor, ESR, and anti-CCP. Cardiac enzymes and fasting blood glucose tests are not used to diagnose this condition. ANA is used to diagnose autoimmune diseases. An elevated ESR is used to detect inflammation of joints associated with RA. Rheumatoid factor is useful in the diagnosis of RA. Anti-CCP appears early in the course of RA and is present in the blood of most clients with the disease.

A client is scheduled for elective cardioversion to treat chronic high-rate atrial fibrillation. Which finding indicates that further preparation is needed for the procedure? a) The client's digoxin has been withheld for the last 48 hours. b) The client is wearing a nasal cannula delivering oxygen at 2 L/min. c) The defibrillator has the synchronizer turned on and is set at 120 joules (J). d) The client has received an intravenous dose of a conscious sedation medication.

b) The client is wearing a nasal cannula delivering oxygen at 2 L/min. -rationale: During the procedure, any oxygen is removed temporarily because oxygen supports combustion, and a fire could result from electrical arcing. Digoxin may be withheld for up to 48 hours before cardioversion because it increases ventricular irritability and may cause ventricular dysrhythmias after the countershock. The defibrillator is switched to synchronizer mode to time the delivery of the electrical impulse to coincide with the QRS and avoid the T wave, which could cause ventricular fibrillation. Energy level typically is set at 120 to 200 J for a biphasic machine. The client typically receives a dose of an intravenous sedative or antianxiety agent.

The registered nurse is instructing a new nursing graduate about hemodialysis. Which statement made by the new nursing graduate indicates an understanding of the procedure for hemodialysis? Select all that apply. a) "Sterile dialysate must be used." b) "Dialysate contains metabolic waste products." c) "Heparin sodium is administered during dialysis." d) "Dialysis cleanses the blood of accumulated waste products." e) "Warming the dialysate increases the efficiency of diffusion."

c) "Heparin sodium is administered during dialysis." d) "Dialysis cleanses the blood of accumulated waste products." e) "Warming the dialysate increases the efficiency of diffusion." -rationale: Heparin sodium is used during dialysis, and it inhibits the tendency of blood to clot when it comes in contact with foreign substances. Option 4 is the purpose of dialysis. The dialysate is warmed to approximately 100°F to increase the efficiency of diffusion and to prevent a decrease in the client's blood temperature. Dialysate is made from clear water and chemicals and is free from any metabolic waste products or medications. Bacteria and other microorganisms are too large to pass through the membrane; therefore, the dialysate does not need to be sterile.

Which interventions are the most appropriate for a client who is experiencing thrombocytopenia? Select all that apply. a) Use a straight-edge razor for shaving. b) Obtain a rectal temperature every 8 hours. c) Check secretions for frank or occult blood. d) Give vitamin K by the intramuscular route. e) Encourage fluid intake to avoid constipation. f) Provide oral sponges or a soft toothbrush for oral care.

c) Check secretions for frank or occult blood. e) Encourage fluid intake to avoid constipation. f) Provide oral sponges or a soft toothbrush for oral care. -rationale: Thrombocytopenia is a condition in which the platelets fall below the number needed for normal coagulation. When a client has thrombocytopenia, the risk of bleeding is greatly increased. To monitor for bleeding, the nurse should check all secretions for frank or occult blood. Valsalva maneuvers (as in straining to have a stool, vomiting, or sneezing) could cause intracerebral bleeding when the platelet count is low. To avoid constipation, the nurse would encourage the client to take more fluids and increase his or her dietary fiber. The nurse should encourage the client to use a soft toothbrush or oral sponges to decrease irritation to the mouth and bleeding from the gums. An electric razor is recommended for shaving during times when the client is thrombocytopenic. The nurse should not take rectal temperatures or use any rectal suppositories because of the risk for injury to the rectal membranes with resultant bleeding. Medications should not be given subcutaneously or intramuscularly because use of these routes carries a risk for hemorrhage into the tissues.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? a) Call a code. b) Call the health care provider. c) Check the client's status and lead placement. d) Press the recorder button on the electrocardiogram console.

c) Check the client's status and lead placement. -rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment.

The client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs and/or symptoms? a) Flat neck veins b) Nausea and vomiting c) Hypotension and dizziness d) Hypertension and headache

c) Hypotension and dizziness -rationale: The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? a) Roast pork b) Cheese omelet c) Pasta with sauce d) Tuna fish sandwich

c) Pasta with sauce -rationale: Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. The serum ammonia level assesses the ability of the liver to deaminate protein byproducts. Normal reference interval is 10 to 80 mcg/dL (6 to 47 mcmol/L). Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. Foods high in protein should be avoided since the client's ammonia level is elevated above the normal range; therefore, pasta with sauce would be the best selection.

The nurse is preparing to care for a client receiving Prednisone for treatment of rheumatoid arthritis (RA). The nurse should plan to address which problem as the priority? a) Anxiety b) Fatigue c) Risk for infection d) Need for social isolation

c) Risk for infection -rationale: The client receiving steroid therapy are at risk for immunodeficiency has inadequate immune response and is at risk for infection. The priority concern would be risk for infection. The question presents no data indicating that the client is experiencing anxiety. Fatigue may be a problem and the client may need to be placed on protective isolation, but these are not the priority problems for this client. Infection can be life-threatening and is the priority.

An erythrocyte sedimentation rate (ESR) determination is prescribed for a client with a connective tissue disorder. The client asks the nurse about the purpose of the test. What should the nurse tell the client about the purpose of the test? a) Determines the presence of antigens b) Identifies which additional tests need to be performed c) Confirms the diagnosis of a connective tissue disorder d) Confirms the presence of inflammation or infection in the body

d) Confirms the presence of inflammation or infection in the body -rationale: The ESR is a blood test that can confirm the presence of inflammation or infection in the body. It is particularly useful for the management of connective tissue disease because the rate measured directly correlates with the degree of inflammation and later with the severity of the disease. The other options are incorrect.

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? a) Hypertension, tachycardia, and fever b) Hypotension, bradycardia, and hypothermia c) Restlessness, irritability, and generalized weakness d) Headache, deteriorating level of consciousness, and twitching

d) Headache, deteriorating level of consciousness, and twitching -rationale: Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing increased intracranial pressure and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates. Tachycardia and fever are associated with infection. Generalized weakness is associated with low blood pressure and anemia. Restlessness and irritability are not associated with disequilibrium syndrome.

A client receiving chemotherapy is experiencing mucositis. The nurse should advise the client to use which item as the best substance to rinse the mouth? a) Alcohol-based mouthwash b) Hydrogen peroxide mixture c) Lemon-flavored mouthwash d) Weak salt and bicarbonate mouth rinse

d) Weak salt and bicarbonate mouth rinse -rationale: An acidic environment in the mouth is favorable for bacterial growth, particularly in an area already compromised from chemotherapy. Therefore, the client is advised to rinse the mouth before every meal and at bedtime with a weak salt and sodium bicarbonate mouth rinse. This lessens the growth of bacteria and limits plaque formation. The other substances are irritating to oral tissue. If hydrogen peroxide must be used because of the presence of severe plaque, it should be a weak solution, because hydrogen peroxide dries the mucous membranes.