Uworld Test #18
7-year-old client receives a scalp laceration to the back of the head while on a playground, and the new nurse prepares to irrigate the wound. Which actions by the new nurse would require the experienced nurse to intervene? Select all that apply. 1. Administers the prescribed analgesic 30 minutes before irrigating the wound 2. Cleanses the wound from the most to the least contaminated area 3. Obtains a 10-mL syringe and a 27-gauge needle 4. Reviews the child's most recent immunization record 5. Uses continuous pressure to irrigate and repeats until drainage is clear
Answer 2, 3 To perform wound irrigation: Administer the analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect (Option 1). Don a gown and mask with face shield to protect from splashing fluid and sterile gloves to maintain surgical asepsis and prevent infection. Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution. Attach an 18- or 19-gauge needle or angiocatheter to the syringe and hold 1 in (2.5 cm) above the area. Use continuous pressure to flush the wound, repeating until drainage is clear (Option 5). Dry the surrounding wound area to prevent skin breakdown and irritation.
The clinic nurse prepares to administer a newly prescribed dose of sumatriptan to a client with a migraine headache. Which item in the client's history would cause the nurse to question the prescription? 1. Blood urea nitrogen of 12 mg/dL (4.28 mmol/L) 2. BMI of 34 kg/m2 recorded during today's examination 3. Past medical history of uncontrolled hypertension 4. Takes alprazolam as prescribed for anxiety
Answer 3 Sumatriptan relieves migraines by constricting dilated cranial blood vessels. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because the vasoconstrictive effects can cause hypertensive urgency, angina, decreased cardiac perfusion, and acute myocardial infarction.
The nurse enters a client's room just as the unlicensed assistive personnel (UAP) is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene? 1. UAP applies the anti-embolism stockings while maintaining the client in supine position 2. UAP carefully smoothes out any wrinkles over the length of the stockings 3. UAP checks that the toe opening of the stockings is located on the plantar side of the foot ] 4. UAP rolls down and folds over the excess material at the top of the stockings
Answer 4 Anti-embolism stockings are part of venous thromboembolism (VTE) prophylaxis in hospitalized clients. Anti-embolism stockings improve blood circulation in the leg veins by applying graduated compression. When fitted properly and worn consistently, the stockings decrease VTE risk. The stockings should not be rolled down, folded down, cut, or altered in any way. If stockings are not fitted and worn correctly, venous return can actually be impeded.
A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective? 1. I'm not worried about the device firing now because I know it won't hurt." 2. I will let my daughter fix my hair until my health care provider says I can do it." 3. I will look into public transportation because I won't be able to drive again." 4. "I will notify my travel agent that I can no longer travel by plane."
Answer: 2 . After placement of an implantable cardioverter defibrillator, clients are instructed to avoid lifting the arm on the side of the ICD above the shoulder (until cleared by the health care provider) to avoid dislodging the lead wire system. . Option 1) Firing of the ICD may be painful. Clients have described the feeling as a blow to the chest. (Option 3) Driving may be approved by the health care provider after healing has occurred. Long-term decisions are based on the ongoing presence of dysrhythmias, frequency of ICD firings, and state laws regarding drivers with ICDs. (Option 4) Travel is not restricted. The ICD may set off the metal detector in security areas. A hand-held wand may be used but should not be held directly over the ICD. The client should carry the ICD identification card and a list of medications while traveling.
A 10-year-old is implementing behavioral strategies to manage nocturnal enuresis. The client tells the nurse, "I want to go to sleep-away camp during the summer, but if I have an 'accident,' I'm afraid that other kids will tease me." What is the best response by the nurse? 1. "Don't worry. Your problem will be resolved by then." 2. "It would be better if you thought about going to day camp instead." 3. "We can ask your health care provider about a medication trial that may help." 4. "You could always wear a pull-up just in case."
Answer: 3 Pharmacological interventions such as desmopressin and tricyclic antidepressants are often used for nocturnal enuresis treatment in children age >5 years when there has been little or no response to behavioral approaches and/or when short-term improvement of enuresis is desired for attending sleepovers or overnight camp.
The nurse is discussing feeding and eating practices with the mother of a 1-year-old. Which statement made by the mother indicates a need for further instruction? 1. "I give my child chopped fruit rather than juice." 2. "I make sure my child drinks plenty of water between meals." 3. "My child is fussy at bedtime so I put him to sleep with a bottle of milk." 4. "When I give my child a new food, I wait a week before trying a second new food."
Answer: 3 The practice of using a bottle with milk to calm a child at bedtime should be discouraged. A child who falls asleep drinking a fluid high in carbohydrates will likely develop extensive dental caries, a condition known as baby bottle tooth decay.
The emergency department nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway? 1. Head-tilt chin-lift in the supine position on a backboard 2. Head-tilt chin-lift in the Trendelenburg position 3. Jaw-thrust maneuver in semi-Fowler's position 4. Jaw-thrust maneuver in the supine position on a backboard
Answer: 4 If there is any suspicion of spinal injury, the jaw-thrust maneuver should be used for airway assessment to avoid any shifting of unstable vertebrae and subsequent spinal cord damage.
At 8 AM, medications are prescribed for assigned clients. Which medication should the nurse administer first? 1. Acetylsalicylic acid for a client with a history of coronary artery disease and ischemic stroke 2. Metformin for a client with serum glucose of 285 mg/dL (15.8 mmol/L) who is scheduled for a CT scan with contrast 3. Morphine sulfate for a client with terminal lung cancer who has chronic bone pain 4. Pyridostigmine for a client with myasthenia gravis exacerbation who reports difficulty swallowing
Answer: 4 Myasthenia gravis (MG) is a chronic, neurologic autoimmune disorder that involves damage to acetylcholine receptors at the neuromuscular junctions, which results in skeletal muscle weakness. The ocular (ptosis) and facial muscles, along with those responsible for chewing and swallowing, are affected initially; however, weakness can progress to the respiratory muscles (eg, intercostal, diaphragm). Pyridostigmine (Mestinon) is a first-line drug that inhibits acetylcholine breakdown and is prescribed to temporarily increase muscle strength in clients with MG. It is the priority medication as difficulty swallowing indicates weakness of the muscles involved in swallowing and increases aspiration risk.
The community health nurse provides an education program about risk factors for prostate cancer. Which of the following statements by program attendees indicate that teaching has been effective? Select all that apply. 1. "African American men have a higher risk for prostate cancer than other men." 2. "Eating large amounts of red meat may increase my risk for prostate cancer." 3. "I should avoid taking NSAIDs to prevent prostate cancer." 4. "My father had prostate cancer, so I have an increased risk for it." 5. "My risk for prostate cancer increases as I become older."
Answers: 1, 2, 4, 5 Clients can lower the risk for prostate cancer by avoiding modifiable (ie, those the client can control) risk factors, which include: Diet high in red meat, animal fat, high-fat dairy products, and refined carbohydrates (Option 2) Low fiber intake Obesity
The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take? Click on the exhibit button for additional information. 1. Give all medications, including acetaminophen, and reassess in 30 minutes 2. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes 3. Hold the haloperidol and notify the health care provider (HCP) immediately 4. Hold the hydrochlorothiazide and notify the HCP immediately
NMS symptoms - diaphoresis, tachypnea, hypertension, tachycardia, dysrhythmia, altered mental status, rigid muscle, fever
