*Elevate Module 3 Q Review Quiz

A 5 ft. 2 in. slender, female client presents to the clinic with symptoms of back pain and states, "I think I am getting shorter." Which information would be appropriate for the nurse to provide? 1. Spend time in the sunlight. 2. Swim at least three times a week. 3. Walk at least 30 minutes most days. 4. Include yogurt and cheese in diet. 5. Take regularly scheduled prescribed corticosteroids.

1., 3. & 4. Correct: The client with osteoporosis is usually female, and small framed. Back pain from collapsed vertebrae and shortening are symptoms. Exposure to light converts vitamin D stores in the skin. Weight bearing exercises like walking will promote bone density. Yogurt and cheese are high in calcium. 2. Incorrect: Swimming is a non weight bearing exercise and will not promote bone density. 5. Incorrect: This individual should not be taking corticosteroids as these drugs will promote the loss of calcium from the bones.

What sign and symptom should the nurse expect to find during the physical assessment of a client who has a history of rheumatoid arthritis? 1. Nodules over bony prominences 2. Reports of stiffness that is worse in the evening. 3. Reports of loss of appetite 4. Warm, swollen joints 5. Pain in joints

1., 3., 4. & 5. Correct: Firm bumps of tissue (nodules) over bony prominences, such as on elbows, are called rheumatoid nodules, and are a sign of rheumatoid arthritis. Morning stiffness that can last for hours is a symptom of rheumatoid arthritis. Over time, rheumatoid arthritis can cause joints to deform and shift out of place. Weight loss is a common symptom of rheumatoid arthritis. Affected Joints will be tender, red, warm, and swollen. 2. Incorrect: The stiffness will be worse in the morning after a prolonged time of inactivity during sleep.

A client who delivered a 9 pound 12 ounce (4.17 kg) baby 1 hour ago, has saturated 2 peri-pads in 15 minutes. Which nursing actions should take priority? 1. Notify the primary healthcare provider. 2. Massage the fundus. 3. Monitor Hemoglobin and Hematocrit levels 4. Begin an infusion of oxytocin. 5. Obtain pulse rate and BIP and compare with baseline.

2. & 5. Correct: The only answer that will STOP BLEEDING! The fundus is boggy! Massage the fundus. The pulse rate and B/P compared with baseline may give indication of possible complication excessive blood loss. 1. Incorrect: Doesn't stop the bleeding. You have to say, if I could only do ONE thing. Stop the bleeding and compare v/s to baseline for early sign blood loss. 3. Incorrect: This is good, but how will it stop the bleeding and help identify early blood loss? 4. Incorrect: The most common reason for saturating 2 peri-pads is a boggy fundus. The priority is to massage the fundus and stop the bleeding! If postpartum hemorrhage continues, an infusion of oxytocin may be initiated.

The house supervisor sends a LPN to assist on a busy medical-surgical unit. Which client could the charge nurse assign to the LPN? 1. Being discharged with a new Hickman port. 2. With a deep vein thrombosis (DVT) on a heparin infusion. 3. Two-days post gastric bypass taking clear liquids. 4. With Alzheimer's disease awaiting transfer to nursing home. 5. A transfer from post-anesthesia care unit (PACU) following a mastectomy.

3. & 4. Correct: The LPN should be assigned stable clients who do not require initial teaching or frequent assessments. The client who is two days post gastric bypass has already advanced to clear liquids and would be appropriate for the LPN. Also, a client who has Alzheimer's disease awaiting transfer would have needs that could be addressed by the LPN, and therefore is a suitable assignment. 1. Incorrect: This client has a new Hickman port which is an implanted access device used for chemotherapy or medications given long term. There is a great deal of teaching necessary regarding the care of this port. This client should be assigned to the RN. 2. Incorrect: This client will need frequent assessment of circulation in the area of the DVT and monitoring for evidence of bleeding complications. Additionally, PTT levels will be drawn every 6 hours that may require the nurse to adjust the heparin infusion rate. This client is not appropriate for the LPN.

A client has been admitted with advanced cirrhosis. The nurse's assessment reveals an abdominal girth increase of 5 inches (12.7 cm) and a weight increase of 6 lbs. (2.72 kg) since yesterday's measurements. Based on this data, what would be the nurse's priority assessment? 1. Stool for occult blood 2. Ammonia blood level 3. Blood pressure 4. Level of consciousness

3. Correct: In ascites, the client is in FVD and we worry about shock. If my blood pressure drops, I will have decreased perfusion of my vital organs. Poor perfusion leads to organ damage and failure. 1. Incorrect: We are worried about bleeding because the liver is sick, but this is not the first priority in this case. Third spacing (ascites) has increased placing the client at risk for FVD and shock. 2. Incorrect: Ammonia level would indicate a worsening liver condition, but this is not a priority here. 4. Incorrect: LOC is a good indicator of perfusion, but it may be affected by other factors, such as the ammonia level, as well. The BP will tell us the most about shock, and that is what I am worried about here.

An elderly client is experiencing ongoing fecal incontinence with 6-7 small, brown, liquid stools each day. The client eats a regular diet, does not receive any stool softeners or laxatives, and sits in the wheelchair for 1 hour three times a day. What underlying cause of the liquid stools should a nurse suspect? 1. Fecal impaction 2. Recent antibiotic use 3. Inadequate roughage in the diet 4. Inactivity from sedentary lifestyle

1. Correct: The nurse should suspect a fecal impaction. The client is at risk for fecal impaction secondary to constipation. Pressure on the colonic mucosa causes seepage of liquid stool around the area of impaction. 2. Incorrect: This client is at risk for constipation and fecal impaction. A recent antibiotic use may cause diarrhea but the question stem does not mention antibiotic use. 3. Incorrect: Inadequate roughage would not cause diarrhea, but roughage could be added to a regular diet to prevent constipation. 4. Incorrect: The client's inactivity contributes to the potential for constipation and fecal impaction, but the impaction is causing the liquid stools.

The nurse recognizes that Rho(D) immune globulin would be indicated for which Rh negative client? 1. Elective abortion at sixteen weeks gestation 2. Requires amniocentesis 3. Diagnosed with an ectopic pregnancy 4. Forty-eight hours post delivery of term Rh positive baby 5. Twenty weeks gestation

1., 2., 3., & 4. Correct: All of these clients may need to receive the Rho(D) immune globulin because they could have some bleeding and therefore develop antibodies against a Rh positive fetus. 5. Incorrect: An optional Rho(D) immune globulin dose may have been given during pregnancy by the practitioner, but it is 28 weeks, not 20 weeks.

A client diagnosed with ulcerative colitis has a new prescription for a biologic agent. What is the priority education the nurse needs to make certain the client receives? 1. If you miss a dose, take it as soon as you remember. 2. Stay away from people who are sick. 3. Do not receive a live vaccine while using a biologic agent. 4. Common side effects include headache and cold symptoms.

2. Correct: Biologics are immunomodulators which means that they alter the body's immune response. Since these agents can suppress the immune system, making the client more prone to infection. Biologics are used to treat many inflammatory conditions, such as ulcerative colitis, rheumatoid arthritis, and psoriatic arthritis. They can also be used in adults and children to treat Crohn's disease or juvenile idiopathic arthritis. 1. Incorrect: If the client misses a dose of the medicine, they should take it as soon as they remember, and then go back to your regular injection schedule. Do not use extra medicine to make up the missed dose. But this is not the priority at of the options available. 3. Incorrect: Although clients taking a biologic agent should not receive a "live" vaccine, this is not the priority. The vaccine may not work as well during this time, and may not fully protect the client from disease. Live vaccines include measles, mumps, rubella (MMR), polio, rotavirus, typhoid, yellow fever, varicella (chickenpox), or zoster (shingles). 4. Incorrect: Common side effects do include headache and cold symptoms. However, is this the priority for client education? No.

A client diagnosed with celiac disease has been prescribed a gluten-free diet. Which meal, if chosen by the client, would indicate to the nurse that the client understands this diet? 1. Cream based chicken soup 2. Marinated baked chicken with peas 3. Chicken grilled with green salad 4. Battered-coated tilapia with green beans

3. Correct: Fresh meats, fish and poultry (not breaded, batter-coated or marinated), fruits and vegetables are allowed on a gluten-free diet. 1. Incorrect: This may contain hidden gluten as wheat may be used as a thickener. 2. Incorrect: Fresh meats, fish, and poultry are allowed, but not if breaded, batter-coated, or marinated. The baked chicken is marinated. 4. Incorrect: Fresh meats, fish, and poultry are allowed, but not if breaded, batter-coated, or marinated. The tilapia is batter-coated.

A client who is three days post-op cholecystectomy complains of severe abdominal pain. During the initial morning assessment the client states, "I had two almost black stools last night." Which nursing action is the most important? 1. Start an IV with D5W at 125 mL/hr 2. Insert a nasogastric tube 3. Contact the primary healthcare provider 4. Obtain a stool specimen

3. Correct: What's going on inside? They are hemorrhaging. Assume the worst. The primary healthcare provider is the only one who can stop the bleeding. 1. Incorrect: There's nothing wrong with starting an IV, but isn't the client bleeding while you do this? 2. Incorrect: How does that help the bleeding stop? It doesn't. 4. Incorrect: You are going to wait on a stool specimen and Hemoccult? Don't delay care! Notify the primary healthcare provider first.

For a client with Paget's disease affecting the spine. Which assessment finding would the nurse expect to find? 1. Severe hip pain 2. Walking with a limp 3. Upper extremity grip weakness 4. A shuffling gait 5. Tingling and numbness in lower extremity.

1., 2. & 5. Correct: Paget's disease is a chronic skeletal bone disorder in which there is excessive bone resorption followed by the marrow being replaced by fibrous connective tissue. The new bone is larger, disorganized, and weak. These clients have severe pain, may walk with a limp, and may become bow legged. With the spine affected by Paget's disease the lower extremity may have tingling and numbness from spinal nerve root compression. 3. Incorrect: Muscle weakness is not a symptom. 4. Incorrect: This is a manifestation of Parkinson's disease which is related to brain and nerve signals. It is not related to Paget's disease.

The nurse is to administer oxytocin 0.5 milliunits/min IV to a client admitted for labor induction. Oxytocin is available as 10 units/1000 ml 0.9% normal saline. How many mL/hour of the oxytocin should be administered? 1. 3 mL/hour 2. 6 mL/hour 3. 10 mL/hour 4. 12 mL/hour

1. Correct: 3 mL/hour will deliver oxytocin 0.5 milliunits/min. Calculations for IV Oxytocin Solution NOTE 1 Unit = 1,000 milliunits TO MAKE SINGLE-STRENGTH IV SOLUTION: Add 10 Units of Oxytocin to 1 liter of compatible IV fluid. TO INFUSE: Convert prescribed milliunits/min to mL/hr and set infusion pump. AMOUNT PRESCRIBED: 0.5 milliunits/min CALCULATIONS: 10 Units/1 L = 10,000 milliunits/1,000 mL OR 10 milliunits/1 mL. 10 milliunits/1 mL = 0.5 milliunits/X mL Cross-multiply to get: 0.5 = 10X X = 0.05, so 0.05 mL/min Multiply by 60 minutes to get amount infused per hour. THINK: 0.05 milliunits = 0.05 mL/min 0.05 mL/min x 60 min/hr = 3 mL/hr (0.05 x 60 = 3) Set the infusion pump for 3 mL/hr.

A client has been admitted with advanced Cirrhosis. The nurse's assessment reveals an abdominal girth increase of 5 inches (12.7 cm) and a weight increase of 6 lbs.(2.71 kg) since yesterday's measurements. What further assessment findings would the nurse expect? 1. Hypotension 2. Cool extremities 3. Tachycardia 4. CVP reading of 8 mm/Hg 5. Radial pulses 4+/4+

1., 2. & 3. Correct: These are signs and symptoms of FVD due to 3rd spacing and shock is what you are afraid of. We would expect the heart rate to increase in FVD in an effort to move what little volume you have left through the system. 4. Incorrect: This is a high CVP, and with FVD you would expect it to be low. 5. Incorrect: Pulses are evaluated on a 4 point scale, so 4 would be a bounding pulse which would indicate fluid volume excess.

A client at 28 weeks gestation reports swollen hands and feet during her prenatal visit. Which additional signs/symptoms would be of concern to the nurse? 1. Increased deep tendon reflexes 2. Blurred vision 3. Blood glucose 120 mg/dL (6.7 mmol/L) 4. Muscle spasms 5. Headache

1., 2., 4., & 5 Correct: The deep tendon reflexes will be increased (hyperactive) with preeclampsia. Muscle spasms indicate nerve/muscle irritation. Headache and blurred vision are indicators of increasing blood pressure. This client is going into preeclampsia. 3. Incorrect: Mild blood sugar elevation is not related to preeclampsia.

The nurse is assessing a pregnant client who thinks she is in labor. Which statement by the client would alert the nurse that the client is likely experiencing true labor? 1. "The pain is in my back, and comes around to my abdomen." 2. "The contractions seem to increase when I begin walking around." 3. "The pain is in my lower abdomen and groin." 4. "My contractions are coming every 5 minutes." 5. "Changing my position does not help with the pain intensity."

1., 2., 4., & 5. Correct: All of these are signs of true labor. 3. Incorrect: The pain from true labor is in the back and comes around to the abdomen.

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client? 1. Alternating pressure mattress 2. Hospital bed 3. Bath chair 4. Suction equipment 5. Oxygen 6. Mechanical hoist lift

1., 2., 4., & 5. Correct: An alternating pressure mattress will help to prevent pressure ulcers. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. The client with hepatic encephalopathy is unresponsive and may need suctioning if unable to clear secretions from the oropharynx. The client at the end stages of liver disease will be hypoxemic, so oxygen therapy is provided. 3. Incorrect: The unresponsive client will not need a bath chair. This client will receive a bed bath. 6. Incorrect: Mechanical hoist lifts are expensive and require special training to use.

In which client should the nurse question a prescription for a contraction stress test? 1. Client at 26 weeks gestation. 2. Client with a history of 4 Cesarean section deliveries. 3. Client at 38 weeks with gestational diabetes. 4. Client at 37 weeks gestation. 5. Client with placenta previa. 6. Client with preterm membrane rupture

1., 2., 5. & 6 Correct: 26 weeks is too early to stimulate contractions. This could lead to a preterm delivery. Stimulating contractions in a client with previous cesarean deliveries is not recommended. This may lead to uterine rupture. Stimulating contractions in a client with placenta previa is not recommended. This may lead to hemorrhage. Conditions such as preterm membrane rupture may increase risk of preterm labor and delivery. 3. Incorrect: There is no reason to suspect complications from a contraction stress test for this client. 4. Incorrect: There is no reason to suspect complications from a contraction stress test for this client.

A staff nurse has been assigned to care for a client who has just returned from open carpal tunnel release surgery. Which instructions would the charge nurse provide to the staff nurse about the plan of care of this client? 1. Monitor the dressing for tightness. 2. Maintain hand at the level of the heart. 3. Check vital signs every 15 minutes times 4. 4. Perform neurovascular check to extremity. 5. Check dressing for drainage.

1., 3., 4., & 5. Correct: The client's dressing should be monitored for both tightness and drainage. We would worry about compartment syndrome with tightness and excess bleeding with drainage. Vital signs are needed every 15 minutes for the first hour. Neurovascular checks are important with this client and should be done. 2. Incorrect: Place the hand above the level of the heart to decrease edema.

Which condition requires the nurse to discontinue an intravenous infusion of oxytocin to a laboring client? 1. Onset of nausea and vomiting 2. Contraction every 90 seconds lasting 70 seconds 3. Maternal blood pressure 140/90 4. Early decelerations in the fetal heart rate 5. Signs of fetal distress

2. & 5. Correct: These contractions are too long and too often. Any sign of fetal distress and the oxytocin should be discontinued. 1. Incorrect: Many laboring clients become nauseated and vomit during labor. Also, common side effects of oxytocin include nausea and vomiting. This would not require the discontinuation of oxytocin. 3. Incorrect: Maternal hypotension requires discontinuation of oxytocin. This BP is not worrisome. 4. Incorrect: Early decels are generally not harmful and happen as baby is descending through the birth canal during the later stages of labor. These are not related to the oxytocin infusion.

A client who is gravida 2 para 1 is visiting the obstetric clinic for a checkup. The first delivery was a cesarean for failure to progress, and the client indicates a desire for a vaginal delivery this time. The nurse knows the most important factor in determining the possibility of a vaginal birth after cesarean (VBAC) is what? 1. The length and difficulty of the previous labor. 2. The type of incision used for the cesarean. 3. The position of the fetus before delivery. 4. Total number of pregnancies desired.

2. Correct: A VBAC is often requested by a client for a number of reasons. There is less pain after delivery with a shorter recovery period and less chance of infection. A VBAC can also potentially increase the number of pregnancies possible, since cesarean sections dramatically limit the number of children. The main factor that determines whether the client could safely have a VBAC is the type of uterine incision made for the previous C-section. Those who have had a low, transverse incision are candidates for trial of labor after cesarean (TOLAC). 1. Incorrect: Obviously, in this situation, the client had experienced failure to progress in the previous pregnancy, necessitating the need for a C-section. The length and difficulty of the previously attempted birth would have affected the decision to have the first C-section, but would not impact the current choice to attempt a VBAC. 3. Incorrect: The position of the fetus prior to delivery does not have a significant bearing on the decision to have a VBAC. Clients who intend to try a vaginal birth are very closely monitored prior to labor. If the obstetrician determines by ultrasound that the fetus is incorrectly positioned, there is the possibility of "turning" the fetus prior to the onset of labor. Only in extreme circumstances would the fetal position prevent vaginal birth. 4. Incorrect: The factor that is most important in determining the chance for a VBAC is not the number of pregnancies desired, but rather the position of the uterine incision made with the last C-section. The ability to actually have a successful VBAC may affect the total number of children desired.

Immediately following a below-the-knee amputation (BKA), the nurse positions the client to prevent complications. What intervention related to position of the residual limb is a priority at this time? 1. Flat on the bed 2. Elevate foot of the bed 3. Position of comfort 4. Dependent position

2. Correct: It is normal to experience post-operative swelling after a BKA. Immediately after surgery, the foot of the bed should be elevated to reduce swelling. An ACE compression bandage will be used to reduce swelling and prevent hemorrhage. The other positions would not be as appropriate since swelling is an issue after a below the knee amputation. 1. Incorrect: Flat on the bed will not relieve swelling. Post-operatively for a BKA, hemorrhage and swelling are the biggest concerns immediately following surgery. 3. Incorrect: Position of comfort may increase swelling. Immediately following a BKA, elevating the foot of the bed and the ACE compression wrap are used to prevent hemorrhage and swelling. Positioning for comfort is not appropriate. 4. Incorrect: Placing in a dependent position will increase swelling. Swelling post-operatively is a normal occurrence, and elevating the foot of the bed along with the use of an ACE wrap will help prevent swelling.

A client arrives to the emergency department after an altercation resulting in a knife wound to the abdomen. Which intervention should the nurse perform? Exhibit Wound: 1. Place the client in trendelenburg position. 2. Instruct the client to lie quietly in a low Fowler's position. 3. Establish IV line immediately. 4. Cover exposed intestine with sterile dressings moistened normal saline. 5. Notify the surgeon at once.

2., 3., 4. & 5. Correct: Low Fowler's position and staying calm and quiet help to minimize protrusion of body tissues. IV line needed for possible volume replacement and medications. Cover exposed intestines with sterile dressings moistened with sterile saline solution. Have someone notify the surgeon at once and you stay with the client and stay calm. 1. Incorrect: The client should be placed in the low Fowler's position and instructed to lie quietly. These actions minimize protrusion of body tissues.

A nurse is planning care for a client admitted to the unit after application of a halo apparatus to immobilize the cervical spine. What interventions should the nurse include? 1. Clean around pins once daily with a small brush. 2. Use the log roll technique when turning client in bed. 3. Assist client with daily shower. 4. Have client sit up slowly with assistance. 5. Inspect for skin breakdown under halo vest.

2., 4., & 5. Correct: Turn the client in bed every 2 hours by means of a triple log roll technique, in which 3 nurses roll the client. 1st nurse stands behind the head of the bed and places hands firmly on the client's head and neck, turning them as 1 unit. 2nd nurse stands at the client's side and moves the shoulders. 3rd nurse stand at the client's side and moves the client's hips and legs. All 3 nurses turn the client at the same time into desired position and onto previously positioned pillow. Administer mild analgesics to control headache and discomfort around the pin site. Begin sitting and ambulating by assessing the client's tolerance to upright position, accompany the client when ambulating, and consider the client's use of a walker. Inspect skin under halo vest looking for skin breakdown. 1. Incorrect: Clean around pins at least twice daily with sterile q-tips. A brush may cause abrasions on the skin. 3. Incorrect. Assist client with a sponge bath to help keep the vest dry. Showers will cause the vest to become wet and should not be taken. This can lead to skin breakdown.

The nurse is developing the plan of care for a child with a fractured femur in Bryant's traction. The nurse is aware that planned interventions should focus on assessing for what major complication? 1. Infection at the pin sites. 2. Slipping counter traction. 3. Neurovascular impairment. 4. Skin breakdown and decubiti.

3. Correct: Bryant's traction is a type of skin traction with the potential for several complications. Though the traction is important, this child is being treated for a fractured femur. The major complication with any fracture is neurovascular integrity. Nursing assessment priority is neurovascular assessment, including areas such as pulses, sensation, motor function, edema, skin temperature and capillary refill in bilateral toes. 1. Incorrect: Bryant's traction is a type of skin traction, not skeletal traction. Skin traction is non-invasive so there are no pin sites or invasive wires. 2. Incorrect: Any type of traction has the potential for slippage of knots since the pulley weights are attached by ropes or held by tape to skin. While the nurse needs to frequently verify those attachments are secure, loss of counter traction is not the worst complication. 4. Incorrect: Because the client is kept supine in this traction, there is a high potential for skin breakdown to the buttocks or sacral area. Special interventions are required to prevent development of decubiti for clients in Bryant's traction.

A client, scheduled for a total hysterectomy for advanced cervical cancer, is crying and states, "I want to have more children! I do not know if I should have this procedure." Which responses by the nurse are appropriate? 1. Ask why the client feels this way. 2. Tell the client that her health must be her priority. 3. Explain to the client that cryotherapy may be an option for treatment. 4. Advise the client to delay surgery until she is absolutely sure. 5. Encourage client to discuss with surgeon again about the total hysterectomy. 6. Allow her to express her feelings.

5. & 6. Correct: This may be anticipatory grieving and being scared. Let the client talk and encourage her to talk again to the primary healthcare provider. She may need reassurance that she is making the right decision. 1. Incorrect: This is non therapeutic communication and will make the client feel she must defend her feelings. 2. Incorrect: This is negating the client's feelings and is not helpful in this situation. 3. Incorrect: Cryotherapy is destruction of tissue by freezing with liquid nitrogen. Cryotherapy may be used with precursor lesions (mild to moderate dysplasia). It is not an appropriate treatment for advanced cervical cancer. 4. Incorrect: The cancer is already in an advanced stage. Will the waiting help her survive?