Evidence-Based Practice
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis? "I will avoid contact with my family until I am done with the test." "I will come back in 1 week to have the test read." "If the test area turns red that means I have tuberculosis." "Because I had a previous reaction to the test, this time I need to get a chest X-ray."
"Because I had a previous reaction to the test, this time I need to get a chest X-ray." Explanation: A client who previously had a positive PPD test (a reaction to the antigen) can't receive a repeat PPD test and must have a chest X-ray done instead. The test should be read 48 to 72 hours after administration. Redness at the test area doesn't indicate a positive test; an induration of greater than 10 mm indicates a positive test. The client doesn't need to avoid contact with people during the test period.
A nurse is teaching new staff members about groups considered at highest risk for suicide. Which group should the nurse emphasize? Depressed persons, physicians, and persons living in rural areas Alcohol abusers, widows, and young married men Adolescents, those in chronic pain, and persons who are unemployed Women, divorced persons, and substance abusers
Adolescents, those in chronic pain, and persons who are unemployed Explanation: Studies of those who commit suicide reveal the following high-risk groups: adolescents; those in chronic pain; persons who are unemployed; divorced, widowed, and separated persons; professionals, such as physicians, dentists, and attorneys; students; unemployed persons; persons who are depressed, delusional, or hallucinating; alcohol or substance abusers; and persons who live in urban areas. Although more women attempt suicide than men, women typically choose less lethal means and, therefore, are less likely to complete their attempts.
A visitor asks the nurse about entering the room of a client who has contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). The nurse explains the necessary precautions needed to visit the client. What statement by the visitor reflects understanding of the contact precautions teaching? "By using gowns, gloves, and washing my hands, I will decrease the spread of MRSA." "The mask will decrease the risk of my friend spreading MRSA." "The use of these masks and gloves will decrease the risk of me getting MRSA." "I will wash my hands after I go in the room and if I touch anything in my friend's room."
"By using gowns, gloves, and washing my hands, I will decrease the spread of MRSA." Explanation: Contact precautions for MRSA require gloves and gowns. A mask does keep respiratory secretions in isolation, but the client has MRSA and is on contact precautions. The visitor should wash hands before the visit and after the visit to decrease the spread of the MRSA.
A nurse is teaching new staff members about groups considered at highest risk for suicide. Which group should the nurse emphasize? Alcohol abusers, widows, and young married men Adolescents, those in chronic pain, and persons who are unemployed Women, divorced persons, and substance abusers Depressed persons, physicians, and persons living in rural areas
Adolescents, those in chronic pain, and persons who are unemployed Explanation: Studies of those who commit suicide reveal the following high-risk groups: adolescents; those in chronic pain; persons who are unemployed; divorced, widowed, and separated persons; professionals, such as physicians, dentists, and attorneys; students; unemployed persons; persons who are depressed, delusional, or hallucinating; alcohol or substance abusers; and persons who live in urban areas. Although more women attempt suicide than men, women typically choose less lethal means and, therefore, are less likely to complete their attempts.
After nasal surgery, the client expresses concern about how to decrease facial pain and swelling while recovering at home. Which instruction would be most effective for decreasing pain and edema? Take analgesics every 4 hours around the clock. Apply cold compresses to the area. Use a bedside humidifier while sleeping. Use corticosteroid nasal spray as needed to control symptoms.
Apply cold compresses to the area. Explanation: Applying cold compresses helps to decrease facial swelling and pain from edema. Analgesics may decrease pain, but they do not decrease edema. A corticosteroid nasal spray would not be administered postoperatively because it can impair healing. The use of a bedside humidifier promotes comfort by providing moisture for nasal mucosa, but it does not decrease edema.
A nurse manager in a pediatric intensive care unit notices an increase in healthcare-associated infections. What should the nurse manager do next? Report the issue to the Centers for Disease Control and Prevention. Contact infection control to obtain infection rates of other units in the facility. Gather data on possible reasons for this increase. Talk with the hospital administrator about the concerns.
Gather data on possible reasons for this increase. Explanation: Gathering data about the reasons for infection or injury is within the scope of nursing practice. It wouldn't be appropriate for the nurse manager to contact infection control or the Centers for Disease Control and Prevention at this time. After gathering supporting data, the nurse manager should speak with the hospital administrator about concerns and findings.
A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority? Ineffective breathing pattern Impaired physical mobility Impaired gas exchange Impaired airway clearance
Impaired gas exchange Explanation: Impaired gas exchange should be the nurse's first priority because of the lack of ventilation due to the surgical procedure and pain. There is no indication that the airway is not patent, and mobility and breathing pattern are not first priorities.
The nurse understands that assessment of blood pressure in clients receiving antipsychotic drugs is important. What is a reason for this assessment? This provides additional support for the client. It will indicate the need to institute antiparkinsonian drugs. Most antipsychotic drugs cause elevated blood pressure. Orthostatic hypotension is a common side effect.
Orthostatic hypotension is a common side effect. Explanation: Orthostatic hypotension is common during the first few weeks of treatment with antipsychotic drugs. An elevated blood pressure usually results from MAOI antidepressants. Additional support should be through therapeutic communications. A problem with the blood pressure is not indicative of antiparkinsonian drugs.
A client has been prescribed diuretic therapy for hypertension. It has been causing frequent urination at night and now the client is refusing to take the morning dose of furosemide. What would be the best response by the nurse? Take the blood pressure and then discuss with the client the dangers of an increased blood pressure if the medication is not taken. Reinforce the reason for the medication. Respect the decision if the client still refuses the medication, and chart the refusal. Reinforce how much the edema has decreased and how effective the medication has been, and encourage the client to take the medication. Tell the client that the extra fluid will be gone and urination will not be as frequent.
Reinforce the reason for the medication. Respect the decision if the client still refuses the medication, and chart the refusal. Explanation: The client needs to understand the importance of extra fluid removal and how it helps control blood pressure. The nurse needs to be respectful that the client still has a choice in whether to take the medication.
A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis? The client sees their physician for a check-up yearly. The client has never traveled outside of the country. The client works in a healthcare insurance office. The client had a liver transplant 2 years ago.
The client had a liver transplant 2 years ago. Explanation: A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate healthcare, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a healthcare worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.
A nurse is planning a program about cancer for a woman's club. What should the nurse include in the discussion of risk factors for ovarian cancer? a 28-year-old woman who has been taking hormonal contraceptives for 10 years a 35-year-old woman who breast fed two children a 60-year-old Caucasian woman with a small frame and fair skin color a 42-year-old woman who has never been pregnant
a 42-year-old woman who has never been pregnant Explanation: The incidence of cancer increases with age in women who have never been pregnant. Being an older female with a small frame and fair skin are risk factors for osteoporosis. Women who breast feed have a lower risk of breast and ovarian cancer. Oral contraceptive therapy reduces the risk of ovarian cancer. The risk is lower the longer the pills are used. This lower risk continues for many years after the pill is stopped.
A physician orders prednisone to control inflammation in a client with interstitial lung disease. During client teaching, the nurse stresses the importance of taking prednisone exactly as ordered and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience hyperglycemia and glycosuria. acute adrenocortical insufficiency. GI bleeding. restlessness and seizures.
acute adrenocortical insufficiency. Explanation: Administration of a corticosteroid such as prednisone suppresses the body's natural cortisol secretion, which may take weeks or months to normalize after drug discontinuation. Abruptly discontinuing such therapy may cause the serum cortisol level to drop low enough to trigger acute adrenocortical insufficiency. Hyperglycemia, glycosuria, GI bleeding, restlessness, and seizures are common adverse effects of corticosteroid therapy, not its sudden cessation.
A client with advanced cirrhosis of the liver is jaundiced and malnourished. Which problem is associated with cirrhosis of the liver? small bowel ulcerations related to jaundice dilute urine in large amounts related to kidney excretion of bile byproducts ascites related to portal hypertension mental alertness and increased perception
ascites related to portal hypertension Explanation: The jaundice is a result of inability of the liver to break down the end products from red blood cells, resulting in elevated bilirubin levels. Small bowel ulcerations do not occur as a result of elevated bilirubin levels and are not problems commonly associated with cirrhosis. The remaining choices are all associated with advanced cirrhosis. Ascites presents because of portal hypertension; clear dilute urine is incorrect as it would be dark due to the inability to eliminate some of the bile byproducts. Confusion and disorientation would occur when the brain is inundated by high levels of circulating toxins because of a failing liver not mental alertness and increased perception.
The nurse is instructing the client with chronic obstructive pulmonary disease (COPD) to do pursed-lip breathing. What is the expected outcome of this exercise? deeper diaphragmatic breathing better elimination of carbon dioxide improved oxygen intake stronger intercostal muscles
better elimination of carbon dioxide Explanation: Pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles.
The nurse is instructing the client with chronic obstructive pulmonary disease (COPD) to do pursed-lip breathing. What is the expected outcome of this exercise? stronger intercostal muscles deeper diaphragmatic breathing improved oxygen intake better elimination of carbon dioxide
better elimination of carbon dioxide Explanation: Pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles.
While hospitalized, a child develops a clostridioides difficile infection. The nurse can anticipate adding which type of precautions for this client? airborne precautions contact precautions droplet precautions standard precautions
contact precautions Explanation: Contact precautions are used for serious illnesses that are easily transmitted by direct client contact or by contact with items in the client's environment. Clostridioides difficile infection is an example of an infection that is spread in this manner. Droplet precautions are used for serious illnesses transmitted by large particle droplets. Standard precautions are used for all clients. Airborne precautions are used for suspected illnesses transmitted by airborne nuclei.
Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? opioid overdose type 1 diabetes mellitus myasthenia gravis extreme anxiety
extreme anxiety Explanation: Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.
A positive tuberculin skin test indicates that a client will develop full-blown tuberculosis. is actively immune to tuberculosis. has produced an immune response. has an active case of tuberculosis.
has produced an immune response. Explanation: The tuberculin skin test is based on the antigen/antibody response and will show a positive reaction after an individual has been exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria. Thus, a positive tuberculin skin test indicates the production of an immune response. Exposure doesn't confer immunity. A positive test doesn't confirm that a person has (or will develop) tuberculosis.
A client is receiving streptomycin to treat tuberculosis. What should the nurse evaluate to determine an adverse effect of the drug? difficulty swallowing IV infiltration decreased serum creatinine hearing loss
hearing loss Explanation: Streptomycin can cause toxicity to the eighth cranial nerve, which is responsible for hearing, balance, and body position sense. Nephrotoxicity is a side effect that would be indicated with an increase in creatinine. Streptomycin does not cause difficulty in swallowing. Streptomycin is given via intramuscular injection.
The nurse is administering theophylline ethylenediamine to a client with chronic obstructive pulmonary disease. Which is an expected outcome of administering this drug? decreased alveolar elasticity relaxed bronchial smooth muscle reduced bronchial secretions strengthened myocardial contractions
relaxed bronchial smooth muscle Explanation: Theophylline ethylenediamine is a xanthine derivative that acts directly on bronchial smooth muscle to relax and dilate the bronchi and relieve bronchial constriction and spasms. When the drug exerts its primary desired effect, dyspnea and shortness of breath decrease. Theophylline ethylenediamine does not reduce bronchial secretions or decrease alveolar elasticity. Theophylline ethylenediamine does increase the strength of myocardial contractility, but this is not the action for which it is used.
In a client who has been burned, which medication should the nurse expect to use to prevent infection? mafenide meperidine gamma benzene hexachloride diazepam
mafenide Explanation: The topical antibiotic mafenide is ordered to prevent infection in clients with partial-thickness and full-thickness burns. Gamma benzene hexachloride is a pediculicide used to treat lice infestation. Diazepam is an antianxiety agent that may be administered to clients with burns, but not to prevent infection. The opioid analgesic meperidine is used to help control pain in clients with burns.
The nurse is administering theophylline ethylenediamine to a client with chronic obstructive pulmonary disease. Which is an expected outcome of administering this drug? relaxed bronchial smooth muscle decreased alveolar elasticity strengthened myocardial contractions reduced bronchial secretion
relaxed bronchial smooth muscle Explanation: Theophylline ethylenediamine is a xanthine derivative that acts directly on bronchial smooth muscle to relax and dilate the bronchi and relieve bronchial constriction and spasms. When the drug exerts its primary desired effect, dyspnea and shortness of breath decrease. Theophylline ethylenediamine does not reduce bronchial secretions or decrease alveolar elasticity. Theophylline ethylenediamine does increase the strength of myocardial contractility, but this is not the action for which it is used.
The nurse on the oncology unit is caring for a client with a total white blood cell (WBC) count equal to 2000/µL (2.0 ×109/L). Which intervention is most important to include in the plan of care? Monitor temperature every 4 hours restrict visitors and provide a private room avoid rectal thermometers and suppositories perform proper hand hygiene
perform proper hand hygiene Explanation: The client with a total WBC equal to 2000/µL (2.0 ×109/L) is demonstrating neutropenia and is at increased risk for infection. Proper hand hygiene is the most important intervention to prevent infection for this client. Monitoring the client's temperature is important to detect the infection early. Avoiding rectal thermometers and suppositories prevent the spread of bacteria from rectum into the blood stream, and restricting visitors and providing a private room aid in the prevention of infection, but proper hand hygiene is most important.
The nurse on the oncology unit is caring for a client with a total white blood cell (WBC) count equal to 2000/µL (2.0 ×109/L). Which intervention is most important to include in the plan of care? perform proper hand hygiene restrict visitors and provide a private room Monitor temperature every 4 hours avoid rectal thermometers and suppositories
perform proper hand hygiene Explanation: The client with a total WBC equal to 2000/µL (2.0 ×109/L) is demonstrating neutropenia and is at increased risk for infection. Proper hand hygiene is the most important intervention to prevent infection for this client. Monitoring the client's temperature is important to detect the infection early. Avoiding rectal thermometers and suppositories prevent the spread of bacteria from rectum into the blood stream, and restricting visitors and providing a private room aid in the prevention of infection, but proper hand hygiene is most important.
The nurse works with the health care team to establish a policy regarding sleep positions for infants with gastroesophageal reflux. What information should the nurse search for first? expert opinions published national standards data from retrospective studies policies from other hospitals
published national standards Explanation: Published national standards are based on the best evidence and, when available, should serve as the foundation for nursing unit policies. Policies from other hospitals may or may not be evidence based. Retrospective studies and expert opinions should only be used to form policy when data from experimental studies or national standards are not available.
A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects to administer which neuromuscular blocking agent? atracurium vecuronium succinylcholine pancuronium
succinylcholine Explanation: Succinylcholine, a depolarizing blocking agent, is the drug of choice when short-term muscle relaxation is desired — for example, during ECT or intubation. Vecuronium, pancuronium, and atracurium are nondepolarizing blocking agents used for intermediate- or long-term muscle relaxation.
A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by using a cuffed tracheostomy tube. suctioning the tracheostomy tube frequently. keeping the tracheostomy tube plugged. using the minimal-leak technique with cuff pressure less than 25 cm H2O.
using the minimal-leak technique with cuff pressure less than 25 cm H2O. Explanation: To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.
While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at an adult child's home with six other people. During the client's visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is "All family members need to be treated." "Just be careful not to share linens and towels with family members." "After you're treated, family members won't be at risk for contracting scabies." "If someone develops symptoms, tell them to see a physician right away."
"All family members need to be treated." Explanation: When someone sharing a home with others contracts scabies, all individuals in the home need prompt treatment whether or not they're symptomatic. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.
A female client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide? "Apply sulconazole nitrate twice daily by massaging it gently into the lesions." "Apply one applicator of tioconazole intravaginally at bedtime for 7 days." "Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days." "Apply one applicator of terconazole intravaginally at bedtime for 7 days."
"Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days." Explanation: A client with primary herpes genitalis should apply topical acyclovir ointment in sufficient quantities to cover the lesions every 3 hours, six times per day for 7 days. Terconazole and tioconazole treat vulvovaginal candidiasis. Sulconazole nitrate treats tinea versicolor.
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? The client exhibits restlessness and confusion. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. The client exhibits bronchial breath sounds over the affected area. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher.
The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. Explanation: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.
The nurse instills 5 mL of normal saline before suctioning a client's tracheostomy tube. Which finding indicates the instillation is effective? The client coughs. The secretions are thinned. There is minimal friction when the catheter is passed into the tracheostomy tube. There is humidification for the respiratory tract.
The secretions are thinned. Explanation: The primary purpose of instilling 5 mL of normal saline solution before suctioning a tracheostomy tube is to thin the secretions to be suctioned. The saline may stimulate a cough; however, this is not the reason for using saline. The tracheostomy tube is larger than the suction catheter, so the catheter will easily pass into the tube without lubrication. Humidification is provided by a nebulizer if needed
The nurse palpates a client's fundus, and notes it is 1 in. (3 cm) above the umbilicus and displaced to the right. What would be priority nursing actions? Select all that apply. Ask the client how many pads she is soaking per hour. Massage the fundus and express clots. Have the client void and reassess the fundus. Carefully observe the client for any discomfort. Assist to semi-Fowler's position and reassess the fundus.
Have the client void and reassess the fundus. Ask the client how many pads she is soaking per hour Explanation: A full bladder can cause uterine atony, increase the amount of lochia, and displace the position of the uterus for assessment of the involution of the uterus. When palpating the fundus, the patient should void first and then lie in a supine position for accuracy, not semi-Fowler's. The nurse may massage the uterus and attempt to express clots; however, this is not the priority nursing action. Asking the client how many pads she is soaking per hour will also indicate whether there is a problem. After having the client void and reassessing the fundus, if the findings were still unexpected, it may be appropriate to notify the charge nurse.
Which factors influence safe and effective medication administration for elderly clients? There is less efficient absorption, detoxification, and elimination. There is more likelihood of taking medications on time. There is an increase in lipid solubility and distribution throughout the body. There is a lower risk of drug interactions.
There is less efficient absorption, detoxification, and elimination. Explanation: When giving medications to elderly individuals, consideration needs to be made for physiologic changes associated with aging. There may be poor absorption from the intestines as well as inadequate elimination. In addition, the liver may be inefficient in detoxification. For the elderly, there is an increased risk of drug interactions because of the number of medications prescribed. They could forget to take the meds. There is less likelihood of solubility and distribution.
The nurse is caring for a client who has been diagnosed with atypical pneumonia. The nurse should assess this client carefully for which symptom? dry cough. high fever. severe chills. tachypnea.
dry cough. Explanation: Atypical pneumonia is characterized by a gradual onset of symptoms, such as dry cough, headache, sore throat, fatigue, nausea, and vomiting. Typical pneumonia is characterized by tachypnea, fever, chills, and productive cough with purulent sputum.
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis? "Because I had a previous reaction to the test, this time I need to get a chest X-ray." "If the test area turns red that means I have tuberculosis." "I will come back in 1 week to have the test read." "I will avoid contact with my family until I am done with the test."
"Because I had a previous reaction to the test, this time I need to get a chest X-ray." Explanation: A client who previously had a positive PPD test (a reaction to the antigen) can't receive a repeat PPD test and must have a chest X-ray done instead. The test should be read 48 to 72 hours after administration. Redness at the test area doesn't indicate a positive test; an induration of greater than 10 mm indicates a positive test. The client doesn't need to avoid contact with people during the test period.
A client asks the nurse why epoetin alfa is administered during dialysis sessions. Which response by the nurse is accurate? "The medication is given to eliminate the rise of creatinine, a naturally occurring electrolyte excreted by the kidneys." "The medication will assist in your activity level when you are not in the hospital." "When clients are on a renal diet, this medication produces products to stimulate increased renal output." "The medication is a form of erythropoietin that stimulates red blood cell production."
"The medication is a form of erythropoietin that stimulates red blood cell production." Explanation: Epoetin alfa stimulates red blood cell production essential for clients with chronic renal failure. It is not used to eliminate the rise of creatinine, to assist activity levels, or to increase renal output.
After nasal surgery, the client expresses concern about how to decrease facial pain and swelling while recovering at home. Which instruction would be most effective for decreasing pain and edema? Take analgesics every 4 hours around the clock. Use corticosteroid nasal spray as needed to control symptoms. Use a bedside humidifier while sleeping. Apply cold compresses to the area.
Apply cold compresses to the area. Explanation: Applying cold compresses helps to decrease facial swelling and pain from edema. Analgesics may decrease pain, but they do not decrease edema. A corticosteroid nasal spray would not be administered postoperatively because it can impair healing. The use of a bedside humidifier promotes comfort by providing moisture for nasal mucosa, but it does not decrease edema.
A school-age child with a dog bite is brought to the emergency department by the parents. What is the nurse's priority action? Determine the child's vaccination history. Clean and irrigate the bite wounds. Interview the parents about the incident. Notify the health care provider for antibiotic prescription.
Clean and irrigate the bite wounds. Explanation: Not every dog bite requires antibiotic therapy, but cleaning the wound is necessary for all injuries involving a break in the skin. Rabies vaccine is used if there is suspicion that the dog has rabies. The infection rate for dog bites has been reported to be as high as 50%.
A nurse manager in a pediatric intensive care unit notices an increase in healthcare-associated infections. What should the nurse manager do next? Report the issue to the Centers for Disease Control and Prevention. Gather data on possible reasons for this increase. Talk with the hospital administrator about the concerns. Contact infection control to obtain infection rates of other units in the facility.
Gather data on possible reasons for this increase. Explanation: Gathering data about the reasons for infection or injury is within the scope of nursing practice. It wouldn't be appropriate for the nurse manager to contact infection control or the Centers for Disease Control and Prevention at this time. After gathering supporting data, the nurse manager should speak with the hospital administrator about concerns and findings.
A nurse notices that a large number of clients who receive oxytocin to induce labor vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene? Notify the physicians and explain that they need to teach their clients before inducing labor. Report the physicians for providing inferior care. Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction. Initiate a protocol order that allows the nurse to administer promethazine before administering oxytocin.
Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction. Explanation: The best intervention by the nurse is to initiate a unit policy that involves the multidisciplinary team. This approach creates an atmosphere of collegiality and professionalism with the goal of providing the best care for clients in labor. Telling the physicians they need to teach their clients blames the physician and doesn't promote multidisciplinary teamwork. Reporting the physicians is unnecessary because nothing indicates that the physicians provided inferior care. The nurse can approach the medical staff about initiating a protocol order that allows the nursing staff to administer promethazine; however, this option doesn't address the current problem — the lack of client education.
A client taking furosemide and digoxin for exacerbation of heart failure reports weakness and heart fluttering. What would be the priority action by the nurse? Tell the client to rest more often to decrease symptoms. Offer the client clear instructions about avoiding foods that contain caffeine. Tell the client to stop taking the digoxin and to stop all physical activity. Investigate the symptoms further with the client and suggest contacting the physician.
Investigate the symptoms further with the client and suggest contacting the physician. Explanation: Furosemide is a potassium-wasting diuretic. A low potassium level may cause weakness and palpitations. Telling the client to rest does not address the priority. Telling the client to stop the digoxin is out of scope of practice. Addressing the diet does not answer the question.
What is the rationale that supports multidrug treatment for clients with tuberculosis? Multiple drugs allow reduced drug dosages to be given. Multiple drugs potentiate the drugs' actions. Multiple drugs reduce development of resistant strains of the bacteria. Multiple drugs reduce undesirable drug adverse effects.
Multiple drugs reduce development of resistant strains of the bacteria. Explanation: Use of a combination of antituberculosis drugs slows the rate at which organisms develop drug resistance. Combination therapy also appears to be more effective than single-drug therapy. Many drugs potentiate (or inhibit) the actions of other drugs; however, this is not the rationale for using multiple drugs to treat tuberculosis. Treatment with multiple drugs does not reduce adverse effects and may expose the client to more adverse effects. Combination therapy may allow some medications (e.g., antihypertensives) to be given in reduced dosages; however, reduced dosages are not prescribed for antibiotics and antituberculosis drugs.
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? The client exhibits bronchial breath sounds over the affected area. The client exhibits restlessness and confusion. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher.
The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. Explanation: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.
A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an I.V. injection of a medication. What is the medication the nurse tells the client they'll receive during this test? immunoglobulin G edrophonium azathioprine cyclosporine
edrophonium Explanation: The most useful and reliable diagnostic test for myasthenia gravis is the edrophonium test. Within 30 to 60 seconds after injection of edrophonium, most clients with myasthenia gravis will demonstrate a marked improvement in muscle tone that lasts about 4 to 5 minutes. Cyclosporine, an immunosuppressant, is used to treat myasthenia gravis, not to diagnose it. Immunoglobulin G is used during acute relapses of the disorder. Azathioprine is an immunosuppressant that's sometimes used to control myasthenia gravis symptoms.
A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it is a respiratory stimulant. inhibits the cough reflex. is a respiratory depressant. may induce bronchospasm.
may induce bronchospasm. Explanation: Acetylcysteine must be used cautiously in a client with asthma because it may induce bronchospasm. The drug isn't a respiratory depressant or stimulant. It's a mucolytic agent that decreases the viscosity of respiratory secretions by altering the molecular composition of mucus. Acetylcysteine doesn't inhibit the cough reflex.
A client has been diagnosed with hypothyroidism. Which statement by the client would demonstrate appropriate teaching by the nurse? "I will increase fiber and fluids in my diet." "I should stop taking the prescribed daily aspirin." "I should stop attending group activities." "I will increase daily caloric consumption."
"I will increase fiber and fluids in my diet." Explanation: Clients with hypothyroidism typically have constipation. A diet high in fiber and fluids can help prevent this. Group activities have nothing to do with the current issue. A nurse would not change medical prescriptions by telling the client to stop taking the prescribed aspirin. Increasing caloric consumption is not appropriate with hypothyroidism.
A client admitted with acute pyelonephritis now reports having a severe migraine, but declines PRN analgesics. What should the nurse discuss with this client? Select all that apply. The client with pyelonephritis cannot use analgesics. Alternative therapies such as relaxation or music can help. Using opioids will prolong the inpatient hospital stay. Short-term use of opioids has a high addiction risk. Ask the client which migraine treatments are helpful when at home.
Ask the client which migraine treatments are helpful when at home. Alternative therapies such as relaxation or music can help. Explanation: The nurse should respect the client's opposition to analgesics, but this should be explored. A discussion will likely reveal a variety of alternative options, many of which may be known to the client already. Opioids are not the best drug of choice for migraines. Short-term use of opioids will not independently prolong the hospital stay and do not carry a higher risk of addiction.
A client taking furosemide and digoxin for exacerbation of heart failure reports weakness and heart fluttering. What would be the priority action by the nurse? Investigate the symptoms further with the client and suggest contacting the physician. Offer the client clear instructions about avoiding foods that contain caffeine. Tell the client to stop taking the digoxin and to stop all physical activity. Tell the client to rest more often to decrease symptoms.
Investigate the symptoms further with the client and suggest contacting the physician. Explanation: Furosemide is a potassium-wasting diuretic. A low potassium level may cause weakness and palpitations. Telling the client to rest does not address the priority. Telling the client to stop the digoxin is out of scope of practice. Addressing the diet does not answer the question.
Which factors influence safe and effective medication administration for elderly clients? There is more likelihood of taking medications on time. There is less efficient absorption, detoxification, and elimination. There is an increase in lipid solubility and distribution throughout the body. There is a lower risk of drug interactions.
There is less efficient absorption, detoxification, and elimination. Explanation: When giving medications to elderly individuals, consideration needs to be made for physiologic changes associated with aging. There may be poor absorption from the intestines as well as inadequate elimination. In addition, the liver may be inefficient in detoxification. For the elderly, there is an increased risk of drug interactions because of the number of medications prescribed. They could forget to take the meds. There is less likelihood of solubility and distribution.
Which action is a priority for the nurse when finding medications at a client's bedside? Leave the medications, as the client will take them after the next meal. Remove the medications from the room and discard them into an appropriate disposal bin. Label the medications and place them back in the medication room. Leave the medications and seek the nurse who left them in the room.
Remove the medications from the room and discard them into an appropriate disposal bin. Explanation: Disposing of the medications in the appropriate manner reflects best practice of nursing and medication administration. Leaving the medications by the client's bed would create a risk for another client to take them, for this client to take them inappropriately, or for them to get lost. It would be incorrect and unsafe to label medications that were taken out by another nurse.
A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client? developing a list of people with whom the client has had contact client teaching about the importance of TB testing reviewing the risk factors for TB client teaching about the cause of TB
developing a list of people with whom the client has had contact Explanation: To lessen the spread of TB, everyone who had contact with the client must undergo a chest X-ray and TB skin test. Testing will help determine if the client infected anyone else. Teaching about the cause of TB, reviewing the risk factors, and the importance of testing are important areas to address when educating high-risk populations about TB before its development.
A client with iron deficiency anemia was prescribed ferrous sulfate. Which statement by the caregiver would indicate a need for further instruction on proper administration? "I give the medication in the morning before breakfast." "I give the ferrous sulfate at a different time than my child's other medications." "I encourage my child to drink lots of fluids." "I mix the medication in milk to make it taste better."
"I mix the medication in milk to make it taste better." Explanation: Ferrous sulfate absorbs better with juices containing vitamin C. However, food containing calcium will decrease the medication's absorption. Ferrous sulfate should be given on an empty stomach if tolerated. Many medications alter the absorption of ferrous sulfate and should be administered at least 1-2 hours apart. Drinking lots of fluid will help with constipation, a common side effect of ferrous sulfate
A nurse is preparing to conduct research and is searching the literature for evidence-based research information. Which source would the nurse most likely use to obtain appropriate information with the strongest level of evidence? Select all that apply. Johanna Briggs Institute Cumulative Index to Nursing and Allied Health Literature (CINAHL) National Guideline Clearinghouse Cochrane Collaboration MEDLINE
Cochrane Collaboration National Guideline Clearinghouse Johanna Briggs Institute Explanation: Information obtained from the Cochrane Collaboration and Johanna Briggs Institute are considered level I evidence which involve a systematic review of all relevant randomized controlled trials (RCTs). Information from the National Guideline Clearinghouse provides level I evidence, identifying clinical practice guidelines based on systematic reviews of RCTs. Information from MEDLINE and CINAHL provide reviews of descriptive or qualitative studies or articles of original quantitative studies, which are considered lower levels of evidence.
The nurse is screening clients for cancer prevention. Which is the recommended screening protocol for colon cancer in asymptomatic clients who have a low-risk profile? Fecal occult blood testing should be performed annually after age 50 and up to age 75. Digital rectal examinations are recommended every 5 years after age 40 years. A diet low in saturated fat should be implemented after age 50. Sigmoidoscopy is recommended if symptoms of colon problems are present
Fecal occult blood testing should be performed annually after age 50 and up to age 75. Explanation: The screening protocol recommended by the American and Canadian Cancer Societies for early detection of cancer in asymptomatic people includes: Beginning at age 50, men and women should have fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy every year until age 75 unless determined otherwise by a health care provider (HCP). A diet low in saturated fat and high in fruit and fiber is not a screening protocol but is good dietary advice for all clients.
A 26-week gestation pregnant woman has completed a 1-hour glucose screening test. What action should the nurse take first if the glucose level is 150 mg/dL (8.3 mmol/L)? Instruct the client on proper diet. Document the results as normal. Refer the client for a 3-hour glucose test. Teach the client how to administer insulin.
Refer the client for a 3-hour glucose test. Explanation: Between 24 and 28 weeks' gestation, the client is evaluated for gestational diabetes. A 50-g glucose load is administered, and the plasma glucose levels are checked at 1 hour. If the results are more than 130-140 mg/dL (7.2-8 mmol/l), such as with this client, further testing such as the 3-hour glucose tolerance test is needed to determine gestational diabetes. The American Diabetes Association says that if the fasting glucose is greater than 95mg/dL (5.3 mmol/L) and the glucose level at 1 hour is greater than 180 mg/dL (10 mmol/L), the 3-hour test is not warranted, because this is a definitive diagnosis of gestational diabetes. A definitive diagnosis would need to be made before the nurse can give diet instructions or teach insulin administration.
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? An obstruction is present in the chest tube. The client is developing subcutaneous emphysema. The chest tube system is functioning properly. There is a leak in the chest tube system.
The chest tube system is functioning properly. Explanation: Fluctuation of fluid in the water-seal column with respirations indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client's skin around the chest tube insertion site. A leak in the system is indicated when continuous bubbling occurs in the water-seal column.
