NPQ
The nurse is caring for a client experiencing pain following a urological endoscopic procedure for suspected renal obstruction. Which intervention has the highest priority?
1. Administer analgesics and antispasmodics for pain and spasm. 2. Discuss the client's fears related to possible diagnosis. 3. Implement continuous bladder irrigation to prevent clot formation. 4. Continue fasting regimen 6 to 8 hours following procedure. #1 is correct. Following a urological endoscopic procedure, the client with obstructive pathology may experience urinary retention if the instruments used during the examination caused further edema. The client will experience bladder spasms and pain. Therefore it is appropriate to administer analgesics and antispasmodics. 2. Incorrect: The client may experience fear related to the diagnosis, but the physiological pain should be treated. Once the pain is controlled, the client's knowledge deficit may be addressed. 3. Incorrect: Bladder spasms are painful and must be addressed. Continuous bladder irrigation is used post-operatively following a transurethral resection of the prostate to prevent formation of blood clots which can obstruct the urinary output. 4. Incorrect: Unless contraindicated, the client may begin oral intake.
When educating parents on appropriate cooling measures to use when their child has a temperature, the nurse should include which of the following? Select all that apply.
A) -Have your child wear minimal amounts of clothing (cooling) -keep the room cool (comfort) -Apply moist compresses to the skin (cooling) -Increase air circulation in the room (cooling & comfort)
A client tells a nurse about feeling pressured into signing advanced directives by another healthcare provider. The client reports an inability to discuss wishes with family and would like to revoke the advanced directives. What is the best response from the nurse? 1) "I will speak to the nurse manager to organize a family meeting." 2) "Are you having second thoughts about something you signed?"
A) #2 In this situation, it would be important for the nurse to immediately address any concerns clients have regarding their advanced directives. If clients are unsure about anything they signed, it would need to be addressed. Clients should not feel pressured into signing documents if they do not understand or need more education. #1: "I will speak to the nurse manager to organize a family meeting." It would be important for the nurse to address this issue with the family. The nurse manager would be an appropriate person to organize a family meeting and review the advanced directives with the family. A meeting would allow clients and their families to discuss their wishes should clients not be able to make them for themselves. The nurse first assists clients to alter their advanced directive as desired.
A client in the emergency department is told a myocardial infarction has occurred and a stent will need to be placed. The client states, "I am happy I did not have a heart attack." Which is the nurse's first response? 1) Educate the client about the health condition that has occurred 2) ask the diagnosing health care providers to speak with the client 3) Give the client pamphlets about heart attacks 4) make a referral to social work for further suppor
A) 1 It is important for the nurse to take time with clients to explain that a myocardial infarction is a heart attack. It is important for healthcare providers to use appropriate language and not medical jargon with clients. The nurse will need to assess clients' understanding of their diagnosis. Wrong) 2 It is appropriate for the healthcare providers to speak with the clients and inform them that they have had a heart attack and educate them on their diagnosis. It would be more appropriate to first educate clients and assess their learning level.
A nurse cares for a postoperative client with an indwelling urinary catheter in place. Which would be the best reason for the nurse to advocate for removing the catheter? 1) The client has clear and adequate urine output. 2) The catheter impedes mobility 3) The client's temperature is normal 4) the client experiences pain from the catheter
A) 1 The client has clear and adequate urine output. This would be the best reason to use to advocate for removal of the catheter. It indicates that the client is producing enough urine and it is a healthy color. Dark urine or limited output could indicate a potential problem and is possibly a reason for the catheter to stay in place for further monitoring. Wrong) The client experiences pain from the catheter. Catheters can cause positional pain or pain from an infection. If a client is experiencing pain from a catheter, the best action by the nurse is to assess the position and make changes if appropriate. If pain continues, a urine sample should be obtained to assess for an infection. Indications for indwelling catheter: Client must be postoperative, have an epidural, have an obstruction, be deeply sedated, require strict intake and output, require spine immobilization, be post-pelvic surgery, have an open sacral or perineal wound, or have other ongoing and clearly documented needs.
A nurse cares for a newborn client who may have aspirated meconium during the birth process. Which symptoms indicate to the nurse that the client has aspirated meconium? 1) low muscle tone 2) wet lung sounds 3) low O2 saturation 4) acrocyanosis 5) increased HR
A) 1,3,5 Low muscle tone could be an indication that the infant's body is not receiving enough oxygen as a result of aspiration. This would indicate that the infant is struggling to breathe, and low O2 saturation is a common symptom of meconium aspiration. The infant is not getting enough oxygen into the lungs, and immediate interventions would be needed. An increased heart rate would indicate that the infant is working too hard to breathe and could be a result of meconium aspiration. Wrong answers: 4) Acrocyanosis -Central cyanosis would be an indication of respiratory compromise from meconium aspiration. Acrocyanosis, or blue hands and feet, is a normal finding in the first 24 hours after birth. 2) Wet lung sounds - Fluid in the lungs may be normal in a newborn delivered by cesarean or rapid vaginal delivery. This is called transient tachypnea of the newborn.
A client with a history of hypotension during hemodialysis requires dialysis today. The nurse reduces the client's risk of hypotension from hemodialysis with which interventions? 1) ensure dialysate is warmed prior to treatment 2) ensure the client does not eat immediately before or during treatment 3) Ask the HCP to clarify the client's antihypertensive medication orders
A) 2, 3 Ensure dialysate is warmed prior to treatment. Body temperature increases during treatment and may lead to peripheral dilation and hypotension. Decreasing the dialysate to below core body temperature can reduce the potential or severity of hypotension during treatment. Ensure the client does not eat immediately before or during treatment. Feeding the client immediately before or during dialysis increases the risk of hypotension due to splanchnic vasodilation. If syncope results (loss of consciousness due to a drop in cardiac output) this would subsequently increase the risk of aspiration. **eating causes blood to enter the stomach for digestion -> increases risk low BP and aspiration risk. Ask the healthcare provider to clarify the client's antihypertensive medications orders. Some clients require antihypertensive medications timed to be administered after hemodialysis treatments. Vasodilators such as nitroglycerine patch particularly increase the risk for hypotension during treatment. However, the use of antihypertensive in relation to hemodialysis treatments should be individualized, so the nurse should consult the healthcare provider to clarify what is most appropriate for this client. The fluid shift that occurs during dialysis is significant. Consider that clients are normally dialyzed every 2-3 days when the average person with functioning kidneys voids multiple times in any 24-hour period. The rapid change in cardiac output can result in hypotension. Avoid food during dialysis and clarify the timing of antihypertensive medications. If other interventions are not effective, midodrine (an alpha1 agonist) may be ordered to help with hypotension. Intravenous vasopressors are not used for hypotension during dialysis.
The nurse manager creates the daily assignments. Which clients are appropriate to assign to the practical nurse (PN)? SATA 1) A postoperative client who has a hemoglobin of 7.1 g/dL 2) A client who has heart failure and a peripheral IV catheter that needs to be removed 3) A client with quadriplegia who requires routine care and suctioning of a tracheostomy 4) A client who pulled out a nasogastric tube and needs it replaced
A) 2, 3, 4 PNs can remove peripheral IVs (NOT central lines). PNs can provide tracheostomy care. PNs can reinsert and provide interventions to a client with a NG tube. PNs are able to perform many of the same nursing interventions as registered nurses (RNs). PNs practice under the supervision of RNs and are restricted from performing certain tasks, such as administering IV medications and administering blood products.
A nurse cares for a client with an arterial line whose blood pressure readings have been trending WNL. When assessing the client, the nurse notes a sudden low reading. The nurse performs which initial interventions? Select all that apply: 1) admin a 500 mL fluid bolus 2) call the HCP 3) check the BP manually 4) flush the arterial catheter line 5) zero the arterial line transducer
A) 3,4,5 Check the BP manually. One way to check the accuracy of the arterial line blood pressure is to compare it to a manual blood pressure. If the manual and arterial blood pressures are similar, contact the HCP immediately. Flush the arterial line catheter line. Flush the arterial line any time the line is zeroed. The arterial line is zeroed to ensure there are no air bubbles. Air bubbles in the line can cause an inaccurate pressure reading. Zero the arterial line transducer: Zero the arterial line to make sure the reading is accurate before performing any interventions. A sudden drop in blood pressure may be a crisis or an equipment malfunction. Visualizing the client while performing these interventions helps identify if there are any symptoms that correlate with low blood pressure readings. Always check the accuracy of sudden low blood pressure readings, either invasive or noninvasive, with a manual blood pressure reading before notifying the healthcare provider (HCP) or performing interventions. If a quick, focused assessment, including general appearance and a manual blood pressure reading, are normal, the nurse troubleshoots the equipment. If a focused assessment and manual blood pressure reading are abnormal, the nurse quickly performs further assessment and immediately contacts the HCP. **Arterial line: internal reading of blood pressure that nurse can monitor. If manual BP is different than transducer= then troubleshoot equipment.
The nurse witnesses the client with acute confusion pulling on the indwelling urinary catheter. Which intervention does the nurse perform first? 1) assess the catheter 2) apply mitt restraints 3) apply soft restraints 4) redirect the client verbally
A) 4 Redirect the client verbally. Verbal redirection should be done immediately in an attempt to prevent harm to the client. Trauma to the neck of the bladder from the catheter's balloon can occur, and there would be significant trauma to the urethra should the client pull out the catheter with the balloon inflated. wrong) The nurse would not use soft wrist restraints unless providing verbal redirection, assessing the catheter, and trying soft mitt restraints all failed to protect the client from harm. The nurse knows that restraint use is a last resort for the client with confusion. The first step to manage a client with confusion or agitation is verbal redirection. When therapeutic lines and tubes may be accidentally removed because of continued agitation or confusion, the nurse tries less restrictive soft mitt restraints first before using soft wrist restraints. The nurse also takes measures to hide and secure any catheters, IVs, and other lines or tubes.
A 67-year-old client is visiting with the nurse in the healthcare clinic. The client's spouse tells the nurse that the client does not always respond when she talks to him and he doesn't participate in family activities as much anymore. Which step should the nurse perform first?
A) Check inside the client's ear for occlusion. The risk of hearing loss increases as an adult grows older, and the nurse has several tests to determine whether the client is suffering from hearing loss. Without further information, the first and quickest action by the nurse is to look inside the client's ears to determine if there is a physical occlusion present that is contributing to the hearing loss. Wrong answers: -Perform the confusion assessment method (CAM) test. This test is used to assess for delirium. This test does not need to be performed since this client is suspected to have hearing loss, not delirium. -Assess the client using the mini-cognition test. This testis used to assess for Alzheimer's. This test does not need to be performed since this client is suspected to have hearing loss, not Alzheimer's.
A nurse works in the medical-surgical unit of the hospital and is performing safety checks on medical equipment. Which of the following is an example of a device factor that would contribute to an adverse event? Select all that apply.
A) Faulty connectors on a chest tube drainage system. A medical device is anything used for treatment, diagnosis or prevention of disease in the medical field. Examples of medical device errors that contribute to adverse events include faulty connections, holes in tubing, telemetry monitoring system failure, or pump failure. A) A hole in a portion of a urinary catheter tube A medical device is anything used for treatment, diagnosis or prevention of disease in the medical field. Examples of medical device errors that contribute to adverse events include faulty connections, holes in tubing, telemetry monitoring system failure, or pump failure. Wrong answers: -Environmental distractions that interrupt work. This factor is not directly related to a medical device, so they wouldn't be considered to be device factors that contribute to a medical event. -Poor lighting in the room. This factor is not directly related to a medical device, so they wouldn't be considered to be device factors that contribute to a medical event.
A nurse is admitting a client from a PACU who just received a permanent atrioventricular pacemaker for a complete heart block. Which action should the nurse implement first?
A) Initiate continuous cardiac monitoring Attach the cardiac monitor to assess the function of the pacemaker before making other appropriate assessments (e.g., assess incision site for bleeding and draining, auscultate lungs sounds for atelectasis, IV fluids and postop antibiotics for reestablishing fluid volume). If the atrioventricular (dual-chambered) pacemaker is working properly, pace spikes should be visible prior to the P waves and QRS complexes (electrical capture). If the pacemaker is not working properly (e.g., failure to capture, failure to sense), the HCP should be contacted immediately.
The student nurse is reviewing the chart of an assigned client and notes that the client has bone resorption. Which of the following would the student expect to see when assessing this client?
A) Kyphosis. Bone resorption is the process of bone breakdown in the body by osteoclasts, in order to release minerals into the bloodstream, such as calcium. When this happens faster than bones can rebuild, a client will develop osteoporosis as the bones become porous, or less dense.
The nurse receives shift report on a client with increased intracranial pressure (ICP). The nurse steps into the room to assess the client and notes that the client is in high-Fowler's position. Which of the following actions is appropriate?
A) Lower the head of the bed to High-Fowler's position includes the head of the bed at 90 degrees or greater. This is inappropriately high for a client with increased intracranial pressure, because it increases intrathoracic pressure, which decreases venous outflow from the brain. The client's head of bed should be kept between 30-45 degrees, because this position is optimal to increase venous outflow from the brain, which leads to decreased ICP. Chart the client's position and check the external ventricular drain....Based on the information given in the scenario, the nurse needs to immediately lower the head of the bed to help increase venous outflow and decrease ICP.
A client has overdosed on a benzodiazepine. The nurse has given the client flumazenil as the antidote, and begins to monitor for which type of reaction from the effects of the antidote?
A) Seizure Giving an antidote to a drug overdose is necessary, but can result in some adverse events for the client. With a benzodiazepine overdose, flumazenil is given. This abrupt lack of benzodiazepine in the body can lead to irritability, restlessness, nausea, vomiting, tremors and even seizures. Sedation.... This is not an effect of flumazenil, nor is it an effect of a reduced level of benzodiazepine in the body.
A nurse is admitting a patient with congestive heart failure (CHF) treated with atenolol for an acute exacerbation of chronic obstructive pulmonary disease (COPD). The nurse notes a potential drug-to-drug interaction with one of the patient's newly prescribed medications. Which of the following drugs can interfere with the patient's current prescription? albuterol corticosteroid ipratropium theophylline
Albuterol should not be used. The patient takes atenolol for CHF which is a beta-blocker. Albuterol is a beta agonist that has the opposite pharmacological effect of atenolol. In a patient taking atenolol, the therapeutic capability of albuterol may be greatly decreased. Ipratropium, corticosteroids, and theophylline have no potential interaction with atenolol.
The nurse cares for an adult client reporting difficulty breathing. Which actions does the nurse take? (audio clip: wheezing, closed airway breathing) 1) Administer prescribed bronchodilator via a nebulizer. 2) Prepare to assist in the placement of an advanced airway.
Answer) 2 Stridor is often a medical emergency because it is the manifestation of a narrowed or partially obstructed upper airway. The nurse should prepare to assist the healthcare provider in placing an advanced airway. If less invasive measures are successful, that is notable, but the nurse first prepares for emergency airway management. Expectant management requires close monitoring for progression to loss of airway. Other interventions, client status permitting, might include humidified oxygen, IV dexamethasone, and nebulized epinephrine. #1) Administer prescribed bronchodilator via a nebulizer. Bronchodilators administered via a nebulizer are prescribed in the treatment of bronchospasm, the narrowing of the smooth muscles in the lower airway. The audio clip represents stridor, or narrowing of the upper airway. This is not the nurse's priority action.
Which of the following words follows the rules of basic word structure?
Esophagogastroduodenoscopy. It contains three roots, with three combining vowels and a suffix. Also known as an EGD, it is a gastrointestinal procedure in which a medical videoscope is passed into the GI tract from the mouth to the duodenum for visual inspection of the stomach and intestines.