NU270 Clinical Decision Making / Clinical Judgment
A client has a plaster cast applied to the left leg. Which comment by the client following the procedure should the nurse address first? "My toes are stiff." "My pain is a 3." "My cast is still wet." "My toes are pink."
"My toes are stiff." Explanation: Compartment syndrome is characterized by neurovascular compromise. Stiffness of the toes may be a preliminary finding that the client is having trouble with motor function. pg.1107
The nurse is preparing to administer insulin to an obese client. At what angle will the nurse plan to insert the needle into the client? 10 to15 degrees 45 degrees 90 degrees 20 to 30 degrees
90 degrees Explanation: Insulin injections are given subcutaneously to clients with obesity at a 90-degree angle. Other answers are incorrect.
A nurse is working in the emergency department. Which situation would lead the nurse to suspect possible abuse of a client? Select all that apply. A 6-year-old is being seen for the 5th time for a urinary tract infection A 15-month-old with shortness of breath after peanut ingestion A 3-year-old with a deep finger laceration A 3-month-old with a fractured femur A baby with contrecoup injuries to the brain
A 6-year-old is being seen for the 5th time for a urinary tract infection A baby with contrecoup injuries to the brain A 3-month-old with a fractured femur Explanation: Re-occurring urinary tract infections signal the possibility of sexual abuse of the child. The nurse must assess for further signs of abuse both with parents present and without. A fracture of the femur in a 3-month-old is uncommon given the infant's age and level of development. Contrecoup injuries of the brain in a baby should generate suspicion that the baby has been shaken. A 15-month-old with an allergic reaction to a peanut ingestion and a 3-year-old with a deep finger laceration should not signal abuse to the assessor. The problems are commonly seen in the pediatric emergency room.
What should a nurse recognize as a property of ibuprofen/Motrin? (Select all that apply.) Antipyretic Antibacterial Antipruritic Anti-inflammatory Analgesic
Anti-inflammatory Analgesic Antipyretic Explanation: Like the salicylates, the NSAIDS have anti-inflammatory, antipyretic, and analgesic effects.
A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first?
Apply warm blankets to the client. Explanation: The nurse should apply warm blankets to the client because the client is hypothermic with a temperature of 96.2°F (35.7°C). The client can be assessed further by checking vital signs and using an oxygen saturation monitor. The health care provider should be notified about the client's temperature but an intervention should be done first to ensure the client begins warming immediately.
Following a renal biopsy, a client reports severe pain in the back, the arms, and the shoulders. Which intervention should be offered by the nurse? Enable the client to sit up and ambulate. Distract the client's attention from the pain. Assess the patient's back and shoulder areas for signs of internal bleeding. Provide analgesics to the client.
Assess the patient's back and shoulder areas for signs of internal bleeding. Explanation: After a renal biopsy, the client should be on bed rest. The nurse observes the urine for signs of hematuria. It is important to assess the dressing frequently for signs of bleeding, monitor vital signs, and evaluate the type and severity of pain. Severe pain in the back, shoulder, or abdomen may indicate bleeding. In such a case, the nurse should notify the physician about these signs and symptoms. The nurse should also assess the client for difficulty voiding and encourage adequate fluid intake.
The nurse is caring for a client who is 24 hours after gastric bypass surgery. The client has experienced four episodes of vomiting in the past 12 hours, each producing between 500 and 800 ml of bright yellow-green liquid emesis. What action should the nurse take? Contact health are provider for a STAT abdominal x-ray prescription. Ask client to only take clear fluids until the health care provider can assess. Request additional antiemetic medication be prescribed. Increase the client's intravenous fluid rate to replace losses.
Contact health are provider for a STAT abdominal x-ray prescription. Explanation: The client is producing bilious emesis (bright yellow-green liquid emesis that resembles bile), which is a warning sign of gastrointestinal obstruction. Obstruction is a rare but serious complication of gastric bypass procedures. The nurse should request the prescription for an x-ray to investigate this possibility. The nurse should also keep the client NPO (not on clear fluids) and may increase fluids, but this is dependent on the client's hydration status and current blood pressure and urine output: information that is not provided. While antiemetic medication may be requested, the diagnosis of the bowel obstruction is most important. If an obstruction is present, the client's vomiting will not be well controlled with medication.
Which of the following medications needs to be withheld for 5 to 7 days prior to cataract surgery? Prednisone Glucophage Coumadin Lasix
Coumadin Explanation: It has been common practice to withhold any anticoagulant therapy such as Coumadin to reduce the risk for retrobulbar hemorrhage (after retrobulbar injection) for 5 to 7 days before surgery. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, Surgical Management, p. 1895.
Which of the following would lead a nurse to suspect that a client has a rotator cuff tear? Pain worse in the morning Minimal pain with movement Difficulty lying on affected side Ability to stretch arm over the head
Difficulty lying on affected side Explanation: Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head. Many clients find that the pain is worse at night and that they are unable to sleep on the affected side.
When auscultating the heart sounds of a client who's 34 weeks pregnant, the nurse detects a systolic ejection murmur. Which action should the nurse take? Consult with a cardiologist. Contact the client's primary health care provider. Document the finding, which is normal during pregnancy. Explain that this finding may indicate a cardiac disorder.
Document the finding; it is normal during pregnancy During pregnancy, a systolic ejection murmur over the pulmonic area is a common finding. Typically, it results from increases in blood volume and cardiac output, along with changes in heart size and position. Other cardiac rhythm disturbances also may occur during pregnancy and don't require treatment unless the client has concurrent heart disease. The nurse should document the finding and check for the murmur during the next visit. The nurse need not consult a cardiologist or the primary care health provider and shouldn't tell the client that this finding indicates a cardiac disorder.
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? Hypercalcemia Hyperkalemia Hypokalemia Hypocalcemia
Hypercalcemia Explanation: The normal reference range for serum calcium is 8.6 to 10.2 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia. The client's other laboratory findings are within their normal ranges, so the client doesn't have hypernatremia, hypochloremia, or hypokalemia.
The client is having a Weber test. During a Weber test, where should the tuning fork be placed? Under the bridge of the nose In the midline of the client's skull or in the center of the forehead Near the external meatus of each ear On the mastoid process behind the ear
In the midline of the client's skull or in the center of the forehead Explanation: The Weber test is performed by striking the tuning fork and placing its stem in the midline of the client's skull or in the center of the forehead. In the Rinne test, the tuning fork is struck and placed on the mastoid process behind the ear. The tuning fork is not placed near the external meatus of each ear or under the bridge of the nose.
The nurse is reviewing the morning laboratory test results for a client with cardiac problems. Which finding is a priority to report to the healthcare provider? Na+ 140 mEq/L Ca++ 9 mg/dL K+ 3.1 mEq/L Mg++ 2 mEq/L
K+ 3.1 mEq/L Explanation: All laboratory levels are within normal limits except for the K+, which is low. A low K+ level can cause ventricular tachycardia or fibrillation. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Table 25-4 Common Serum Laboratory Tests and Implications for Patients With Cardiovascular Disease, p. 694.
A client comes to the emergency department, reporting that a bee has flown into his ear and is stuck. The client reports a significant amount of pain. Which of the following would be most appropriate to use to remove the bee? Mineral oil Tweezers Hair pin Irrigation
Mineral oil Explanation: An insect in the ear canal can be dislodged by instilling mineral oil, which kills the insect and allows removal. Irrigation is contraindicated because the insect would swell. Hair pin or tweezers should not be used due to the risk for trauma.
A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: cholelithiasis. appendicitis. peptic ulcer disease. cirrhosis.
Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.
When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as what? Informed consent Self-determination Pro-choice Nonmaleficence
Nonmaleficence Explanation: Nonmaleficence is the principle of creating no harm. It refers to preventing or minimizing harm to an individual. The other options do not represent the situation presented in the question.
The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following? Cherry angiomas Telangiectasias Ecchymoses Petechiae
Petechiae Explanation: Petechiae are small red or purple macules, usually 1 to 2 mm in size, associated with bleeding tendencies. A patient with a history of anticoagulant use would fall in this category. Ecchymoses are round or irregular macular lesions larger than petechiae. Cherry angiomas are papular, round, red or purple lesions that are normal-age related changes. Telangiectasias are spider-like or linear bluish or red lesions associated with varicosities.
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? Rubbing the back Reinforcing dressings or applying pressure if bleeding is frank Encouraging the client to breathe deeply Elevating the head of the bed
Reinforcing dressings or applying pressure if bleeding is frank Explanation: The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply and rubbing the back will not help manage and minimize hemorrhage and shock.
A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test? Serum calcium Serum potassium Serum bilirubin Serum amylase
Serum amylase Explanation: Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.
The nurse is reviewing the client's urinalysis results. The finding that is most suggestive of dehydration of the client is: Specific gravity 1.035 Creatinine 0.7 mg/dL Protein 15 mg/dL Bright yellow urine
Specific gravity 1.035 Explanation: Specific gravity is reflective of hydration status. A concentrated specific gravity, such as 1.035, is suggestive of dehydration. Bright yellow urine suggests ingestion of multiple vitamins. Proteinuria can be benign or be caused by conditions which alter kidney function. Creatinine measures the ability of the kidney to filter the blood. A level of 0.7 is within normal limits.
Dilutional hyponatremia occurs in which disorder? Pheochromocytoma Addison disease Diabetes insipidus (DI) Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Explanation: Clients diagnosed with SIADH exhibit dilutional hyponatremia. They retain fluids and develop a sodium deficiency.
Which STD seems to accelerate in HIV-positive clients? Herpes Trichomoniasis Syphilis Gonorrhea
Syphilis Explanation: Syphilis seems to accelerate in HIV-positive clients and proceeds directly from primary to tertiary disease in some clients. Chlamydia is associated with a high risk of HIV.
A client is being sent home with subcutaneous heparin after a total hip replacement. The nurse understands what symptom would indicate a serious drug reaction? Hypotension Tarry stools Stomach pain Headache
Tarry stools Explanation: Tarry stools would be an indication of gastrointestinal bleeds. The most common adverse effect of heparin is bleeding.
What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis? Inform the physician if the client's temperature remains low Teach the client how to apply an elastic sleeve Avoid elevating the area Offer cold applications to promote comfort and to enhance circulation
Teach the client how to apply an elastic sleeve Explanation: In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. The nurse informs the physician if the client's temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.
A client's BUN test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise? The client is on a low protein diet. The client has a history of osteoarthritis. The client is lactose intolerant. The client is dehydrated.
The client is dehydrated. Explanation: The BUN test measures the amount of urea nitrogen in the blood. Urea, the major nitrogenous end-waste product of metabolism, is formed in the liver. The bloodstream carries urea from the liver to the kidneys for excretion. When the kidneys are diseased, they are unable to excrete urea adequately, and urea begins to accumulate in the blood, causing BUN to rise. Normal BUN is 8 to 25 mg/100 mL. Because other factors, such as high dietary intake of protein, fluid deficit, infection, gout, or excessive breakdown of protein stores, can also elevate BUN, it is not a highly sensitive indicator of impaired renal function.
A client has presented to the emergency department after he twisted his ankle while playing soccer. Which assessment findings are cardinal signs that the client is experiencing inflammation? Select all that apply. The ankle is bleeding The client's ankle is visibly red The ankle appears to be swollen The client is experiencing pain The ankle is warmer than the unaffected ankle
The client's ankle is visibly red The ankle appears to be swollen The ankle is warmer than the unaffected ankle The client is experiencing pain Explanation: The cardinal signs of inflammation are rubor (redness), tumor (swelling), calor (heat), and dolor (pain). Bleeding is not among the cardinal signs.
The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse? Random, rapid growth of the tumor Cells colonizing to distant body parts Emission of abnormal proteins Tumor pressure against normal tissues
Tumor pressure against normal tissues Explanation: Benign tumors grow more slowly than malignant tumors and do not emit tumor-specific antigens or proteins. Benign tumors do not metastasize to distant sites. Benign tumors can compress tissues as it grows, which can result in impaired organ functioning.
A client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride PO q.i.d. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client is also confused and incontinent, the nurse suspects neuroleptic malignant syndrome. What steps should the nurse take? Give the client the next dose of fluphenazine and restrict the client to an empty room to decrease stimulation. Give the client the next dose of fluphenazine, call the physician, and monitor the client's vital signs. Withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs. Withhold the client's next dose of fluphenazine, administer an antipyretic agent, and increase the client's fluid intake.
Withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs. Explanation: Neuroleptic malignant syndrome is a dangerous adverse effect of neuroleptic drugs such as fluphenazine. The nurse should withhold the next dose, notify the physician, and continue to monitor the client's vital signs. Although an antipyretic agent may be used to reduce fever, increased fluid intake is contraindicated because additional fluid may further increase the client's fluid volume, elevating the blood pressure even more.
The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing? Atelectasis Uncontrolled pain Wound infection Hyperthermia
Wound infection Explanation: Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 19: Postoperative Nursing Management, p. 474.
A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer? headaches in the morning discomfort when drinking cold liquids weight loss a feeling of swelling at the back of the throat
a feeling of swelling at the back of the throat Explanation: After an initial hoarseness lasting longer than a month, clients with laryngeal cancer will feel a sensation of swelling or a lump in the throat or in the neck. Weight loss often occurs later in the progression of laryngeal cancer due to reduced calorie intake as a result of impaired swallowing and pain. Clients with laryngeal cancer may report burning in the throat when swallowing hot or citrus liquids. Clients with obstructive sleep apnea may experience a morning headache.
A nurse is teaching the parents of a young child how to handle suspected poisoning. If the child ingests poison, the parents should first call an ambulance. call the poison control center. administer ipecac syrup. punish the child for being bad.
call the poison control center. Explanation: Before intervening in any way, the parents should first call the poison control center for specific instructions. Ipecac syrup is no longer recommended for the ingestion of poisons. The parents may have to call an ambulance after calling the poison control center. Punishment for being bad isn't appropriate because the parents are responsible for making the environment safe.
The oncology nurse understands that chemotherapeutic agents are most effective during a particular phase of the cell cycle. This means the agents are: cell cycle-specific. cell targeting. growth fraction. cell cycle-nonspecific.
cell cycle-specific. Explanation: Chemotherapeutic drugs that are most effective during a particular phase of the cycle are known as cell cycle-specific.
A client at 38 weeks' gestation has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client? external cephalic version vacuum extraction trial labor forceps birth
external cephalic version Explanation: External cephalic version is the turning of a fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. A trial birth is performed when a woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good and involves allowing labor to take its normal course as long as descent of the presenting part and dilation (dilatation) of the cervix continue to occur. Forceps, which are not commonly used anymore, and vacuum extraction are used to facilitate birth when other complications are present, but they would be less likely to be used with a fetus in breech position.
An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and periorbital area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of: cretinism. myxedema coma. Hashimoto's thyroiditis. thyroid storm.
myxedema coma. Explanation: Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto's thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.
A client tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous? Nonmobile mass with irregular edges Nonpalpable right axillary lymph nodes Eversion of the right nipple and mobile mass Mobile mass that is soft and easily delineated
nonmobile mass with irregular edges Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A mobile mass that is soft and easily delineated is most commonly a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction — not eversion — may be a sign of cancer.
A client is to undergo extensive dental surgery. The dentist prescribes a course of antibiotics before beginning the procedure and continuing for 5 days after the procedure. This is an example of: curative treatment. synergism. chemotherapy. prophylaxis.
prophylaxis. Explanation: In a situation where an infection is likely to occur, antibiotics can be used as a means of prophylaxis to prevent an infection before it occurs. Synergism is using two antibiotics together to improve their effectiveness. Chemotherapy is the use of drugs to kill cells. Curative treatment involves treating an actual infection to promote a cure.
The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? "I used my voice in excess over the weekend." "I have environmental allergies." "I was chewing ice chips all day long." "I smoke a pack of cigarettes a day."
"I was chewing ice chips all day long." Explanation: Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies, smoking, and excessive use of the voice causing straining are frequent causes. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 22: Management of Patients With Upper Respiratory Tract Disorders, Laryngitis, p. 565.
A client with a nasogastric (NG) tube who is 2 days postoperative bowel resection is reporting increased abdominal pain and nausea. Which action by the nurse would be most appropriate? Check the patency and amount of drainage from the NG tube. Administer an analgesic and antiemetic as ordered. Irrigate the NG tube with water and give an analgesic as ordered. Explain that nausea is common because the NG tube irritates the gag reflex.
Check the patency and amount of drainage from the NG tube. Explanation: The client is experiencing abdominal pain and nausea. This subjective assessment data indicate that the NG tube may not be functioning, so assessment of its patency and the amount of drainage would be the first step. Then appropriate action can be taken if the tube is not patent. Giving an analgesic and antiemetic would alleviate the symptoms of pain and nausea, but would not correct the problem if the NG tube is not draining properly. Irrigations are done after assessment of patency. The gag reflex is triggered during insertion, but once in position does not cause nausea.
A client is admitted to the local psychiatric facility with bipolar disorder in the manic phase. The physician decides to start the client on lithium carbonate therapy. One week after this therapy starts, the nurse notes that the client's serum lithium level is 1 mEq/L. What should the nurse do? Call the physician immediately to report the laboratory result. Continue to administer the medication as ordered. Withhold the next dose and repeat the laboratory test. Observe the client closely for signs and symptoms of lithium toxicity.
Continue to administer the medication as ordered. Explanation: The serum lithium level should be maintained between 1 and 1.4 mEq/L during the acute manic phase; therefore, the nurse should continue to administer the medication as ordered. Unless the client has signs or symptoms of lithium toxicity, the nurse has no need to call the physician, withhold the medication, or repeat the laboratory test. Nonetheless, the nurse should continue to monitor the client's serum lithium level and watch for indications of toxicity if the level begins to rise. Note that it's possible for a client with a normal lithium level to experience lithium toxicity.
Nursing students are reviewing information about depression. The students demonstrate understanding of the information when they state which of the following? Individuals with depression often seek treatment for it. Elderly clients often demonstrate specific symptoms of depression. Depression is commonly underdiagnosed and undertreated. Depression is more common in men than in women.
Depression is commonly underdiagnosed and undertreated. Explanation: Depression is often underdiagnosed and undertreated. Statistics reveal that only one in three people with depression is properly diagnosed and treated. Depression can occur at any age and is most frequently diagnosed in women than in men. Many people experience depression but seek treatment for somatic complaints, not for depression. Elderly clients may exhibit a wide range of symptoms. Nurses need to be aware that decreased mental alertness or withdrawal-type responses may indicate depression in the elderly.
The nurse working in an allergy clinic is preparing to administer skin testing to a client. Which route is the safest for the nurse to use to administer the solution? Intramuscular Intradermal Subcutaneous Intravenous
Intradermal Explanation: The intradermal route is the correct route of administration for skin testing and therefore a safe route. Another safe route is epicutaneous. The type of skin testing being performed determines whether the nurse will administer the solution via the epicutaneous or intradermal route. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 37: Assessment and Management of Patients With Allergic Disorders, p. 1063.
The nurse is providing care to a client who has had a transurethral resection of the prostate. The client has a three-way catheter drainage system in place for continuous bladder irrigation. The nurse anticipates that the catheter may be removed when the urine appears as which of the following? Light pink with few red streaks Light yellow and clear Reddish-pink with numerous clots Dark amber with copious mucous
Light yellow and clear Explanation: Typically a three-way catheter drainage system is removed when the urine appears clear and amber (light yellow). Reddish-pink urine with clots usually occurs in the immediate postoperative period. Eventually the urine becomes light pink within 24 hours after surgery. Dark amber urine suggests concentrated urine commonly associated with dehydration.
When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do? Notify the primary care provider of the problem. Increase the IV tocolytic to help in expulsion of the placenta. Nothing. Normal time for stage three is 5 to 30 minutes. Do a vaginal exam to see if the placenta is stuck in the birth canal.
Nothing. Normal time for stage three is 5 to 30 minutes. Explanation: Following birth, the placenta is spontaneously expelled within 5 to 30 minutes, so there is no problem with this client. No further interventions are needed.
Which of the following is an involuntary rhythmic movement of the eyes that is also associated with vestibular dysfunction? Presbycusis Vertigo Nystagmus Tinnitus
Nystagmus Explanation: Nystagmus is an involuntary rhythmic movement of the eyes; pathologically it is an ocular disorder but is also associated with vestibular dysfunction. Nystagmus can be horizontal, vertical, or rotary, and can be caused by a disorder in the central or peripheral nervous system. Vertigo is defined as the misperception or illusion of motion of the person or their surroundings. Tinnitus is ringing in the ears. Presbycusis is a progressive hearing loss.
Which of the following presents with an onset of heel pain with the first steps of the morning? Ganglion Hallux valgus Morton's neuroma Plantar fasciitis
Plantar fasciitis Explanation: Plantar fasciitis, an inflammation of the foot-supporting fascia, present as an acute onset of heal pain experienced with the first steps in the morning. Hallux valgus (commonly called a bunion) is a deformity in which the great toe deviates laterally. Morton's neuroma is a swelling of the third (lateral) branch of the median plantar nerve. A ganglion, a collection of gelatinous material near the tendon sheaths and joints, appears as a round, firm compressible cystic swelling, usually on the dorsum of the wrist.
A client has meconium-stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12; fetal bradycardia is present. Based on these findings, the nurse should take which action? Reposition the client. Prepare for cesarean birth. Administer amnioinfusion. Start I.V. oxytocin infusion as ordered.
Prepare for cesarean birth. Explanation: Fetal blood pH of 7.19 or lower signals severe fetal acidosis; meconium-stained amniotic fluid and bradycardia are further signs of fetal distress that warrant cesarean birth. Amnioinfusion is indicated when the only abnormal fetal finding is meconium-stained amniotic fluid. Client repositioning may improve uteroplacental perfusion, but only serves as a temporary measure because the risk of fetal asphyxia is imminent. Oxytocin administration increases contractions, exacerbating fetal stress.
When a central venous catheter dressing becomes moist or loose, what should a nurse do first? Notify the physician. Draw a circle around the moist spot and note the date and time. Remove the dressing, clean the site, and apply a new dressing. Remove the catheter, check for catheter integrity, and send the tip for culture.
Remove the dressing, clean the site, and apply a new dressing.A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a circle around the moist spot and note the date and time. She should notify the physician if she observes any catheter-related complications. Only a nurse with the appropriate qualifications may remove a central venous catheter, and a moist or loose dressing isn't a reason to remove the catheter.
Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They demonstrate understanding of the information when they state which of the following as the form of the genetic viral material? Ribonucleic acid (RNA) Glycoprotein envelope Viral core Deoxyribonucleic acid (DNA)
Ribonucleic acid (RNA) Explanation: HIV is a retrovirus that carries its genetic material in the form of RNA rather than DNA. HIV consists of a viral core containing the viral RNA, surrounded by an envelope consisting of protruding glycoproteins.
Which would be the priority nursing diagnosis for a client diagnosed with borderline personality disorder (BPD)? Disturbed thought process Personal identity disturbance Ineffective coping Risk for self-mutilation
Risk for self-mutilation Explanation: One of the first diagnoses to consider is risk for self-mutilation because protection of the client from self-injury is always a priority. Disturbed thought process, ineffective coping, and personal identity disturbance are all potential nursing diagnoses, but they would not be the priority.
A nurse is admitting a new client with a deep vein thrombosis in her left leg. During the admission process, which information provided by the client would be a contraindication to anticoagulant therapy? Three vaginal births, the most recent 18 months ago Diet that includes many green, leafy vegetables every day Scheduled eye surgery in 1 week A cerebral vascular bleed 10 years ago
Scheduled eye surgery in 1 week Explanation: Contraindications to anticoagulant therapy include recent or impending eye surgery, recent cerebral vascular bleeds, and recent childbirth. A diet including green leafy vegetables is not a contraindication.
A nurse is caring for a client with advanced heart failure. The client can't care for themself and hasn't been able to eat for the past week because of dyspnea. The client doesn't want a feeding tube inserted and expresses their desire for "nature to take its course." The client's family is pleading with the client to have a feeding tube inserted. What is the most appropriate action for the nurse to take? Ask a priest to talk with the client about the importance of preserving life. Schedule feeding tube placement and hope that the nurse can persuade the client to agree to it. Talk with the client's family about the client's right to decide for themself. Schedule a conference to help the client and the client's family reach a consensus about the feeding tube.
Talk with the client's family about the client's right to decide for themself. Explanation: Advocating for a client's wishes is a key nursing role. It's especially important when a client's family disagrees with the client's wishes. The nurse should be sure that the client has all the information needed to make an informed decision. Then the nurse should support the client's decision. The nurse shouldn't contact a clergyman without the client's consent, call a family conference, or schedule intubation in violation of the client's wishes.
A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect? Neither venous nor arterial insufficiency Trauma Venous insufficiency Arterial insufficiency
Venous insufficiency Explanation: Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gaiter area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.
A nurse is preparing a presentation for a local community about hearing loss and prevention. Which of the following would the nurse integrate into the presentation as the most effective preventive measure? Obtaining prompt treatment for ear infections Maintaining daily hygiene for the ears Wearing ear protection when exposed to noise Having yearly audiometric testing
Wearing ear protection when exposed to noise Explanation: Noise is a serious and very common factor associated with hearing loss. Hearing loss from noise is permanent, because noise destroys the hair cells in the organ of Corti. Therefore, wearing ear protection when exposed to noise is the most effective preventive measure available. Although appropriate ear hygiene and prompt treatment for infections are important, protecting the ears from noise is the priority. Audiometric testing is the single most important diagnostic instrument for detecting hearing loss; however, routine testing each year is not a current recommendation.
The nurse has just received change-of-shift report for four clients. Based on this report, the nurse should assess which client first? a 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours a 52-year-old with pneumonia and chronic back pain who is requesting pain medication a 38-year-old who is 2 days postmastectomy due to breast cancer, having difficulty coping with the diagnosis an 84-year-old with resolving left-sided weakness who is slightly confused and has been awake most of the night
a 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours Explanation: Urine output should be at least 500 mL in 24 hours (20 mL/h); this client's output has been just 15 mL/h for the past 2 hours requiring further assessment by the nurse. The nurse should first assess all clients and address physiological needs including pain control and safety measures; the nurse should then take time with the client having difficulty coping in order to listen and further determine her needs.
The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of vitiligo. anemia. albinism. local arterial insufficiency.
anemia. Explanation: In light-skinned individuals, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance. Albinism is a condition of total absence of pigment in which the skin appears whitish pink. Vitiligo is a condition characterized by the destruction of melanocytes in circumscribed areas of skin, resulting in patchy, milky-white spots. Local arterial insufficiency is characterized by marked localized pallor.
A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately: clean the wound with povidone-iodine and apply a gauze dressing. reintroduce the tube and attach it to water seal drainage. cover the opening with petroleum gauze. call a physician and obtain a chest tray.
cover the opening with petroleum gauze. Explanation: If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress because tension pneumothorax may develop. If tension pneumothorax does develop, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions.
After a fall at home, a client hits their head on the corner of a table. Shortly after the accident, the client arrives at the ED, unable to see out of their left eye. The client tells the nurse that symptoms began with seeing spots or moving particles in the field of vision but that there was no pain in the eye. The client is very upset that the vision will not return. What is the most likely cause of this client's symptoms? eye trauma angle-closure glaucoma chalazion retinal detachment
retinal detachment Explanation: A detached retina is associated with a hole or tear in the retina caused by stretching or degenerative changes. Retinal detachment may follow a sudden blow, penetrating injury, or eye surgery.
A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in thought content. motor ability. intellectual function. emotional status.
thought content. Explanation: Hallucinations are disturbances of thought content. They are not disturbances in motor ability, intellectual function, or emotional status.
