Practice comp 2 corrections
A client with Addison's disease is scheduled for discharge after being hospitalized for an adrenal crisis. Which statements would indicate that the nurse's teaching has been effective? Select all that apply. "I have to take my steroids for 10 days." "I need to weigh myself daily to be sure I don't eat too many calories." "I need to call my healthcare provider to discuss my steroid needs before I have dental work." "I will call the healthcare provider if I start to feel fatigued, weak, or dizzy." "If I feel like I have the flu, I'll carry on as usual because this is an expected response." "I need to obtain and wear a medical alert bracelet."
Correct response: "I need to call my healthcare provider to discuss my steroid needs before I have dental work." "I will call the healthcare provider if I start to feel fatigued, weak, or dizzy." "I need to obtain and wear a medical alert bracelet." Explanation: Dental work can be a cause of physical stress, therefore, the client's healthcare provider should be informed, and may need to adjust the steroid dosage. Fatigue, weakness, and dizziness are symptoms of inadequate dosing. The healthcare provider should be notified if these symptoms occur. A medical alert bracelet allows health care providers to access the client's history of Addison's disease if it can't be communicated by the client. For this client, routine administration of steroids is a lifetime treatment. Daily weight is monitored for changes in fluid balance, not caloric intake. Influenza is an added physical stressor. The client's healthcare provider should be informed, and steroid dosage may need adjusted.
The nurse performs a routine prenatal assessment on a woman at 35 weeks gestation and finds vital signs: blood pressure 138/88 mm Hg, pulse 82/min, respirations 18/min, temperature 99.1° F (37.3°C). Which statement is most appropriate for the nurse to make at this time? "Your pulse is low. Do you exercise a lot?" "Your blood pressure is slightly high. I will check it again before you leave." "You have a slight temperature. Do you feel hot?" "Your vital signs are all normal. I will document them on your chart."
Correct response: "Your blood pressure is slightly high. I will check it again before you leave." Explanation: A blood pressure reading of 138/88 mm Hg is nearing hypertension range and could be a sign of developing gestational hypertension. Conversely, the client may be experiencing "white coat" syndrome or could be anxious during the prenatal visit. In order to obtain an accurate blood pressure reading, the nurse should allow the woman to rest for a period of time and recheck the blood pressure in the same arm and while the woman is in the same position. This blood pressure is considered approaching high. All other vitals are within normal range.
An employee health nurse is assisting a stressed working mother with value clarification. Which of the following best defines value clarification? A process by which people come to understand their own values and value systems. A belief about the worth of something, about what matters, that acts as a standard to guide one's behavior. An organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. A systematic inquiry into principles of right and wrong conduct, of virtue and vice, and of good and evil, as they relate to conduct.
Correct response: A process by which people come to understand their own values and value systems. Explanation: Value clarification is a process by which people come to understand their own values and value systems. A value is a belief about the worth of something, about what matters, that acts as a standard to guide one's behavior. A value system is an organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. Ethics is a systematic inquiry into principles of right and wrong conduct, of virtue and vice, and of good and evil, as they relate to conduct.
A client with schizophrenia tells a nurse preparing him for discharge that he has no home or family and has been living on the street. Which action is most appropriate? Offering the client the names and phone numbers of various community homeless shelters Asking the client to describe how he feels about living in such desperate conditions Asking the physician to refer the client to social services for further evaluation Documenting the client's response and informing the charge nurse of the situation
Correct response: Asking the physician to refer the client to social services for further evaluation Explanation: A homeless person may have complex underlying needs; a trained social worker must explore these needs and issues in order to provide the most appropriate interventions. Offering the client the names and numbers of shelters may be helpful, but the nurse isn't in a position to follow up on the client's care after discharge. Although having the client discuss his feelings may be therapeutic, there's a need at this point for direct intervention to ensure the client's safety and well-being. Documenting the information and informing the charge nurse is useful, but doesn't ensure appropriate intervention.
If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first? Call the physician. Apply a dry sterile dressing to the site. Clamp the catheter. Tell the client to take and hold a deep breath.
Correct response: Clamp the catheter. Explanation: If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp. If a clamp isn't available, the nurse may place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension set and restart the infusion. Calling the physician, applying a dry sterile dressing to the site, and telling the client to take a deep breath aren't appropriate interventions at this time.
59s Upon shift report, the nurse learns the following laboratory values: pH, 7.44; PCO2, 30mmHg; and HCO3,21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance is the client most likely experiencing?
Correct response: Compensated respiratory alkalosis Explanation: The question states that the client has a history of acid-base disturbance. The nurse would first note that the pH has returned to close to normal indicating compensation. The nurse then assess the PCO2 (normal: 35 to 45 mm Hg) and HCO3 (normal: 22 to 27mEq/L) levels. In a respiratory condition, the pH and the PCO2 move in opposite direction; thus, the pH rises and the PCO2 drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the pH and the bicarbonate move in the same direction; if the pH is low, the bicarbonate level will be low, also. In this client, the pH is at the high end of normal, indicating compensation and alkalosis. The PCO2 is low, indicating a respiratory condition (opposite direction of the pH).
A nurse caring for a client in labor notes that her blood pressure (BP) rises during contractions. Which of the following should be the nurse's next action? Administer prescribed antihypertensive medication Increase the rate of IV oxytocin Continue to monitor BP Position the client on her side
Correct response: Continue to monitor BP Explanation: During contractions, blood flow to the intervillous spaces changes, compromising fetal blood supply. Increased BP is expected during pain and contractions, but it should return to precontraction levels, ensuring adequate blood flow to the fetus.
Umbilical cord prolapse necessitated cesarean birth of a preterm, low-birth-weight neonate. Immediately after birth, the neonate is limp, gasping for air, unresponsive to stimulation, and has blue discoloration of the face, lips, and torso. Which intervention should the nursery nurse perform first? Establish I.V. access through an umbilical venous catheter. Initiate cardiac compressions. Administer low-flow oxygen through a nasal cannula. Determine unresponsiveness and assess the need for resuscitation.
Correct response: Determine unresponsiveness and assess the need for resuscitation. Explanation: The nurse should determine unresponsiveness and assess the need for resuscitation. If resuscitation is necessary, the nurse should initiate it immediately. After addressing airway, breathing, and circulation the nurse should establish I.V. access. Oxygen should be administered through a bag-valve mask, not a nasal cannula. It may be necessary to begin cardiac compressions depending upon the neonate's heart rate.
The nurse is caring for a client with chest tubes and, during the assessment, palpates a crackling sensation around the area of insertion. Which of the following is the most appropriate intervention at this time? Drawing a circle with a skin marker around the area of this sensation Clamping the chest tube and call the physician Informing respiratory therapy that the chest tube apparatus needs to be changed, as there is probably a crack Applying a cool compress to the area to cause vasoconstriction
Correct response: Drawing a circle with a skin marker around the area of this sensation Explanation: The sensation being palpated is referred to as subcutaneous emphysema, which is not usually a serious complication. The air is spontaneously absorbed if the underlying air leak is treated or stops spontaneously. It would not be appropriate to clamp the chest tube or change the apparatus. A cool compress would not be effective to reduce the air in the subcutaneous tissue.
A nurse is teaching a client with osteomalacia how to take ordered vitamin D supplements. Which adverse effects should the nurse instruct the client to report? GI upset and metallic taste Dry skin, hair loss, and inflamed mucous membranes Flushing and orthostatic hypotension Sensory neuropathy and difficulty maintaining balance
Correct response: GI upset and metallic taste Explanation: The nurse should instruct the client to report GI upset and metallic taste because these are early signs and symptoms of vitamin D toxicity. Such toxicity also may cause headache, weakness, renal insufficiency, renal calculi, hypertension, arrhythmias, muscle pain, and conjunctivitis. Dry skin, hair loss, and inflamed mucous membranes suggest vitamin A toxicity. Flushing and orthostatic hypotension (effects of vasodilation) may result from nicotinic acid and nicotinamide supplements, which are used to correct niacin deficiency. Sensory neuropathy and difficulty maintaining balance suggest pyridoxine toxicity.
A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor? Active phase Latent phase Expulsive phase Transitional phase
Correct response: Latent phase Explanation: The latent phase of the first stage of labor is associated with irregular, short, mild contractions; cervical dilation of 3 to 4 cm; and abdominal cramps or lower back discomfort. During the active phase, the cervix dilates to 7 cm and moderately intense contractions of 40 to 50 seconds' duration occur every 2 to 5 minutes. Fetal descent continues throughout the active phase and into the transitional phase, when the cervix dilates from 8 to 10 cm and intense contractions of 45 to 60 seconds' duration occur every 1½ to 2 minutes. The first stage of labor doesn't include an expulsive phase.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? Serum sodium level of 124 mEq/L Serum creatinine level of 0.4 mg/dl Hematocrit of 52% Serum blood urea nitrogen (BUN) level of 8.6 mg/dl
Correct response: Serum sodium level of 124 mEq/L Explanation: In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.
The nurse is preparing a client with sinus tachycardia for cardioversion. What is the nurse's priority action? Keep the client awake and alert Keep the side rails up for client safety Set the machine on SYNC and charge at 200 watts Set the machine on DEFIB and charge at 400 watts
Correct response: Set the machine on SYNC and charge at 200 watts Explanation: If cardioversion is needed, the nurse should set the machine on SYNC and look for a marker on each QRS complex. The nurse should anticipate that the cardioversion will be started at a low energy level and increase as needed. The client will be sedated for this procedure. Lowering the side rails will make it easier to place paddle electrodes.
A newly hired nurse on unit orientation prepares to administer vitamin K to a neonate. The nurse draws up 1 mg of vitamin K and prepares to administer a subcutaneous injection in the left, lateral anterior thigh. Which action by the nurse preceptor is best? Praise the nurse for accurately preparing to administer the injection. Stop the nurse and have her reevaluate her injection techniques. Distract the neonate by talking to her in a calm voice. Stop the nurse and instruct her to administer the vitamin K using the Z-track method.
Correct response: Stop the nurse and have her reevaluate her injection techniques. Explanation: Vitamin K should be administered by I.M. injection. Therefore, the nurse preceptor should stop the nurse and have her reevaluate her injection techniques. The nurse preceptor can praise the nurse after the injection is administered correctly. The nurse preceptor can distract the neonate by talking calmly to her, but she should first stop the nurse from administering the medication by the wrong route. The injection should be administered by the I.M. route, not by the Z-track method.
A college student is outraged by the recent end of his long-term relationship. For his creative writing class, he writes an essay on anger management. Which defense mechanism is he using? Repression Introjection Undoing Sublimation
Correct response: Sublimation Explanation: Sublimation involves redirecting socially unacceptable behavior and needs into acceptable actions. This client is exhibiting sublimation because he's redirecting his anger in an acceptable way. Repression is the unconscious blocking out of unacceptable feelings or thoughts. Undoing involves attempting to "undo" harm a person feels he may have done to anther. Introjection is the process of absorbing the values or characteristics of another person or group into one's own ego.
The nurse is instructing the spouse of a client who had an incision and drainage procedure for an abscess how to care for the wound at home. The nurse should instruct the spouse to: clean the incision and drainage sites simultaneously. clean from the incision site to the drainage site. clean from the drainage site to the incision site. clean both sites independently.
Correct response: clean both sites independently. Explanation: The sites should be treated as separate sites to avoid cross contamination. This adheres to the principle of cleaning from the least contaminated area to the most contaminated area. Each site is considered a separate area for wound care.
A mother brings her 2-year-old adopted Korean child to the clinic for an initial checkup. The child has been living with the adopted family for several weeks. The nurse notes an irregular area of deep blue pigment on the child's buttocks extending into the sacral area. The nurse should: do nothing concerning this finding. ask the mother in private how the bruise occurred. notify social services of a case of possible child abuse. question the mother about the family's discipline style.
Correct response: do nothing concerning this finding. Explanation: This lesion is a Mongolian spot, which is common in children of Asian or African heritage. The key word in the description is pigment. A bruise results from bleeding into subcutaneous or muscle tissue; it is not a pigment change in the skin. Notifying social services is inappropriate as this is a normal finding. Asking about the family's discipline style suggests the nurse has interpreted this normal finding as a bruise and not as pigment variation.
A client is taking phenytoin as an antiepileptic medication. The nurse should instruct the client to obtain: increased iron. increased calcium. frequent dental examinations. frequent eye examinations.
Correct response: frequent dental examinations. Explanation: Phenytoin causes hyperplasia of the gums, and the client needs frequent dental examinations and meticulous oral hygiene. Phenytoin therapy may contribute to a folic acid deficiency, but it is not related to iron or calcium metabolism. A need for frequent eye examinations is not related to the side effects of phenytoin.
After cataract removal surgery, the client is instructed to report sharp pain in the operative eye because this could indicate which postoperative complication? detached retina prolapse of the iris extracapsular erosion intraocular hemorrhage
Correct response: intraocular hemorrhage Explanation: Sudden, sharp pain after eye surgery should suggest to the nurse that the client may be experiencing intraocular hemorrhage. The health care provider (HCP) should be notified promptly. Detached retina and prolapse of the iris are usually painless. Extracapsular erosion is not characterized by sharp pain.
The expected outcome for using thiamine for a client being treated for an alcohol addiction is to: prevent the development of Wernicke's encephalopathy. decrease the client's withdrawal symptoms. aid the client in regaining strength sooner. promote elimination of alcohol from the body faster.
Correct response: prevent the development of Wernicke's encephalopathy. Explanation: Thiamine specifically prevents the development of Wernicke's encephalopathy, a reversible amnestic disorder caused by a diet deficient in thiamine secondary to poor nutritional intake that commonly accompanies chronic alcoholism. It is characterized by nystagmus, ataxia, and mental status changes. Because the client would rather drink alcohol than eat, the client is depleted of vitamins and nutrients. Alcohol also is an irritant that causes a "malabsorption syndrome" in which vitamins and nutrients are not absorbed properly in the gastrointestinal tract. Thiamine is not associated with decreasing withdrawal symptoms, helping clients regain their strength, or promoting elimination of alcohol from the body.
A clinical nurse specialist developed clinical pathways for common orthopedic conditions. The interdisciplinary team uses these pathways to: provide a care plan for caregivers to ensure continuity of care. provide a step-by-step care plan. accurately bill the client for services provided. describe the pathophysiology of the diagnosis.
Correct response: provide a care plan for caregivers to ensure continuity of care. Explanation: Clinical pathways provide care plans that ensure continuity of care for clients with like diagnoses. Each clinical pathway is then modified to meet individual client needs. Clinical pathways don't provide a step-by-step care plan, help bill the client, or describe the pathophysiology of the diagnosis.
When caring for a client with diabetes insipidus, the nurse expects to administer: vasopressin. furosemide. regular insulin. 10% dextrose.
Correct response: vasopressin. Explanation: Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus experiences polyuria. Insulin and dextrose are used to treat diabetes mellitus and its complications, not diabetes insipidus.
A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? Performing passive range-of-motion (ROM) exercises on the client's legs once each shift Keeping a pillow between the client's legs at all times Turning the client from side to side every 2 hours Maintaining the client in semi-Fowler's position
Keeping a pillow between the client's legs at all times Explanation: After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.
The maximum transfusion time for a unit of packed red blood cells (RBCs) is: 1 hour. 2 hours. 4 hours. 6 hours.
4 hours. Explanation: A unit of packed RBCs may be transfused over a period of between 1 and 4 hours. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. The nurse should discard any blood not given within this time, or return it to the blood bank, in accordance with facility policy.
A client is seen in the clinic with suspected parathormone (PTH) deficiency. Which electrolyte levels would the nurse expect to be abnormal in a client with PTH deficiency? Select all that apply. Sodium Potassium Calcium Chloride Glucose Phosphorous
calcium, phosphhurs
A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis? Shock Stroke Seizures Hyperglycemia
shock
When developing the plan of care for a child diagnosed with phenylketonuria (PKU), the nurse should establish which goal? meeting the child's nutritional needs for optimal growth ensuring that the special diet is started at age 3 weeks maintaining serum phenylalanine level higher than 12 mg/100 mL (720 µmol/L) maintaining serum phenylalanine level lower than 2 mg/100 mL (120 µmol/L)
Correct response: meeting the child's nutritional needs for optimal growth Explanation: The goal of care is to prevent intellectual disabilities by adjusting the diet to meet the infant's nutritional needs for optimal growth. The diet needs to be started upon diagnosed, ideally within a few days of birth. Serum phenylalanine level should be maintained between 3 and 7 mg/100 mL (180 to 420 ?mol/L). Significant brain damage usually occurs if the level exceeds 10 to 15 mg/100 mL (600 to 900 ?mol/L). If the level drops below 2 mg/100 mL (120 ?mol/L), the body begins to catabolize its protein stores, causing growth restriction.
A client who has been diagnosed with type 1 diabetes has an insulin drip to aid in lowering the serum blood glucose level of 600 mg/dL (33.3 mmol/L). The client is also receiving ciprofloxacin IV. The health care provider (HCP) prescribes discontinuation of the insulin drip. What should the nurse do next? Discontinue the insulin drip, as prescribed. Hang the next IV dose of antibiotic before discontinuing the insulin drip. Inform the HCP that the client has not received any subcutaneous insulin yet. Add glargine to the insulin drip before discontinuing it.
Correct response: Inform the HCP that the client has not received any subcutaneous insulin yet. Explanation: Because subcutaneous administration of insulin has a slower rate of absorption than IV insulin, there must be an adequate level of insulin in the bloodstream before discontinuing the insulin drip; otherwise, the glucose level will rise. Adding an IV antibiotic has no influence on the insulin drip; it should not be piggy-backed into the insulin drip. Glargine cannot be administered IV and should not be mixed with other insulins or solutions.
A student nurse witnesses a registered nurse performing a procedure on a client without obtaining informed consent for the procedure. The student nurse recognizes that the registered nurse is guilty of committing: breach of confidentiality. assault and battery. harassment. neglect of duty.
Correct response: assault and battery. Explanation: Performing a procedure on a client without informed consent can be grounds for charges of assault and battery. Harassment means to annoy or disturb someone, and breach of confidentiality refers to conveying information about the client. Neglect of duty is failure to perform care that a prudent nurse would provide under similar circumstances.
A nurse is providing cardiopulmonary resuscitation (CPR) to a child, age 4. The nurse should: compress the sternum with both hands at a depth of 1½″ to 2″ (4 to 5 cm). deliver 12 breaths/minute. perform only two-person CPR. use the heel of one hand for sternal compressions.
Correct response: use the heel of one hand for sternal compressions. Explanation: The nurse should use the heel of one hand and compress one-third to one-half the depth of the chest. The nurse should use the heels of both hands clasped together and compress the sternum 1½″ to 2″ (at least 5 cm) for an adult. For a small child, two-person rescue may be inappropriate. For a child, the nurse should deliver 20 breaths/minute instead of 12 breaths/minute.
A client who has been treated for chronic renal failure (CRF) is ready for discharge. The nurse should reinforce which dietary instruction? "Be sure to eat meat at every meal." "Eat plenty of bananas." "Increase your carbohydrate intake." "Drink plenty of fluids, and use a salt substitute."
Correct response: "Increase your carbohydrate intake." Explanation: A client with CRF requires extra carbohydrates to prevent protein catabolism. In a client with CRF, unrestricted intake of sodium, protein, potassium, and fluid may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit intake of sodium; meat, which is high in protein; bananas, which are high in potassium; and fluid, because the failing kidneys can't secrete adequate urine. Salt substitutes are high in potassium and should be avoided.
A client with a history of cardiac problems reports severe chest pain. What should be the nurse's first response? Notify the health care provider (HCP). Administer an analgesic to control the pain. Assess the client's pain. Start oxygen at 2 L/min via nasal cannula.
Correct response: Assess the client's pain. Explanation: The nurse's first response is to further assess the client's pain. After a thorough assessment, additional appropriate actions may be to notify the HCP, administer an analgesic, and administer oxygen.
To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard? The client is maintained on strict bed rest. The head of the bed is at a 30-degree angle. The client receives a complete bed bath each morning. The nurse checks the applicator's position every 4 hours.
Correct response: The client receives a complete bed bath each morning. Explanation: The client shouldn't receive a complete bed bath while the applicator is in place. In fact, she shouldn't be bathed below the waist because doing so puts the nurse at risk for radiation exposure. During this treatment, the client should remain on strict bed rest, but the head of her bed may be raised to a 30- to 45-degree angle. The nurse should check the applicator's position every 4 hours to ensure that it remains in the proper place.
A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record? To transmit health records between insurance companies. To investigate the quality of care in the agency. To inform family and others concerned about the client's care. To release the entire health record for research.
Correct response: To investigate the quality of care in the agency. Explanation: Medical records may occasionally be used to investigate the quality of care in the agency. A medical record is not used to transmit health records between insurance companies, to inform family and others concerned about the client's care, or to release the entire health record for research, as these actions would jeopardize the individual's right to privacy.
