Practice Exam 1

The nurse has completed client instruction about lorazepam. Which of the following client statements indicate that the client understands this teaching?

Answer: I can develop a dependency on this medication Lorazepam is a benzodiazepine that is given for anxiety. It is addictive and clients can develop a tolerance, so it should not be stopped abruptly due to withdrawal symptoms. Mood stabilizers are prescribed for mood swings and mood stabilization. Antidepressants should be taken for at least 6 month to 1 year after symptoms have subsided

What is the best nursing response to a client who is experiencing an acute myocardial infarction (MI) and asks why the nurse is administering intravenous morphine?

Answer: Morphine decreases the heart's need for oxygen and also have you heart not work as hard When given to treat acute MI, morphine eliminates pain, reduces preload and afterload, reduces vascular resistance, reduces cardiac workload, and reduces the oxygen demand of the heart. Morphine does not increase myocardial contractility, raise blood pressure, or increase preload or afterload.

A client with a pulmonary embolism is experiencing chest pain and apprehension. What is the nurse's priority intervention?

Answer: Administering ordered analgesic Once a pulmonary embolism has been diagnosed and the amount of hypoxia determined, chest pain and the accompanying apprehension can be treated with analgesics as long as respiratory status isn't compromised. Guided imagery and emotional support can be used in conjunction with pain medication. Positioning the client on his left side when a pulmonary embolism is suspected may prevent a clot from breaking off and traveling through the heart into the arterial circulation.

· An infant is brought to the emergency department. The infant is limp and has central cyanosis, a heart rate of 60 beats/minute, and a respiratory rate of 12 breaths/minute. The parents state that they have an advance directive for their infant, who has a terminal illness. A nurse's initial action should be to:

Answer: Ask to see a copy of the advanced directive To have information about how to proceed, the nurse must evaluate the advanced directive. Until the nurse evaluates the legitimacy and content of the form, it is inappropriate to administer oxygen or provide palliative care.

· What is appropriate to include in a teaching plan for a 9-year-ol who has had diabetes for several years?

Answer: Beginning to be able to self-administer injections with adult supervision Children between the ages of 8 - 10 are developmentally ready to begin to give their own injections with adult supervision. Their fine motor skills are developed enough to accomplish this skill

An adolescent diagnosed with thalassemia major (Cooley's anemia) is at risk for which condition?

Answer: Chronic hypoxia and iron overload Thalassemia major increases destruction of red blood cells (RBCs), shortens the life span of RBCs, and causes anemia. The body responds by increasing RBC production, but it can't produce adequate numbers of mature cells. This process results in chronic hypoxia. In addition, children with thalassemia major require multiple transfusions of packed RBCs. The combination of excessive RBC destruction and multiple transfusions deposits excess iron that damages organs and tissues. Thalassemia major doesn't place the adolescent at risk for hypertrophy of the thymus or thyroid or polycythemia vera, which involves excessive RBC production that can lead to thrombosis.

The nurse reads the new medication prescriptions for a 4-year-old child with nephrotic syndrome on the chart as shown. What should the nurse do?

Answer: Contact the prescriber for clarification There are many problems with this medication prescription. The abbreviation QOD is ambiguous and open to various interpretations. The abbreviation D/C may be interpreted as "discontinue" or "discharge." The prescriber should have specifically stated when to start the lower dose because the nurse could reason beginning the medication that day, the next or even the day after that. The only safe thing to do is call for clarification.

The client with peripheral artery disease reports both legs hurt when walking. What should the nurse instruct the client to do?

Answer: Enroll in a supervised exercise training program Decreased blood flow is a common characteristic of all periphery artery disease. When the demand for O2 to the working muscles becomes greater than the supply, pain is the outcome. The nurse should suggest that the client enroll in a supervised exercise training program that will assist the client to gradually increase walking distance without pain. Not walking and resting will not increase blood flow to the legs. Support stockings may be prescribed, but the client should improve their capacity to walk and exercise.

A nurse is taking a client's blood pressure and fails to recognize an auscultatory gap. What should the nurse do to avoid recording an erroneously low systolic blood pressure

Answer: Inflate the cuff to at least another 30 mmHG after the nurse can't palpate the radial pulse. The nurse should wrap an appropriate sized cuff around the client's upper arm and then place the diaphragm of the stethoscope over the brachial artery. The nurse should then rapidly inflate the cuff until unable to palpate or auscultate the pulse, then continue inflating until the pressure rises another 30 mmHg. Having the client lie down, inflating the cuff to at least 200 mmHg, and taking the blood pressure readings in both arms aren't appropriate measures

A laboring client at -2 station has a spontaneous rupture of membranes, and a cord immediately protrudes from the vagina. What should the nurse do first?

Answer: Place a gentle pressure upward on the fetal head The nurse should place a hand on the fetal head and provide gentle upward pressure to relive the compression on the cord. Doing so allows oxygen to continue flowing to the fetus. The cord should never be placed back into the vagina because doing so may further compress it. Administering O2 is an appropriate measure it will not serve a useful purpose until the pressure is relieved on the cord, enabling perfusion to the baby. Turning the client to their left side facilitates better perfusion to the birth parent, but until the compression on the cord is relieved, the increase O2 will not serve it purpose.

The nurse is teaching a client with adult macular degeneration (AMD) about safety precautions. Which information should the nurse include in the teaching plan?

Answer: Turn the head from side to side when walking To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. A patch does not address the problem of hemianopsia. Appropriate client positioning and placement of personal items will increase the client's ability to cope with the problem but will not affect safety

· A client is admitted to a mental health unit. While assessing the client, the nurse finds the client exhibiting signs of hyperexcitability, increasing agitations, and distractibility. Based on this assessment, which nursing intervention has priority?

Answer: Use a quiet room for the client away from others Being in a quiet environment away from stimuli will facilitate a sense of control for the client. If the nurse attempts to be firm and set rules, it will most likely heighten the client's agitation. This client is too excited to focus at this time. Group activities or other activities may worsen the client's situation.

A nurse pages a client's primary care physician in response to a low blood pressure reading. When returning the nurse's page, the physician asks the nurse to temporarily hold the client's scheduled antihypertensive and diuretic medications. How should the nurse ensure correct documentation of this telephone order?

Answer: Write "T.O." after the order and write out the physician's and nurse's names When receiving telephone orders, the nurse should record the orders in the client's medical record, read the order back to the ordering practitioner, date and note the time the orders were issued, record T.O. (telephone orders) and the full name and title of the physician or nurse practitioner who issued the orders, and then sign the orders with name and title. It is unnecessary to obtain a confirmation from another practitioner or to have the order witnessed.

A nurse working in the ICU. After receiving shift report, who should the nurse see first?

Answer: A client with aortic stenosis who has a BP of 84/52 mmHg Hypotension in a client with aortic valve problems can indicate cardiogenic shock. The nurse should assess this client for other symptoms such as dyspnea or chest pain. The other clients are experiencing expected symptoms of their medical diagnosis.

A nurse is preparing the plain of care for a client with neurogenic flaccid bladder. Which outcome is appropriate for this client?

Answer: The client's bladder does not become over distended Flaccid bladder is a type of neurogenic bladder commonly resulting from trauma. The client's bladder continues to fill and overflow incontinence is common. Stasis of urine can lead to infection, therefore, fluid is encouraged. The client does not feel pain or discomfort and will not have sensation or control over urination.

During a routine prenatal examination, a client who is at 32 weeks gestation becomes dizzy, lightheaded, and pale. After placing the client in a supine position, what is the priority nursing action?

Answer: Turn the client on her left side As the uterus gets larger, it increases pressure on the inferior vena cava. This inhibits venous return causing dizziness, lightheadedness, and pallor when the client is supine. Turning the client on her left side relives the pressure on the vena cava and restores venous return. Although they're valuable assessments, listening to fetal heart tone and measuring maternal blood pressure don't alleviate the symptoms. Deep breathing has no effect on venous return, and will not relieve the client's symptoms.

A nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles of heat and cold application, the nurse should

Answer: Remove the warm compress for at least 15 minutes after each 20-minute application Because heat and cold can injure skin, either should be applied for only a limited time. Warm compresses increase circulation and promote fluid absorption in the infiltrated area. Removing the compresses every 20 minutes for at least 15 minutes prevents injury to the skin and subsequent rebound vasoconstriction. Cold compresses, which help reduce edema, cause vasoconstriction. Keeping the area covered continuously can lead to skin breakdown.

A client in the first trimester of pregnancy joins a childbirth education class. During this trimester, the class is most likely to cover which physiologic aspect of pregnancy?

Answer: Warning signs of complications In early childbirth education classes, instruction on the physiologic aspects of pregnancy may include warning signs of complications, the anatomy and physiology of pregnancy, nutrition, and fetal development. Signs and symptoms of labor, quickening and fetal movements, and false and true labor are discussed in later classes.