prep u clinical judgement w/ explanation
A waist circumference greater than which value indicates excess abdominal fat in men? 88.90 cm (35 in) 76.20 cm (30 in) 63.50 cm (25 in) 101.60 cm (40 in)
101.60 cm (40 in) Explanation: A waist circumference >101.60 cm (>40 in) for men or >88.90 cm (>35 in) for women indicates excess abdominal fat. Those with a high waist circumference are at increased risk for diabetes, dyslipidemia, hypertension, cardiovascular disease, and atrial fibrillation.
A client could experience increased urination when using which classification of medication? Central nervous system depressants Analgesic medications Cholinergic agents Stool softeners
Cholinergic agents Explanation: Cholinergic agents stimulate the detrusor muscle, which causes more frequent urination.
The nurse is preparing an outline for a class on the physiology of the male sexual response. Which event would the nurse identify as occurring first? Ejaculation Sperm emission Penile vasodilation Psychological release
Penile vasodilation With sexual stimulation, the arteries leading to the penis dilate and increase blood flow into erectile tissue. Blood accumulates, causing the penis to swell and elongate. Sperm emission (movement of sperm from the testes and fluid from the accessory glands) occurs with orgasm. Orgasm results in a pleasurable feeling of physiologic and psychological release. Ejaculation results in the discharge of semen from the urethra.
A client is transferred from the coronary care unit to the step-down unit. Which information should be included in the transfer report? Select all that apply. The client has a "do not resuscitate" prescription. The client uses the bedpan. The client has four grandchildren. The client needs oxygen at 2 L/minute. The client has been in normal sinus rhythm for 6 hours.
The nurse should report that the client is using oxygen, has a "do not resuscitate" prescription, can use the bedpan, and is in normal sinus rhythm. Information about having four grandchildren is not needed to help with the client's continuity of care.
On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as: Chronic angle-closure. Normal tension. Chronic open-angle. Acute angle-closure.
Acute angle-closure.
A client has been diagnosed with cardiac dysfunction and admitted to a health care center. The nurse notices that the client's ankles and feet are swollen. Using critical thinking skills, which nursing intervention does the nurse know to perform next? Organize activities to provide frequent rest periods Weigh client daily at the same time Assess oxygen saturation level Assess client for dependent edema
Assess client for dependent edema Explanation: Initial assessments of swollen ankles and feet are symptoms of dependent edema. Hence, the priority assessment method adopted by the nurse should be oriented toward gathering as much relevant information as possible related to edema. Measuring the client's weight, organizing activities to provide frequent rest periods, and assessing oxygen saturation level are also nursing interventions to be used under appropriate circumstances.
The nurse gives a client 0.25 mg of digoxin instead of the prescribed dose of 0.125 mg. What action should the nurse take after realizing the mistake? No action is needed because of the small dose difference. Hold the next dose of digoxin. Give the prescribed 0.125 mg as soon as possible. Assess the client and notify the physician.
Assess the client and notify the physician. Explanation: This is a medication error. The priority is to assess the client and then to notify the physician of the error and seek further guidance from the physician. The other options do not describe the steps the nurse should take to ensure client safety following a medication error. The other options include decisions and judgments that are outside of the nurse's scope of practice.
The client with rapid-cycling bipolar disorder who is about to receive his 1700 hours dose of carbamazepine tells the nurse he has a sore throat and chills. What should the nurse do next? Call the health care provider (HCP) to report changes. Administer the prescribed amount of carbamazepine. Report the symptoms to the health care provider (HCP) in the morning. First, give the client acetaminophen as prescribed PRN.
Call the health care provider (HCP) to report changes. Explanation: The nurse should call the HCP to report symptoms of a sore throat, fever, and chills because these symptoms may be signs of serious adverse effects of the medication, including potentially fatal hematologic, cardiovascular, and hepatic complications. Giving the dose of carbamazepine is contraindicated in this situation. Giving the acetaminophen would be inappropriate and potentially detrimental to the client's health. Waiting until morning to report the client's symptoms is a serious error in judgment.
Which phase of the Trajectory Model does the nurse recognize is present when the patient is in remission, after an exacerbation of illness? Acute Downward course Comeback Crisis
Comeback Explanation: The acute phase is characterized by severe and unrelieved symptoms or the development of illness complications necessitating hospitalization, bed rest, or interruption of the person's usual activities to bring the illness course under control. The crisis phase is characterized by a critical or life-threatening situation requiring emergency treatment or care and suspension of everyday life activities until the crisis has passed. The comeback phase is characterized by a gradual recovery after an acute period and learning to live with or overcome disabilities and return to an acceptable way of life within the limitations imposed by the chronic condition or disability. It involves physical healing, limitations stretching through rehabilitative procedures, psychosocial coming-to-terms, and biographical reengagement with adjustments in everyday life activities. The downward phase is characterized by rapid or gradual worsening of a condition, including physical decline accompanied by increasing disability or difficulty in controlling symptoms. It requires biographical adjustment and alterations in everyday life activities with each major downward step.
The nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease should be to: enhance myocardial oxygenation. educate the client about his symptoms. decrease anxiety. administer sublingual nitroglycerin.
Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygenation, the myocardium suffers damage. Sublingual nitroglycerin is administered to treat acute angina, but administration isn't the first priority. Although educating the client and decreasing anxiety are important in care delivery, neither are priorities when a client is compromised.
When caring for an older client who is receiving external beam radiation, which is the key point for the nurse to incorporate into the plan of care? The use of disposable utensils and wash cloths Time, distance, and shielding Avoid showering or washing over skin markings. Inspect the skin frequently.
Inspect the skin frequently. Explanation: Inspecting the skin frequently will allow early identification and intervention of skin problems associated with external radiation therapy. The external markings should not be removed, but clients may shower and lightly wash over the skin. Time, distance, and shielding are key in the management of sealed, internal radiation therapy and not external beam radiation. The use of disposable utensils and care items would be important when caring for clients following systemic, unsealed, internal radiation therapy.
Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has? Cancer of the tonsils Laryngeal cancer Cancer of the pharynx Laryngeal polyps
Laryngeal cancer Explanation: Later, the client notes a sensation of swelling or a lump in the throat, followed by dysphagia and pain when talking. Hoarseness is not indicative of pharyngeal cancer; laryngeal polyps; or cancer of the tonsils. pg.558
A primigravid client is experiencing a prolonged second stage of labor with a fetus suspected of weighing more than 4 kg. Which intervention is most important? preparing for a vacuum-assisted delivery preparing for an emergency cesarean birth performing the McRoberts maneuver administering an IV fluid bolus
Performing the McRoberts maneuver A prolonged second stage of labor with a large fetus could indicate a shoulder dystocia at birth. Immediate nursing actions for a shoulder dystocia include suprapubic pressure and the McRoberts maneuver. If after interventions for vaginal birth with a shoulder dystocia fail, an emergency cesarean birth may be needed but is not indicated at this time. A vacuum-assisted birth would be contraindicated due to increased risk of shoulder dystocia with a macrosomic infant. An IV fluid bolus may be indicated for fetal distress, but there is not enough information to establish that they are needed at this time.
The nurse is triaging patients from a 10-car pile-up on the interstate and assesses a patient with a sucking chest wound. What category should this patient be placed in? Priority 3 Priority 1 Priority 4 Priority 2
Priority 1 Triage category "Immediate" is priority 1 (red) and includes injuries that are life threatening but survivable with minimal intervention, such as sucking chest wound, airway obstruction secondary to mechanical cause, and shock.
The nurse is reviewing the lab report for a client in hospice care with breast cancer and brain metastasis. According to the information in the chart, what should the nurse do next? Report the elevated calcium level immediately. Refrain from reporting the results because the client is in hospice care. Document these results on the medical record. Report the elevated potassium level immediately.
Report the elevated calcium level immediately. Explanation: The normal calcium level is 9.0 to 10.5 mg/dL. Hypercalcemia is commonly seen with malignant disease and metastases. The other laboratory values are normal. Hypercalcemia can be treated with fluids, furosemide, or administration of calcitonin. Failure to treat hypercalcemia can cause muscle weakness, changes in level of consciousness, nausea, vomiting, abdominal pain, and dehydration. Although the client is on hospice care, she will still need palliative treatment. Comfort and risk reduction are components of hospice care.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? a) Semi-Fowler's b) Supine c) High-Fowler's d) Prone
Semi-Fowler's The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
What are important nursing priorities on the first postoperative day for a client who has had an open reduction and internal fixation (ORIF) after a right hip fracture? Reorienting frequently to prevent confusion and disorientation, restricting analgesics, and encouraging pursed-lip breathing Supporting the leg to maintain adduction, ensuring adequate pain control, and maintaining bed rest Assessing for skin integrity, enhancing nutritional status, and encouraging position changes while maintaining bed rest Assessing the neurovascular status in the right leg, providing pain control, encouraging position changes, and early ambulation
d Assessing the neurovascular status in the right leg, providing pain control, encouraging position changes, and early ambulation Explanation: Assessing the neurovascular status, including circulation and innervation, is very important postoperatively. Control of pain is also a priority. Maintaining the integrity of the skin through frequent turns and ambulation will prevent pressure ulcers. Correct postoperative positioning involves maintaining the leg in a neutral position and preventing adduction. Bed rest can result in immobility consequences. Assessing skin integrity and nutritional status is positive, but maintaining bedrest is incorrect. Reorienting frequently will not prevent disorientation, and the nurse would not restrict pain measures.
A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample? first thing in the morning before bedtime evening afternoon
first thing in the morning. Rationale: While the specimen can be collected at any time during the day, the first urine voided in the morning is preferred. The first urine is usually more concentrated because the client does not usually consume fluid during the night and the effects of diet and activity are minimized
A client with a chronic mental illness who does not always take her medications is separated from her husband and receives public assistance funds. She lives with her mother and older sister and manages her own medication. The client's mother is in poor health and also receives public assistance benefits. The client's sister works outside the home, and the client's father is dead. Which issue should the nurse address first? family support financial concerns medication compliance marital communicatio
medication compliance Explanation: Medication noncompliance is a primary cause of exacerbation in chronic mental illnesses. Of the issues listed, medications should be addressed first. Other issues, such as family, marriage, and finances, can be addressed as client stabilization is maintained.
