Prep U- The Nursing Process

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? "I like to soak my feet in the hot tub every day." "I walk only to the mailbox in my bare feet." "I stopped smoking and use only chewing tobacco." "I have my wife look at the soles of my feet each day." TAKE ANOTHER QUIZ

"I have my wife look at the soles of my feet each day." Explanation: A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on his own, then a caregiver or family member should help him. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make him unable to tell if the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems? Activity and rest Health promotion Nutrition Self-perception TAKE ANOTHER QUIZ

Activity and rest Explanation: A nursing diagnosis should be based on the collection of data from the client and should contain a precise statement related to the client's health problems. The question stem specifies that the nursing diagnosis should be based on the client's musculoskeletal issues; therefore, the domain of activity and rest would be most pertinent for a nursing diagnosis. The domains of health promotion, nutrition, and self-perception are less relevant than activity and rest to a client with a musculoskeletal injury.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? Acute pain related to biliary spasms Deficient knowledge related to prevention of disease recurrence Anxiety related to unknown outcome of hospitalization Imbalanced nutrition: Less than body requirements related to biliary inflammation

Acute pain related to biliary spasms Explanation: The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

Although nurse practice acts may vary state by state, all recognize several basic principles supporting the legal parameters for all registered nurses. Select the activity that falls under the scope of nursing practice. Appraising and enhancing an individual's health-seeking perspective Changing a patient's health care treatment plan Diagnosing pathology based on the patient's response to treatment Prescribing a physical therapy program to treat a flare-up of a chronic condition TAKE ANOTHER QUIZ

Appraising and enhancing an individual's health-seeking perspective Explanation: The role for all registered nurses includes assessment, evaluation, and the diagnosis of an individual's response to health and illness. Only advanced practice nurses have expanded responsibilities as determined by state law and/or the practice arena.

The nurse is completing discharge instructions for a client. The nurse can best evaluate the likeliness of the client to adhere to the instructions by use of which method? Make the client promise to follow the instructions and be compliant with the plan. Ask the client if he or she agrees with the instructions that are outlined. Ask the client if there is anything in the discharge plan that will interfere with compliance. Observe the client's face to see if he or she is smiling, which can be interpreted as compliance. TAKE ANOTHER QUIZ

Ask the client if there is anything in the discharge plan that will interfere with compliance. Explanation: Some individuals will not openly disagree with people in authority or who possess advanced education. Smiling is not necessarily proof of compliance. Agreeing with the plan of care is not the same as "doing" or complaining but finding out if there is anything in the plan of care that the client does not agree to adhere to is a step to establishing a plan of care that is client oriented.

The nurse is providing care to a client who has had a renal biopsy. The nurse would need to be alert for signs and symptoms of which of the following? Bleeding Infection Dehydration Allergic reaction TAKE ANOTHER QUIZ

Bleeding Explanation: Renal biopsy carries the risk of postprocedure bleeding because the kidneys receive up to 25% of the cardiac output each minute. Therefore, the nurse would need to be alert for signs and symptoms of bleeding. Although infection is also a risk, the risk for bleeding is greater. Dehydration and allergic reaction are not associated with a renal biopsy.

Which type of fracture occurs when a bone fragment is driven into another bone fragment? Impacted Oblique Spiral Transverse

Correct response: Impacted Explanation: An impacted fracture is one in which a bone fragment is driven into another bone fragment.

A client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include hoarseness. a moist cough. a sore throat that feels worse in the evening. a nonedematous uvula. TAKE ANOTHER QUIZ

Correct response: hoarseness. Explanation: Signs of acute laryngitis include hoarseness or aphonia and severe cough. Other signs of acute laryngitis include a dry cough, and a sore throat that feels worse in the morning. If allergies are present, the uvula will be visibly edematous.

After evaluating a client for hypertension, a health care provider orders atenolol, 50 mg P.O. daily. Which therapeutic effect should atenolol have in treating hypertension? Decreased cardiac output and decreased systolic and diastolic blood pressure Decreased blood pressure with reflex tachycardia Increased cardiac output and increased systolic and diastolic blood pressure Decreased peripheral vascular resistance TAKE ANOTHER QUIZ

Correct response: Decreased cardiac output and decreased systolic and diastolic blood pressure Explanation: As a long-acting, selective beta1-adrenergic blocker, atenolol decreases cardiac output and systolic and diastolic blood pressure; however, like other beta-adrenergic blockers, it increases peripheral vascular resistance at rest and with exercise. Atenolol may cause bradycardia, not tachycardia.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? Impaired gas exchange Anxiety Decreased cardiac output Ineffective tissue perfusion (cardiopulmonary) TAKE ANOTHER QUIZ

Correct response: Impaired gas exchange Explanation: For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.

A nurse is planning an in-service program for a group of staff nurses about heart failure and its treatment. The nurse would identify which agent as the most commonly used drug for treatment? Digoxin ACE inhibitors Hydrochlorothiazide Human B type natriuretic peptide TAKE ANOTHER QUIZ

Digoxin Explanation: Digoxin is the drug most often used to treat heart failure. Human B-type natriuretic peptide, ACE inhibitors, or hydrochlorothiazide also may be used, but these drugs are not the most common ones used.

A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client? Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients Risk for falls related to complaints of dizziness Fatigue related to decreased hemoglobin and hematocrit TAKE ANOTHER QUIZ

Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit Explanation: The symptoms indicate impaired tissue perfusion due to a decrease in the oxygen-carrying capacity of the blood. Cardiac status should be carefully assessed. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly) and by peripheral edema.

A nurse is caring for a client after a bone marrow transplant. What is the nurse's priority in caring for the client? Monitor the client's toilet patterns. Monitor the client to prevent sepsis. Monitor the client's physical condition. Monitor the client's heart rate.

Monitor the client to prevent sepsis. Explanation: Until transplanted bone marrow begins to produce blood cells, clients who have undergone a bone marrow transplant have no physiologic means to fight infection, which puts them at high risk for dying from sepsis and bleeding before engraftment. Therefore, a nurse must closely monitor clients and take measures to prevent sepsis. Monitoring client's toilet patterns, physical condition, and heart rate does not prevent the possibility of the client becoming septic.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? Necrotic and hard Pale yet able to blanch with digital pressure Pink to red and soft, bleeding easily White with long, thin areas of scar tissue TAKE ANOTHER QUIZ

Pink to red and soft, bleeding easily Explanation: In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue.

A nurse conducts the Romberg test on a client by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and saves the client from being injured. How should the nurse interpret the client's result?

Positive Romberg test, indicating a problem with equilibrium Explanation: If the client sways and starts to fall during the Romberg test, it indicates a positive result. This means the client has a problem with equilibrium. The examiner or the nurse stands fairly close to the client during the test to prevent the client from falling. The Romberg test is used to assess the client's motor function, including muscle movement, size, tone, strength, and coordination. However, the Romberg test is not used to assess the client's level of consciousness, body mass, or vision.

The nurse is assessing heart sounds in a patient with heart failure. An abnormal heart sound is detected early in diastole. How would the nurse document this?

S3 Explanation: An S3 ("DUB") is heard early in diastole during the period of rapid ventricular filling as blood flows from the atrium into a noncompliant ventricle. It is heard immediately after S2. "Lub-dub-DUB" is used to imitate the abnormal sound of a beating heart when an S3 is present.

A 43-year-old man has been diagnosed with active TB. He is prescribed a multiple drug therapy, including INH and rifampin. A priority assessment by the nurse will be to monitor which combination of laboratory test results?

Serum alanine transaminase, aspartate transaminase, and bilirubin Explanation: The major adverse effect of INH therapy is hepatotoxicity. In hepatotoxicity the hepatic enzyme levels of aspartate transaminase and alanine transaminase will be elevated. Bilirubin will also be elevated, and the patient may present with jaundice. Red and white blood counts and differential would indicate possible hematologic effects, which could be considered adverse effects of the drug therapy, but would not be diagnostic for hepatotoxicity. Thyroid-stimulating hormone, thyroxine, and triiodothyronine levels would indicate a thyroid glandular concern, not hepatotoxicity. Fasting blood sugar and 2-hour postprandial blood sugar would be indicative of diabetes, not hepatotoxicity.

After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered:

Significant Explanation: An induration of 10 mm or greater is usually considered significant and reactive in people who have normal or mildly impaired immunity. Erythema without induration is not considered significant.

A patient at a health care facility has been prescribed diazoxide for hypoglycemia due to hyperinsulinism. What adverse reactions to the drug should the nurse monitor for in the patient?

Tachycardia Explanation: The nurse should monitor for tachycardia, congestive heart failure, sodium and fluid retention, hyperglycemia, and glycosuria as the adverse reactions in the patient receiving diazoxide drug therapy. Myalgia, fatigue, and headache are the adverse reactions observed in patients undergoing pioglitazone HCl drug therapy. Flatulence is one of the adverse reactions found in patients receiving metformin drug therapy. Epigastric discomfort is one of the adverse reactions observed in patients receiving acetohexamide drugs.

An adult client who recently immigrated has been diagnosed with a tapeworm after several months of weight loss. The client has been prescribed albendazole and has presented for a follow-up assessment. What finding should the nurse prioritize for communicating to the provider? The client reports pruritis and his thorax has a yellowish tint. The client has had a "pounding headache" for the past 12 hours and has taken ibuprofen. The client states that he has been sleeping up to 10 hours each night and still feels fatigued. The client has a dry, unproductive cough.

The client reports pruritis and his thorax has a yellowish tint. Explanation: Pruritis and jaundice are suggestive of liver involvement and should be addressed by the provider. Fatigue, headache, and cough all require interventions, but none of these signs and symptoms present such a significant safety risk as hepatotoxicity.

The nurse has developed a plan of care for a client who is having a surgical procedure and is at risk for the development of pneumonia. The nurse devises the outcome statement to read: "The client will have clear lungs by the third postoperative day. " On the third postoperative day, the client has left lower lobe crackles and infiltrates on the chest x-ray. What conclusion does the nurse reach for this client?

The outcome is not achieved, and the plan requires critical reevaluation and revision. Explanation: The client has not achieved the outcome and in fact has potentially developed pneumonia. The plan will require critical- reevaluation, and new outcomes will be required to assist with resolving the potential pneumonia. The other evaluation criteria are not correct for this particular client's condition.

A client has been admitted to the hospital with a large sacral pressure ulcer. The physician orders the wound care protocol to be performed twice a day. What would be a statement on the plan of care that would address the implementation phase of the nursing process for this client? A 6 cm x 4 cm wound with malodorous, yellow exudate The client's wound will heal by 1 cm by the end of 5 days. The client's wound has healed by 0.5 cm on day 3 of wound care. Turn the client every 2 hours. TAKE ANOTHER QUIZ

Turn the client every 2 hours. Explanation: Turning the client every 2 hours is implementing care to allow the pressure ulcer to heal and prevent another formation of a wound. Option A is the assessment phase of the nursing process. Option B is the planning phase of the nursing process, and option C is the evaluation phase of the nursing process.

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? Specific gravity of 1.02 Urine pH of 3.0 Absence of protein Absence of glucose TAKE ANOTHER QUIZ

Urine pH of 3.0 Explanation: Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.010 to 1.025, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.

When assessing a terminally ill client, the nurse notices that the client has copious secretions at the back of the throat and in the mouth. The nurse is preparing a teaching plan for the family about caring for these secretions. Which of the following would be least appropriate to include? Positioning the client on the side with the head supported with a pillow Using a soft toothbrush to vigorously clean the mouth Performing gentle suctioning of the mouth Administering a prescribed anticholinergic agent TAKE ANOTHER QUIZ

Using a soft toothbrush to vigorously clean the mouth Explanation: Secretions are often more distressing to the family than their presence is to the client. Gentle mouth care with a moistened swab or very soft toothbrush helps maintain the integrity of the client's mucous membranes. Other helpful measures include positioning the client on the side with the head supported with pillows to allow secretions to drain freely from the mouth, gently suctioning the oral cavity, and administering prescribed anticholinergic agents sublingually or transdermally. Deeper suctioning may cause significant discomfort to the dying client and rarely is of benefit because secretions tend to reaccumulate quickly.

The nurse administers a medication to the client that induces the secondary action of hypoglycemia. What organ will be most acutely affected by inadequate circulating glucose? brain heart lungs skin TAKE ANOTHER QUIZ

brain While all cells require glucose to function, the brain uses the greatest amount. As a result, hypoglycemia has the greatest impact on the brain, which explains why hypoglycemia has so many neurological signs and symptoms including fatigue; drowsiness; hunger; anxiety; headache; cold, clammy skin; shaking and lack of coordination (tremulousness); increased heart rate; increased blood pressure; numbness and tingling of the mouth, tongue, and/or lips; confusion; and rapid and shallow respirations. In severe cases, seizures and/or coma may occur because the brain cannot function without adequate supplies of glucose.

Which is not one of the general nursing measures employed when caring for the client with a fracture? cranial nerve assessment administering analgesics providing comfort measures assisting with ADLs TAKE ANOTHER QUIZ

cranial nerve assessment Explanation: Cranial nerve assessment would only be carried out for head-related injuries or diseases. General nursing measures include administering analgesics, providing comfort measures, assisting with ADLs, preventing constipation, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing client for self-care.

The health care provider prescribes esmolol for a client with supraventricular tachycardia. During esmolol therapy, what should the nurse monitor? body temperature. heart rate and blood pressure. ocular pressure. cerebral perfusion pressure. TAKE ANOTHER QUIZ

heart rate and blood pressure. Explanation: Because class II antiarrhythmics such as esmolol inhibit sinus node stimulation, they may produce bradycardia. Hypotension with peripheral vascular insufficiency also may occur, especially with esmolol. Class II antiarrhythmics don't alter body temperature, ocular pressure, or cerebral perfusion pressure.

A transverse fracture

is one that is straight across the bone shaft

A spiral fracture .

is one that twists around the shaft of the bone.

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are normal. hypoactive. sluggish. absent.

normal. Explanation: Normal bowel sounds are heard every 5 to 20 seconds. Hypoactive bowel sound is the description given to auscultation of one to two bowel sounds in 2 minutes. Sluggish is not a term a nurse would use to accurately describe bowel sounds. The nurse records that bowel sounds are absent when no sound is heard in 3 to 5 minutes.

An oblique fracture

occurs at an angle across the bone.

The Mantoux test

or Mendel-Mantoux test (also known as the Mantoux screening test, tuberculin sensitivity test, Pirquet test, or PPD test for purified protein derivative) is a tool for screening for tuberculosis (TB) and for tuberculosis diagnosis.

A nurse is caring for a client with bronchogenic carcinoma. Which nursing intervention takes highest priority? offering frequent rest periods removing pulmonary secretions allowing the client to express concerns improving nutritional status TAKE ANOTHER QUIZ

removing pulmonary secretions Explanation: Maintaining a patent airway is the first concern in a client with a condition that may compromise the airway. Therefore, adequate removal of pulmonary secretions is a priority. Although clients may exhibit fatigue, anxiety, or appetite loss, these need to be addressed, but are not the priority.

A client with a history of ischemic heart disease is taking aspirin 81 mg daily. The nurse should explain that less than 81 mg actually reaches target tissue due to:

the first-pass effect.