PrepU: LEVEL 1-Clinical Decision Making / Clinical Judgment

Which of the following disorders is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex? a) Hashimoto's disease b) Addison's disease c) Cushing's syndrome d) Graves' disease

Cushing's syndrome Explanation: The patient with Cushing's syndrome demonstrates truncal obesity, moon face, acne, abdominal striae, and hypertension. In Addison's disease, the patient experiences chronic adrenocortical insufficiency. In Graves' disease, the patient experiences hyperthyroidism. The patient with Hashimoto's disease demonstrates inflammation of the thyroid gland, resulting in hypothyroidism. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 52: Assessment and Management of Patients With Endocrine Disorders, p. 1496. Chapter 52: Assessment and Management of Patients With Endocrine Disorders - Page 1496

Which of the following symptoms would most likely indicate that the client has pyelonephritis? a) Polyuria. b) Nausea and vomiting. c) Costovertebral angle (CVA) tenderness. d) Ascites.

Costovertebral angle (CVA) tenderness. Explanation: Common symptoms of pyelonephritis include CVA tenderness, burning on urination, urinary urgency or frequency, chills, fever, and fatigue. Ascites, polyuria, and nausea and vomiting are not indicative of pyelonephritis. Remediation: Acute pyelonephritis

Which of the following is a term used to describe a soft tissue injury produced by a blunt force? a) Contusion b) Hematoma c) Strain d) Sprain

Contusion Explanation: A contusion is a soft tissue injury produced by blunt force, such as a blow, kick, or fall, that results in bleeding into soft tissues (ecchymosis, or bruising). A hematoma develops when the bleeding is sufficient to form an appreciable solid swelling. A strain, or a "pulled muscle," is an injury to a musculotendinous unit caused by overuse, overstretching, or excessive stress. A sprain is an injury to the ligaments and supporting muscle fibers that surround a joint often caused by a trauma, wrenching or twisting motion. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13

2nd quiz (Clinical judgement?) The nurse is preparing to start an I.V. infusion. Before inserting the needle into a vein, the nurse should apply a tourniquet to the client's arm to accomplish which of the following? a) Immobilize the arm. b) Distend the veins. c) Occlude arterial circulation. d) Stabilize the veins.

Distend the veins. Explanation: Applying a tourniquet obstructs venous blood flow and, as a result, distends the veins. A tourniquet does not stabilize veins or immobilize the arm, nor is it applied to occlude arterial circulation. Remediation: IV catheter insertion

On the second day following an abdominal perineal resection, the nurse notes that the wound edges aren't approximated and one half of the incision has torn apart. What should the nurse do first? a) Cover the wound with a sterile dressing moistened with normal saline. b) Flush the wound with sterile water. c) Apply strips of tape. d) Apply an abdominal binder.

Cover the wound with a sterile dressing moistened with normal saline. Explanation: When dehiscence occurs, the nurse should immediately cover the wound with a sterile dressing moistened with normal saline. If the dehiscence is extensive, the incision must be resutured in surgery. Later, after the sutures are removed, additional support may be provided to the incision by applying strips of tape as directed by institutional policy or by the surgeon. An abdominal binder may also be utilized for additional support. Remediation: Wound care, dehiscence and evisceration

A patient with severe anemia is admitted to the hospital. Due to religious beliefs, the patient is refusing blood transfusions. The nurse anticipates drug therapy with which drug to stimulate the production of red blood cells? a) Sargramostim (Leukine) b) Epoetin alfa (Epogen) c) Filgrastim (Neupogen) d) Eltrombopag (Promacta)

Distend the veins. Explanation: Applying a tourniquet obstructs venous blood flow and, as a result, distends the veins. A tourniquet does not stabilize veins or immobilize the arm, nor is it applied to occlude arterial circulation. Remediation: IV catheter insertion

Twenty minutes after a transfusion of packed red blood cells is initiated, a client reports shivering, headache, and lower back pain. The vital signs show a normal temperature and increased pulse and respiratory rate. What should be the first nursing actions? a) Stop the transfusion, check the oxygen saturation levels, and check the urine volume. b) Stop the transfusion, continue with saline infusion, and notify the physician regarding a suspected hemolytic reaction. c) Slow the transfusion, notify the physician regarding a possible febrile reaction, and follow the physician's orders. d) Slow the transfusion, give an antihistamine as ordered, and notify the physician regarding a possible allergic reaction.

Stop the transfusion, continue with saline infusion, and notify the physician regarding a suspected hemolytic reaction. Explanation: Hemolytic reaction is one of the most severe blood reactions, so prompt action to stop the transfusion is very important, followed by ensuring the IV access is preserved. Remediation: Blood and blood product transfusion reaction management

Which is the best positioning for a client who has a fractured spine as a result of a diving accident? a) Prone with head to the side b) Side-lying with the head midline c) Supine with the head midline d) High Fowler's position with the head to the side

Supine with the head midline Explanation: The best initial position for a person with a cervical fracture is supine with the head immobilized and midline. This position prevents flexion, rotation, and extension of the neck. The other choices are incorrect because they don't create alignment. Remediation: Spinal injury

The client is admitted for a scheduled cardiac catheterization. On the morning of the procedure, while assessing the client's morning laboratory values, the nurse notes a blood urea nitrogen (BUN) of 34 mg/dL and a creatinine of 4.2 mg/dL. The nurse makes it a priority to notify the physician for which of the following reasons? a) These values show a risk for dysrhythmias. b) The client is over-hydrated, which puts him at risk for heart failure during the procedure. c) The client is at risk for bleeding. d) The client is at risk for renal failure due to the contrast agent that will be given during the procedure.

The client is at risk for renal failure due to the contrast agent that will be given during the procedure. Explanation: The contrast medium must be excreted by the kidneys. If there is already a degree of renal impairment (which these laboratory values indicate), the risk for contrast agent-induced nepropathy and renal failure is high. Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 25: Assessment of Cardiovascular Function, p. 682. Chapter 25: Assessment of Cardiovascular Function - Page 682

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: a) allow the client to remain in the chair but move all objects out of his way. b) carefully move the client to a flat surface and turn him on his side. c) place an oral airway in the client's mouth to maintain an open airway. d) hold the client's arm still to keep him from hitting anything.

carefully move the client to a flat surface and turn him on his side. Explanation: When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat nonelevated surface and then position him on his side to ensure that he doesn't aspirate and to protect him from injury. These steps help reduce the risk of injury from falling or hitting surrounding objects and help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of the mouth. Remediation: Seizure disorder