Q Simulator Exam #2

A manufacturing worker comes into the occupational health nurse's clinic reporting a squeezing pain in the chest. What additional signs and symptoms should the nurse monitor for in the client? 1. Dyspnea 2. Dry, flushed skin 3. Indigestion 4. Restlessness 5. Tachycardia

1., 3., 4. & 5. Correct: The nurse should be thinking myocardial infarction (MI)! All of these are signs of an MI.

A client was admitted two days ago in the oliguric phase of acute kidney injury (AKI). What evaluation by the nurse would indicate that treatment has been effective? 1. Variable urine specific gravity 2. Serum K+ 5.5 mEq (5.5 mmol/L) 3. Serum Na+ 140 mEq (140 mmol/L) 4. Minimal crackles auscultated in bases of left lung 5. Urine output = 1250 mL/24 hours

1., 3. & 5. Correct: A fixed specific gravity indicates that the kidneys are not working properly. A variable specific gravity changes based on whether the urine is dilute or concentrated. This is a normal sodium level, which indicates that the client is improving. The serum sodium level would be low in the oliguric phase due to increased dilution of the blood. This urine output is adequate to indicate proper kidney perfusion.

During the admission examination of a client diagnosed with acute pyelonephritis, what signs or symptoms would the nurse expect to find? 1. Dysnea 2. Hematuria 3. Pubic pain 4. Tachycardia 5. Weight gain

2., 4., & 5. Correct: The client with acute pyelonephritis, will often exhibit these signs/symptoms due to the kidney infection.

The nurse sees the following rhythm on the cardiac monitor for a client recovering from a myocardial infarction. What would be the nurse's first action upon entering the client's room? 1. Attempt defibrillation 2. Begin CPR 3. Assess for carotid pulse 4. Administer lidocaine

3. Correct: Although the rhythm strip looks like ventricular fibrillation, you must first check the client. Assess for consciousness, airway, breathing, circulation first.

A client has been admitted with advanced cirrhosis. The nurse's assessment verifies an increase weight of 6 lbs. (2.71 kg) since yesterday's weight and an abdominal girth increase of 5 inches (12.7 cm). What is the priority assessment? 1. Urinary Output 2. Daily weight 3. Blood pressure 4. LOC

3. Correct: Blood Pressure. We said that all of this ascites is coming from the vascular space and it's getting worse, So what could happen to my blood pressure? It will drop!

The nurse is planning care for a client who has incomplete emptying of the bladder with reports of dribbling, hesitancy, and frequency. Which intervention would the nurse include in this plan? Select all that apply 1. After voiding, instruct client to void a second time. 2. Encourage the client to void every 4 hours. 3. Teach client to perform the Credé method. 4. Pour warm water over perineum. 5. Insert indwelling urinary catheter if client unable to void.

1., 2., 3., & 4. Correct: Have client attempt to void again. This is called double voiding. This can improve bladder emptying. Encourage client to void every 4 hours. We do not want urine to sit in the bladder for long periods of time. Stagnant urine can create infection. Place bedpan, urinal, or bedside commode within reach. Perform Credé method over bladder to increase bladder pressure. Provide privacy. Have client listen to sound of running water or place hands in warm water and/or pour warm water over perineum to stimulate urination. Offer fluids before voiding.

A nurse is caring for a client post heart catheterization with a left femoral stick. What signs and symptoms would indicate to the nurse that the primary healthcare provider should be notified? Select all that apply 1. Capillary refill of 6 seconds to left toes. 2. Epigastric discomfort 3. Paresthesia to left leg 4. Left pedal pulse 0/4; Right pedal pulse 2+/4 5. Temperature of 99.9º F (37.72º C)

1., 2., 3., & 4. Correct: These signs and symptoms indicate an emergency with loss of circulation to the extremity. This is an emergency, and the primary healthcare provider is the only one that can save this foot from ischemia. Don't delay. Epigastric pain could indicate the client is having an MI. Always assume the worse!

The nurse is assessing a client admitted with a diagnosis of chronic renal failure. Which finding would the nurse expect to see in the client? 1. Anemia 2. Fluid volume deficit 3. Pruritis 4. Dependent edema 5. Hypokalemia

1., 3., & 4. Correct: The client will have fatigue from anemia and anorexia from toxins. The client may have an uremic frost which causes pruritis. Fluid volume excess leads to edematous extremities.

What assessment finding would indicate to the nurse that further treatment is needed for a client hospitalized with systolic heart failure? 1. S3 heart sound 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.91 kg) 4. Hepatomegaly 5. Increasing BNP level 6. Urine output at 50 mL/hr

1., 4. & 5. Correct: S3 would indicate that the client is not better. S3 is heard when the client is in fluid overload. Hepatomegaly and tenderness in the right upper quadrant of the abdomen result from venous engorgement of the liver. The client is not better. An increase in BNP level would indicate that the heart failure was getting worse, not better.

A client arrives to the emergency department with reports of palpitations, chest discomfort, and light-headedness. The nurse connects the client to a cardiac monitor and notes a weak, thready pulse, and a BP of 90/50. What actions should the nurse take? 1. Administer Atropine 0.5 mg intravenous push (IVP). 2. Prepare for immediate synchronized cardioversion. 3. Provide 100 percent oxygen. 4. Start large bore intravenous access. 5. Set up for endotracheal intubation.

2., & 4. Correct: This client has a rapid heart rate of 188/min. The actual rhythm is atrial tachycardia but can also be identified as supraventricular tachycardia because the heartrate is greater than 150/min. This client is considered unstable so requires oxygen therapy starting at 2 liters/nasal cannula, with O2 saturation monitoring, and synchronized cardioversion. IV access is needed prior to cardioversion incase medications are required.

A home heath nurse is educating a client about home care considerations for clean intermittent catheterization. Which statement made by the client would indicate to the nurse that further teaching is needed? 1. "I will wash the re-usable catheter thoroughly with soap and water after use." 2. "When urine stops flowing, I will press over the bladder area with my free hand." 3. "It is important that maintain sterile technique when catheterizing myself." 4. "Catheterization should be done when I feel the need to void."

3. Correct: This is an incorrect statement by the client so further teaching is needed. Catheterization is done using a clean technique rather than sterile technique when the client is in their own home.

A small community has experienced a mudslide that hit a restaurant causing mass casualties. What would the nurse do first? 1. Assess the immediate area for electrical wires on the ground. 2. Attend to victim injuries as they are encountered. 3. Activate the community emergency response team. 4. Triage and tag victims according to injury.

3. Correct: With mass casualties, community response teams are needed.

When an explosion occurs at a local shopping center, an off-duty nurse quickly begins to triage those injured. The nurse knows which client needs immediate attention? 1. An elderly adult with a traumatic left eye enucleation. 2. A child with an open, compound fracture of the femur. 3. An adult with a head laceration bleeding profusely. 4. An adolescent with a rigid, board-like lower abdomen.

4. CORRECT: This client's symptoms indicate the presence of internal bleeding. Without emergency surgery, this client will quickly develop hypovolemic shock and may not survive.

A client returns to the unit after having extracorporeal lithotripsy. Which would be the best indicator that the treatment has been effective? 1. The client is relieved of the pain. 2. The urine is free of red blood cells. 3. The urinary output has increased since return to the unit. 4. There is sediment in the urinary catheter drainage bag.

4. Correct: This answer provides visible proof that the renal calculi has been broken up by the shock waves.

A nurse is attempting planning care for a client who has self-care difficulty due to left-sided hemiparesis. Which intervention should the nurse include? 1. Offer to take the client to the toilet every two hours. 2. Instruct client to use disposable razors once to prevent infection. 3. Encourage family members to comb hair for client. 4. Provide the client with a button hook for dressing. 5. Teach the client to rely on furniture for support when walking.

1., & 4. Correct: Offer bedpan or place client on toilet every 1 to 2 hours during the day and three times during the night. The use of a button hook or loop and pile closure on clothes may make it possible for a client to continue independence in this self-care activity.

What signs/symptoms would the nurse expect to assess in a client diagnosed with acute pericarditis? 1. Distended neck veins 2. Muffled heart sounds 3. Narrowed pulse pressure 4. Pain worsens when sitting up and leaning forward 5. Pulsus paradoxus 6. Stabbing chest pain

1., 2., & 6. Correct: The pericardium is a thin, fluid-filled sac that surrounds your heart. An infection of the pericardium, called constrictive pericarditis, can restrict the volume of the heart. As a result, the chambers can't fill with blood properly, so blood can back up into veins, including the jugular veins. Muffled heart sounds are indicative of pericarditis. Fluid is between the heart and chest wall making the heart sounds lowered and distant. The pain is described as a sharp, stabbing chest pain over the center or left side of the chest.

A client had a coronary artery bypass surgery (CABG) x 3 performed 24 hours ago. What assessment findings would make the nurse suspect cardiac tamponade? 1. Bradycardia with wet lungs 2. Increased central venous pressure 3. Distended bilateral neck veins 4. A widening pulse pressure 5. Decreasing blood pressure

2, 3, and 5. CORRECT: Cardiac tamponade occurs when blood or fluid enters the pericardial sac, causing compression of the heart chambers. Such pressure prevents blood from either entering or leaving the heart, thus decreasing cardiac output. Central venous pressure (CVP) increases because of the compression of the right atria, but because no fluid is exiting the heart, blood pressure drops. Since the returning blood cannot enter the heart, neck veins become distended, though lungs remain clear.

What should a nurse include when planning an educational program for a group of women on how to prevent a urinary tract infection (UTI)? 1. Empty bladder at least every 8 hours while awake 2. Take showers rather than prolonged baths 3. Use spemicidal jelly during intercourse 4. Use tampons rather than sanitary napkins 5. Wear cotton underwear

2., 4., & 5. Correct: Take showers and avoid prolonged baths. Sitting in a tub allows bacteria to reach the bladder opening area. Tampons are advised during the menstrual period rather than sanitary napkins or pads because they keep the bladder opening area drier than a sanitary pad, thereby limiting bacterial overgrowth. Cotton underwear for general use is suggested.

The nurse is caring for a client with acute renal failure. The morning assessment findings indicate the client has become confused and irritable. Which finding is most likely responsible for the change in behavior? 1. Hyperkalemia 2. Hypernatremia 3. Elevated blood urea nitrogen (BUN) 4. Limited fluid intake

3. Correct: A client with acute renal failure will have an increased (BUN). Significant elevation in BUN may result in nausea, vomiting, lethargy, fatigue, impaired thought processes, and headache.

The nurse is caring for a client who is receiving enoxaparin after a diagnosis of deep vein thrombosis of the left leg. Which nursing interventions would be appropriate for this client? 1. Monitor PT and aPTT 2. Initiate bedrest 3. Elevate left leg 4. Monitor closely for bleeding 5. Monitor complete blood count

2., 3., 4. & 5. Correct: The main complication of anticoagulant therapy is bleeding. Periodic complete blood counts, including platelet count, and stool occult blood tests are recommended during the course of treatment with enoxaparin sodium Injection. Bedrest will reduce the risk of a clot dislodging. Elevate left leg to decrease swelling and promote venous return.

A client is admitted with arterial disease of the lower extremities. Which client teachings would the nurse initiate? 1. Elevate extremities above the level of the heart. 2. Discourage use of caffeine. 3. Protect extremities from cold exposure. 4. Maintain a warm environment at home. 5. Encourage isometric exercise.

2., 3., 4., & 5. Correct: Caffeine, stress, and nicotine cause vasoconstriction and vasospasm, which impedes peripheral circulation. Warmth promotes arterial flow by preventing the vasoconstriction effects of chilling. Vasodilation will be increased by providing warmth in the environment. Cold causes vasoconstriction. Isometric exercise and walking promote the development of collateral circulation.

As a member of the emergency preparedness planning team at the hospital, which action should the nurse encourage the team to implement? 1. Develop a response plan for each potential disaster. 2. Provide education to employees on the response plan. 3. Practice the response plan on a regular basis. 4. Evaluate the hospital's level of preparedness. 5. Coordinate with neighboring hospitals regarding different emergency response plans.

2., 3., 4., & 5. Correct: Developing a single response plan, educating individuals to the specifics of the response plan, and practicing the plan and evaluating the facility's level of preparedness are effective means of implementing emergency preparedness. Consideration must be given to the proximity of chemical plants, nuclear facilities, schools, and areas where large groups gather.

What potential contributing factors for transient urinary incontinence should a nurse assess in an elderly female client? 1. Chronic urinary retention 2. Fecal impaction 3. Menopause 4. Restricted mobility 5. Stroke

2., & 4. Correct: Transient incontinence: a temporary type of urinary incontinence caused by an illness or a specific medical condition that is short-lived and is, therefore, quickly remedied by appropriate treatment of the condition and a disappearance of symptoms. The potential causes of transient incontinence may be easily remembered by the mnemonic 'delirium, infection, atrophy, pharmaceuticals, excess urine output, restricted mobility, stool impaction' (DIAPERS). Fecal impaction can compress the urethra resulting in urinary incontinence. Use of diuretics can make it difficult to get to the toilet in time to void, thus causing urinary incontinence. Diabetics have polyuria, which can contribute to urinary incontinence. Vaginitis, a condition caused by an infection or inflammation of the vagina, can contribute to urinary incontinence.

A client has sublingual (SL) nitroglycerin prn added to the medication regimen. Which statement made by the client indicates to the nurse that teaching has been effective? 1. "If the medication burns in my mouth, it is old and should be discarded." 2. "I must keep this medication in its original dark, glass bottle." 3. "I can take one tablet every five minutes up to 3 doses for chest pain." 4. "I know that I must put this tablet under my tongue for it to work." 5. "My medication should be renewed yearly."

2., 3., & 4. Correct: These are true statements and would indicate that teaching has been effective.

The nurse is teaching a male client how to perform intermittent self-catheterization. In what order should this procedure be taught? The Correct Order Clean the meatus Lubricate several inches of the catheter tip Hold your penis on both sides just behind the head Insert the catheter 6 inches (15.24 cm) into the urethra Gently, but firmly push past the sphincter muscle 2-3 inches(5-7.6 cm) Allow urine to drain completely

The Correct Order Clean the meatus Lubricate several inches of the catheter tip Hold your penis on both sides just behind the head Insert the catheter 6 inches (15.24 cm) into the urethra Gently, but firmly push past the sphincter muscle 2-3 inches(5-7.6 cm) Allow urine to drain completely