Question Bank #1
A client who underwent a laparoscopic cholecystectomy is being discharged from an outpatient surgical center. Which statement by the client shows the nurse that discharge teaching has been effective? 1. I will need to eat a low fat diet since I no longer have a gallbladder. 2. I can expect drainage from the incisions for a few days. 3. I may have some mild pain from the procedure, but severe pain may indicate a problem. 4. I should plan to limit my activities and not return to work for several weeks.
3. Correct: Clients should not have severe pain after this procedure. 1. Incorrect: The client can resume their usual diet. The liver will produce enough bile to digest fats. 2. Incorrect: The client should not have drainage from the incisions. 4. Incorrect: The client can return to normal activities in 2 to 3 days.
A client at 34 weeks gestation with pregnancy induced hypertension (PIH) reports "heartburn." Which action by the nurse has priority? 1. Administer an antacid per standing orders. 2. Check client's blood pressure. 3. Call the primary healthcare provider immediately. 4. Assure client this is a normal discomfort of pregnancy.
3. Correct: Epigastric discomfort is commonly described as "heartburn" by pregnant clients and epigastric discomfort is a symptom of impending rupture of the liver capsule and seizures associated with worsening PIH and eclampsia. As a new nurse we need to assume the worst. Call the primary healthcare provider. 1. Incorrect: Not a concern as much as impending seizure symptoms. 2. Incorrect: Not a concern as much as impending seizure symptoms. 4. Incorrect: Not in this situation.
The nurse instructs a client taking isoniazid regarding appropriate food choices. Which food choices indicate to the nurse that teaching has been successful? 1. Salad with Blue Cheese dressing. 2. Smothered liver with onions. 3. Smoked salmon 4. Pear salad
4. Correct: Pears are acceptable fruit. 1. Incorrect: Foods high in tyramine such as salad with Blue Cheese dressing can result in severe reactions when client is taking isoniazid. 2. Incorrect: Foods high in tyramine such as smothered liver with onions can result in severe reactions when client is taking isoniazid. 3. Incorrect: Foods high in tyramine such as smoked salmon can result in severe reactions when client is taking isoniazid.
Which client could the telemetry charge nurse safely transfer in order to admit a new client? 1. Pacemaker with history of heart failure. 2. Colon resection with new onset a-fib. 3. Status post CABG with atrial flutter. 4. Chest pain with history of heart failure.
1. Correct: Yes, this client is the least critical. 2. Incorrect: Needs a telemetry bed with new onset a-fib. 3. Incorrect: Arrhythmia and cardiac client should not be transferred. 4. Incorrect: Second best answer but has chest pain and heart failure; very cardiac.
A home care nurse is preparing to perform venipuncture to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What should be the nurse's first action? 1. Hug the client to provide support. 2. Take the client to the emergency department for sedation. 3. Decrease stimuli in the room. 4. Teach the client deep breathing exercises.
3. Correct: A stimulating environment may increase the level of anxiety. 1. Incorrect: Give adequate space while maintaining a safe, calm, non-threatening approach. Hugging will confine the person and intensify feelings. 2. Incorrect: Panic attacks usually last minutes, rarely longer. 4. Incorrect: This is good, however, you need to wait until the panic attack is over.
A term male infant was just delivered vaginally. Which of the following actions by the nurse has priority? 1. Apply identification bands 2. Apply eye ointment 3. Dry the baby 4. Obtain footprints
3. Correct: Cold stress is the biggest danger to a newborn. A newborn is wet and evaporation will rapidly cool the baby which can cause hypoglycemia and respiratory distress. 1. Incorrect: A task that needs to be accomplished before the baby leaves the delivery room, but is not immediate priority. 2. Incorrect: Eye prophylaxis can safely be delayed up to two hours. 4. Incorrect: A task that needs to be accomplished before the baby leaves the delivery room, but is not immediate priority.
A client with Bell's palsy is having difficulty eating. Which action by the nurse will be most helpful? 1. Maintain privacy during meals. 2. Provide a liquid diet high in protein and calories that will be easily swallowed. 3. Assure the client that it does not bother others to observe while eating. 4. Teach the client to chew food on the unaffected side of the mouth for better control.
4. Correct: This will decrease the risk of aspiration. 1. Incorrect: The nurse knows a client at risk for aspiration should NOT be left alone when eating. 2. Incorrect: Liquids too are difficult for the client to manage as lip closure and chewing are impaired. 3. Incorrect: Focuses on other clients not on the client identified in the question.
A nurse is caring for a nonambulatory client who must be decontaminated after a chemical exposure event. What nursing action will best prevent further chemical exposure? 1. Don appropriate personal protective equipment (PPE). 2. Remove only contaminated clothes. 3. Avoid decontaminating the eyes. 4. Use hot water during decontamination.
1. Correct: PPE should be donned prior to contact with the client to prevent contamination of the healthcare worker. 2. Incorrect: All clothes, jewelry, and personal belongings should be removed and placed into appropriate containers. 3. Incorrect: Decontamination of the eyes is performed using a saline solution via nasal cannula or Morgan lens. 4. Incorrect: Hot water is unnecessary unless the client is hypothermic during decontamination procedures.
The nurse is assigned a group of clients on the inpatient psychiatric unit. Which client presents the greatest risk for violence toward others? 1. 24 year old man with paranoid delusions 2. 62 year old woman with bi-polar disorder 3. 72 year old man with major depression 4. 28 year old woman with borderline personality disorder
1. Correct: This client has a diagnosis that is consistent with a risk of violence, and his age falls within the age range for males who are most likely to present a risk of violence toward others. 2. Incorrect: This client may be irritable; however, it is not likely that she will present a great risk for violence. Her age does not fall within the range for women that are most likely to present a threat of violence. 3. Incorrect: This client is more likely to hurt present a risk of violence toward self. 4. Incorrect: This client is more likely to hurt herself, perhaps through self-mutilation
A nurse is working in a walk-in clinic where a mother brings in her 6 year old child stating, "My child is just not right." The nurse's assessment notes an unusual odor to the child's breath, new onset of bed-wetting, and lethargy. What critical test must the nurse perform first? 1. Blood glucose 2. Urinalysis 3. Arterial blood gas 4. Toxicology screen
1. Correct: Yes! This looks like diabetic ketoacidosis (DKA). Good job. 2. Incorrect: Maybe, after the other measures. 3. Incorrect: Too invasive for now and not first. 4. Incorrect: Yes! But not first with the other signs pointing to DKA.
The nurse is planning health promotion strategies for a single parent who is trying to increase physical activity level, but expresses a lack of time. Which interventions would help the client get more regular physical activity into the day? 1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them. 4. Suggest waking one hour earlier in the morning to go to the gym. 5. Suggest walking for 30 minutes with a buddy each afternoon before leaving work.
1., 2. & 3. Correct: This plan will allow her to stay home without adding further time demands to her day. Parking further away is one plan to get more steps into the day, without increasing time demands drastically. Walking with the children allows mom to spend quality time with the children as well as offers a good example for the children. 4. Incorrect: Being a single mom, this plan would not be feasible. The demands of getting the children out earlier would impact the time schedule for the day in a negative way. 5. Incorrect: This plan would only increase time demands and possibly financial demands if the children have to be cared for by someone else at an extra charge each day.
The nurse has been trained to work in a decontamination station for hazardous exposure victims. What should the nurse tell this victim about the process? 1. First you will remove clothing and dispose in hazardous material containment area. 2. You will be placed in a warm shower for decontamination. 3. You will spend a minute or so using soap over the entire body before rinsing. 4. You will spend approximately 15 minutes in the shower. 5. You will apply soap from head to toe and then rinse for a few minutes.
1., 2., 3. & 5. Correct: If the victim can remove his/her own clothing, then instructions should be given to do so and dispose of in hazardous material container. The person will wash for several minutes, beginning with a minute or so of full body rinsing with water to remove any visible contaminants, followed by soap, and final rinse. Times vary with institution and known contaminants. Using soap with good surfactant qualities is important. Generally, the victim is instructed to rinse with tepid water, apply soap from head to toe, and then rinse again with copious amounts of water. 4. Incorrect: Most procedures require about 5 to 6 minutes for the decontamination process. Times may vary depending on policy, contaminants, and the level of ability of the victim.
A client complains of crushing chest pain 3 hours prior to arrival in the emergency department. Initial assessment by the nurse reveals a BP of 90/50, a weak, thready pulse at 108/min, cool, clammy skin, and confusion. Which interventions should the nurse perform? 1. Initiate cardiac monitoring. 2. Monitor intake and output hourly. 3. Position client upright. 4. Limit physical activity. 5. Administer dopamine at 5 micrograms/kg/min.
1., 2., 3., 4. & 5. Correct: This client exhibits signs of cardiogenic shock, a complication of myocardial infarction. Hypotension accompanied by clinical signs of increased peripheral resistance (weak, thready pulse and cool, clammy skin) and inadequate organ perfusion (altered mental status and decreased urinary output) are found in this client. Initiate cardiac monitoring, watching for dysrhythmias, Monitor I&O hourly to make sure kidneys are perfused. Position upright to promote optimal ventilation by reducing venous return and lessen pulmonary edema. Limit activity to decrease oxygen demand. Dopamine is administered to increase BP and cardiac output.
The home care nurse visits a client who has moderate cognitive impairment and whose family provides care for the client. Which suggestions would be helpful for this family to reduce the risk of injury? 1. Suggest that the family lock medications and poisons and keep the keys. 2. Encourage the family to place locks high on the door frame to make it difficult for the client to leave. 3. Suggest that the family go out to dinner at least once per week for respite from responsibility. 4. Suggest that the family remove knobs from stove when not in use. 5. Keep fire extinguishers present and in working order.
1., 2., 4. & 5. Correct: Clients with cognitive impairment may forget that they have taken their medicines and take them again. They may also confuse substances that are harmful with other substances. Locks in places that are not normally expected will make it more difficult for the client with a cognitive impairment to find and open. This is especially useful if the client wanders. The client may turn the stove on and be burned or cause a fire. If the knobs are removed, the home is safer for everyone. Fires are a hazard for people with cognitive impairment; therefore, the presence of a working fire extinguisher could prevent damage from a fire. 3. Incorrect: Respite is important; however, the client may not be safe alone. Clients may become confused and fearful if left alone.
Which interventions should the nurse include for a client with sickle cell crisis who is experiencing pain? 1. Apply cold compresses to affected joints. 2. Massage affected areas gently. 3. Support and elevate swollen joints. 4. Monitor pain level by looking for BP, respiratory, and heart rate elevation. 5. Administer acetacylic acid 325 mg every 4 hours in order to thin the blood.
2. & 3. Correct: Apply local massage gently to affected areas which helps reduce muscle tension. This helps to decrease swelling thus decreasing pain. 1. Incorrect: Apply warm, moist compresses to affected joints or other painful areas. Avoid use of ice or cold compresses. Rationale: Warmth causes vasodilation and increases circulation to hypoxic areas. Cold causes vasoconstriction and compounds the crisis. 4. Incorrect: Although pain can cause vital signs to elevate, it does not always occur. The nurse should assess pain with an objective scale such as having the client rate the pain on a scale of 1-10. Remember that pain is what the client says it is. 5. Incorrect: Acetacylic acid should be avoided because it alters blood pH and can make cells sickle more easily.
Who often performs the responsibilities of a case manager? 1. Physical therapist 2. Social worker 3. Primary healthcare provider 4. Nurse 5. Unlicensed assistive personnel
2. & 4. Correct: A client's case manager can be a nurse, social worker, or other appropriate professional. 1. Incorrect: The physical therapist focuses on one area and would not be the client's case manager. 3. Incorrect: The primary healthcare provider generally does not assume the role of the client's case manager. 5. Incorrect: The unlicensed assistive personnel does not have the education and/or training for case manager.
How might a personal tendency toward stereotyping and countertransference responses effect the nurse's ability to complete a client's cultural assessment? 1. Facilitate the treatment process 2. Fail to recognize unmet needs of the individual client 3. Be open and honest while responding to the client's concerns 4. Anticipate the unmet needs of the individual client.
2. Correct: Both stereotyping and countertransference will decrease the nurse's sensitivity to the client's needs and the culture they represent. 1. Incorrect: Both stereotyping and countertransference also interfere with the treatment process. 3. Incorrect: The nurse will make automatic responses based on preconceived ideas and expectations. The nurse is unable to be open and honest about client concerns. 4. Incorrect: The nurse's need to maintain an unbiased care is important because the client's needs remain unmet.
The nurse is instructing a client in the use of cane. Which is the best description of correct cane technique? 1. Place the cane on weaker side of body to support weaker leg. Using the cane for support, step forward with good leg, and then move weaker leg and cane forward to the good leg. 2. Place the cane on stronger side of body. Place cane forward 6 to 10 inches while client stands with body weight divided between two legs. Weaker leg is advanced to cane, with body weight divided between good leg and the cane. 3. Place cane on weaker side of body. Cane is placed forward 6 to 10 inches while client stands with body weight divided between two legs. Weaker leg is advanced to cane, with the body weight divided between good leg and cane. 4. Place cane on stronger side of body to help support weaker leg. Using cane for support, step forward with good leg and then move weaker leg and cane forward to good leg.
2. Correct: Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client stands with the body weight divided between the two legs. The weaker leg is then advanced to the cane, with the body weight divided between the good leg and the cane. Finally the stronger leg is advanced past the cane and the weaker leg, with the body weight divided between the cane and the weaker leg. 1. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the good leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 3. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the good leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 4. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the good leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling.
The nurse is caring for a client who receives hemodialysis three times a week. What dietary education should the nurse provide for this client? 1. Increase protein intake 2. Restrict fluids 3. Decrease sodium 4. Increase phosphorus 5. Decrease potassium
2., 3., & 5. Correct: The client will get dialyzed every other day so restrict fluid intake. Restrict sodium to decrease thirst and fluid excess. Restrict potassium to decrease the risk of heart arrhythmias associated with hyperkalemia. 1. Incorrect: Normal protein needed, not extra. 4. Incorrect: Low phosphorus foods are needed because phosphorous foods are high in protein.
The nurse is caring for a client with a long history of emphysema. Which clinical signs/symptoms, if noted by the nurse, would support a history of emphysema? 1. Atelectasis 2. Increased AP diameter 3. Breathlessness 4. Use of accessory muscles with respiration. 5. Leans backwards to breathe. 6. Clubbing of fingernails
2., 3., 4., & 6. Correct: Emphysema is described as a permanent hyperinflation of lung beyond the bronchioles with destruction of alveolar walls. Airway resistance is increased, especially on expiration. Inspection reveals dyspnea on exertion, barrel chest, tachypnea, and use of accessory muscles with respiration. Clubbing of fingernails is due to decreased oxygen levels. 1. Incorrect: Atelectasis is collapse of alveolar lung tissue, and findings reflect presence of a small, airless lung. This condition is caused by complete obstruction of a draining bronchus by a tumor, thick secretions, or an aspirated foreign body, or by compression of lung. 5. Incorrect: Client tends to lean forward and uses accessory muscles of respiration to breathe.
Which lab value on a client who is one day postpartum should the nurse report to the primary healthcare provider immediately? 1. Hemoglobin of 11 g/dL (110 g/L) (6.8266 mmol/L) 2. White Blood Cell count of 22,000 mm3 3. Hematocrit of 18% 4. Serum glucose of 80 mg/dL (4.44 mmol/L)
3. Correct: A hematocrit in postpartum women can drop as low as 20% (0.2) and not require transfusion in the absence of symptoms of hypovolemia. A hematocrit of 18% and lower should be reported even in the absence of dizziness, lightheadedness, shortness of breath with exertion, and syncope. 1. Incorrect: A hemoglobin of 11 g/dl (110 g/L) (6.8266 mmol/L) is considered to be normal for pregnancy and postpartum. 2. Incorrect: It is not unusual for a postpartum woman to have a WBC up to 25,000 mm3 without infection because of the healing process of the reproductive system. 4. Incorrect: Serum glucose of 80 m/dL (4.44 mmol/L) is within the normal range of glycemic control.
A client calls the clinic to ask the nurse if it would be okay to take the herbal medication kava-kava to help reduce anxiety. What is the nurse's best response? 1. "Why do you want to take kava-kava?" 2. "I really doubt your primary healthcare provider will approve your taking kava-kava." 3. "Kava-kava can cause liver damage, so we need to consult your healthcare provider." 4. "Do not take Kava-kava for more than a year without a primary healthcare providers supervision."
3. Correct: Kava-kava can cause liver damage. 1. Incorrect: The client has already answered that: anxiety. This question will put the client on the defensive. 2. Incorrect: Judgmental response. Will put the client on the defensive. 4. Incorrect: You should not take this drug for longer than 3 months without a primary healthcare provider's supervision. There have been recent reports of liver damage have occurred.
Exhibit: 0900: Client received to post-anesthesia unit after hysterectomy. Easily aroused. BP 128/72, respirations 18, heart rate 90, skin warm and dry. 1100: Lethargic, Vital signs are BP 100/68, respirations 24, heart rate 102, skin cool and moist. The nurse is caring for a client post hysterectomy. Based on data obtained from the nurse's notes, what should be the nurse's initial response? 1. Retake the vital signs. 2. Administer the ordered dopamine to maintain a blood pressure of 110 systolic. 3. Increase the IV rate of the lactated ringer's solution. 4. Raise the head of the bed to 30 degrees.
3. Correct: The client is exhibiting signs of hypovolemic shock and needs fluid. 1. Incorrect: This delays treatment. The client is going into hypovolemic shock. 2. Incorrect: Dopamine will not help a client in hypovolemic shock. This client needs fluid. 4. Incorrect: Elevating head of bed would not increase B/P.
A psychotic client tells another client, "You are so adorabogalishus." Which form of thought process should the nurse document this client as having? 1. Magical thinking 2. Tangentiality 3. Neologism 4. Perseveration
3. Correct: The psychotic person invents new words, or neologisms, that are meaningless to others but have symbolic meaning to the psychotic person. 1. Incorrect: With magical thinking, the person believes that his or her thoughts or behaviors have control over specific situations or people. 2. Incorrect: With tangentiality, the person never really gets to the point of the communication. Unrelated topics are introduced, and the original discussion is lost. 4. Incorrect: The person who exhibits perseveration persistently repeats the same word or idea in response to different questions.
Which action should the nurse recommend to parents so that their home will be safer for a toddler? 1. Place the child in the center of an adult size bed when napping. 2. Buckle the child into the high chair if parents leave the room during a meal. 3. Anchor top-heavy furniture or fish tanks so that they cannot be pulled over. 4. Allow the toddler to explore stairs in the home if supervised.
3. Correct: Top-heavy furniture, TVs and fish tanks can be pulled over by the toddler, especially if the child is trying to reach something on top of them. 1. Incorrect: The safest place for the toddler to nap or sleep is in a crib. The toddler may easily fall from an adult size bed. 2. Incorrect: The toddler should never be left unsupervised in a high-chair. It can tip if the child tries to climb out, or the child may push against something resulting in a fall. 4. Incorrect: Stairs in the home present a risk for falls and accidents for the toddler. Safety gates should be in place, and the adults should hold the toddler's hand when navigating the stairs.
The nurse is caring for a client immediately following a bilateral salpingo-oophorectomy? Which position would be best for this client? 1. Fowlers 2. Modified sims 3. Side lying 4. Supine
3. Correct: We want to position for comfort with the knees flexed and on the side for airway. 1. Incorrect: Avoided to prevent pooling and edema in pelvis 2. Incorrect: Partial lying on stomach is going to be painful 4. Incorrect: Stretching out straight puts pressure on the abdomen and should be avoided
What independent nursing interventions should the nurse include when planning care for a client who is in a fluid volume excess? 1. Monitor CVP 2. Administer diuretic 3. Monitor for orthopnea 4. Raise HOB to 45 degrees 5. Elevate edematous extremities
3., 4. & 5. Correct: These are independent nursing actions that will increase venous return and decrease edema. Also the nurse should assess for crackles, changes in respiratory pattern, SOB, orthopnea. 1. Incorrect: This is a collaborative intervention. 2. Incorrect: This is a collaborative intervention.
The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? 1. You wouldn't understand what it is for. Just roll over so I can give you the shot. 2. This drug will prevent you from having a seizure. 3. This medication will relax your muscles so that you do not break a bone. 4. Glycopyrrolate will decrease secretions and could slow your heart rate.
4. Correct: Glycopyrrolate reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration. 1. Incorrect: The client has a right to be told the reason the drug is given. 2. Incorrect: This is not the drug's purpose. The ECT will induce a seizure, which is the desire. 3. Incorrect: This is not the drug's purpose.
A client has been on the nursing unit for two hours following a retropubic prostatectomy for the treatment of prostate cancer. The client is receiving a continuous bladder irrigation of normal saline infusing at 1000 mL/hr. The client's urine output for the past two hours is 410 mL. What is the nurse's first action? 1. Inspect the catheter tubing for kinks. 2. Irrigate the catheter with a large piston syringe. 3. Notify the primary healthcare provider. 4. Stop the irrigation flow.
4. Correct: The catheter output should be at least the volume of irrigation input plus the client's actual urine. A severe decrease in output indicates obstruction in the drainage system. The first action is to stop the irrigation flow to prevent further bladder distention. Bladder distention is one of the main causes of hemorrhage in the fresh post op period. 1. Incorrect: The next action is to check the external system for kinks or obstruction. 2. Incorrect: After the external system is checked for kinks or obstruction, and the client's urine output doesn't change, then the catheter is irrigated with 30 to 50 mL of normal saline using a large piston syringe. 3. Incorrect: Of the options listed here, this is the last intervention. If the obstruction is not resolved after irrigating the system, the primary healthcare provider must be notified.
The nurse is caring for a client in the emergency department. In what order would a nurse correctly administer an intravenous push (IVP) medication through a continuous IV infusion of normal saline? Cleanse port with alcohol and administer saline flush. Stop the infusion pump. Assess the IV site for the presence of inflammation or infiltration. Cleanse the port closest to the IV insertion site with alcohol wipes for 15 seconds. Check medication label with healthcare provider's prescription. Administer medication while assessing IV site. Draw up ordered dose of medication aseptically.
First, check medication label with healthcare provider's prescription. Second, Assess the IV site for the presence of inflammation or infiltration. Third, Draw up ordered dose of medication aseptically. Fourth, stop the infusion pump. Fifth, Cleanse the port closest to the IV insertion site with alcohol wipes for 15 seconds. Sixth, Administer medication while assessing IV site. Seventh, Cleanse port with alcohol and administer saline flush.
The nurse is caring for a client that is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery the mother asks to see the infant. What is the nurse's best response? 1. Bring the swaddled fetus to the mother. 2. Explain that the cause of death must be determined before she can see the baby. 3. Ask her if she is sure she wants to see the baby. 4. Tell her it would be better to wait until she is in her room before she sees the baby.
1. Correct: Let the grieving mother see the infant to continue the grieving process. 2. Incorrect: This is an untrue statement, and the cause of death may never be determined. 3. Incorrect: The client is distraught and the nurse should not make her doubt herself. 4. Incorrect: This is non-therapeutic and delays the mothers request. This response may also cause additional fear and anxiety.
The nurse is caring for a client of Puerto Rican descent. The client has several injuries from a car accident and is experiencing pain. Which behavior is likely to be noted upon assessment? 1. Loud crying with pain. 2. Enduring the pain in order to bring honor. 3. Quiet and stoic responses to pain. 4. Refusing pain medication because it is God's will.
1. Correct: Puerto Rican clients tend to cope with pain by loud and outspoken reports of pain. 2. Incorrect: Quietly enduring pain is consistent with the Japanese culture. 3. Incorrect: Stoic responses are consistent with Asian culture. The client is likely to be quiet about the pain thinking that complaints of pain will bring dishonor to the family. 4. Incorrect: Filipino clients tend to view pain as God's will and may refuse medication to relieve the pain.
The nurse is assigned to triage a client presenting to the emergency department who is suspected to have exposure to inhaled anthrax. What assessment findings are expected? 1. Abrupt onset of dyspnea, fever. 2. Small papule on skin resembling an insect bite. 3. Pustular vesicles on skin. 4. Fatigue.
1. Correct: Inhalation of anthrax spores is very serious and clients will experience abrupt dyspnea and fever. Treatment must begin immediately. 2. Incorrect: Cutaneous anthrax manifests itself as papules resembling an insect bite that progresses to depressed black ulcers. 3. Incorrect: Pustular vesicles are consistent with smallpox. 4. Incorrect: Fatigue is a vague symptom that is usually not associated with inhaled anthrax.
The client is worried and distracted, and explains to the nurse that because of the direct admission from the primary healthcare provider's office there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client? 1. An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here so that you can contact your family and friends. 2. I know how you feel. I will be sure to tell your night nurse in shift report that you will probably need something to help you sleep tonight. 3. An unexpected hospital admission can be very stressful. Is there anyone who I can call for you? 4. I can call your primary healthcare provider for you and ask if you could go home today, then schedule another date for your hospital admission.
1. Correct: The case manager should be involved in coordinating the client's care from the date of admission in order to help the client navigate unexpected situations like a last-minute hospital admission. The ability to make telephone calls to notify family and friends will help to decrease the client's sudden sense of isolation from normal daily life, loss of control, and anxiety. 2. Incorrect: Although sleeping medication may be warranted for this client, the nurse neglects to offer a viable solution to the client's problem. 3. Incorrect: Although this is a helpful response, this answer does not include notifying the case manager. 4. Incorrect: Calling the primary healthcare provider is inappropriate, as the client requires hospitalization due to the swift nature of the admission.
In caring for a client exposed to radiation, the nurse knows that the type of damage due to radiation exposure depends on which factors? 1. Dose rate. 2. Organs exposed. 3. The technician. 4. Time of day. 5. Type of radiation.
1., 2. & 5. Correct: The extent of damage due to radiation exposure depends on the quantity of radiation delivered to the body, the dose rate, the organs exposed, the type of radiation, the duration of exposure, and the energy transfer from the radioactive wave or particle to the exposed tissue. 3. & 4. Incorrect: The technician and time of day have no bearing on the type of damage due to radiation exposure.
The charge nurse on the pediatric unit is reviewing the protocol for blood administration with a staff nurse. Which actions by the staff nurse indicate understanding of blood administration? 1. The blood infusion time was within 4 hours. 2. A filter was used when administering the blood. 3. A second nurse checked the blood compatibility. 4. A set of vital signs were taken 5 minutes after the blood infusion started. 5. Two forms of client identification were obtained prior to infusion.
1., 2., 3., 4., & 5. Correct: Blood should hang for no longer than 4 hours because it increases the chances of a reaction. Filters are used when infusing blood. Two nurses must check the blood product label and blood group. Vital signs are checked frequently during a blood transfusion. For example: A baseline set of vital signs are taken, then 5 minutes after the initiation of the transfusion, then 15 minutes after transfusion started and every 15 minutes for one hour, then every 30 minutes for one hour, then hourly until infusion complete. At least two methods of proper identification should be obtained, such as asking client his/her name and checking ID band.
A school nurse is planning a lesson on inhalant abuse for a high school health class. Which information does the nurse need to include? 1. Substances used for inhaling include lighter fluid, spray paint, and airplane glue. 2. Inhalants are absorbed through the lungs and cause central nervous system depression rapidly. 3. Although inhaling can make a person very ill, death is highly unlikely. 4. Inhaling substances can cause abdominal pain, lethargy, and renal failure. 5. Inhalants cause the heart to beat slowly.
1., 2., 4. Correct: All of these statements are correct. 3. Incorrect: Death can occur from respiratory depression or cardiac arrest. 5. Incorrect: Inhalants force the heart to beat rapidly and erratically, leading to cardiac arrest.
A nurse is teaching a group of small farm owners how to prevent pesticide exposure for field workers. What points should the nurse include? 1. Importance of hand washing before eating. 2. Wearing protective clothing while working in the field and at home. 3. Removing clothing and shoes worn in the field before entering the home. 4. Washing fruit and vegetables prior to eating. 5. Boiling all vegetables for a minimum of 5 minutes prior to eating.
1., 3. & 4. Correct: All points are important to include. 2. Incorrect: Yes, wear protective clothing while working in the field but is not necessary to wear protective clothing at home. 5. Incorrect; No, it is not necessary to boil or cook vegetables to remove chemicals from fresh produce
To reduce the risk of developing a complication following balloon angioplasty, the nurse should implement which measure? 1. Monitor cardiac rhythm 2. Assess the puncture site every 8 hours 3. Measure urinary output hourly 4. Prevent flexion of the affected leg 5. Avoid lifting buttocks off the bed
1., 3., 4., & 5. Correct: Notify HCP of rhythm change or chest discomfort. Could be sign of re-occlusion. Decreased UOP could be due to poor renal perfusion, which can result from shock. Frequent VS and UOP needed. Prevent flexion to let the clot stabilize for a while. Increased pressure to puncture wound can cause a hematoma and can cause flexion. 2. Incorrect: Assessments are needed more frequently than every 8 hours.
The nurse is caring for a client on the medical unit. The primary healthcare provider prescribed Lactulose 30 gram orally once a day. Available is Lactulose labeled 10 g per 15 mL. How many mL will the nurse administer? Round your answer to the nearest whole number.
10 g : 15 mL = 30 g : x mL 10 x = 450 x = 45
A client requires assistance to ambulate and needs to use the bathroom. The call light has been left out of reach, rendering the client unable to summon staff for assistance. Which client right is violated? 1. Participate in the plan of care and treatment decisions 2. Freedom from unreasonable restraint 3. Privacy 4. Considerate and respectful care
2. Correct: A client requiring assistance for any activity of daily living needs access to call for assistance from the healthcare staff. Denial of access to care by removal of access devices is unreasonable restraint. 1. Incorrect: The right to participate in the plan of care is not violated in this scenario. 3. Incorrect: The right to privacy is not violated in this scenario. 4. Incorrect: The right to considerate and respectful care is an important element of client care, but is not the client right in this scenario.
The nurse in the outpatient clinic performs an assessment on a client who takes propanolol for management of palpitations associated with mitral valve prolapse. Which statement by the client should be reported immediately to the primary healthcare provider? 1. "My resting pulse was 60 this morning." 2. "I feel a little short of breath when walking." 3. "I have lost 5 pounds in the last 2 weeks." 4. "My blood pressure was lower this visit than last time."
2. Correct: Propranolol is a non selective beta blocker so it blocks sites in the heart and in the lungs. The shortness of breath could be result of the adverse reactions of bronchospams or heart failure. This statement requires immediate investigation by the primary healthcare provider. 1. Incorrect: 60 is a good resting pulse. 3. Incorrect: 5 pounds in 2 weeks is an acceptable weight loss. 4. Incorrect: Decreased BP is an expected finding. If the client is asymptomatic, decreased BP is no big deal.
A nurse wants to find a better way to perform oral care on unresponsive clients. What is the first action for the nurse to take in order to achieve this goal? 1. Try different methods of oral care on unresponsive clients to see what works best. 2. Discuss the issue with the leader of the "best practices" committee. 3. Read all the current literature related to oral care on unresponsive clients. 4. Ask the primary healthcare provider to suggest the best oral care procedure.
2. Correct: The best thing for the nurse to do is to identify a problem, as this is the person directly caring for clients. Then, get with an experienced person who can research "best practice" regarding the issue. 1. Incorrect: This is doing research, which requires the research process be implemented. 3. Incorrect: This will take a lot of time and is best initiated from the "Best Practice" committee. The nurse could definitely be part of the committee. But the Evidence-based care leaders are trained to help nurses through the proper process of Evidence Based research. 4. Incorrect: This is a nursing responsibility.
The nurse is caring for a client who is receiving a prostaglandin agonist for the treatment of glaucoma. Which comment by the client indicates a lack of understanding of the treatment regimen? 1. I must only use the drops in the eye with the increased pressure. 2. My eyes may be different colors, so I will use the drops in both eyes. 3. I must be careful not to overmedicate even if it is just an eye drop. 4. The eyelashes in the eye with the higher pressure may get longer.
2. Correct: The color of the iris may darken in the eye being treated; however, it is important that the client understand that drops should not be placed in the unaffected eye. To do so may result in a subnormal intraocular pressure. 1. Incorrect: This comment shows adequate understanding. The client should only treat the eye with the increased pressure. 3. Incorrect: This comment demonstrates that the client does understand the treatment regimen. 4. Incorrect: This comment shows understanding. The lashes in the eye being treated will lengthen as opposed to the untreated eye.
A nurse is caring for a client in an outpatient clinic. The client lost her husband of 51 years three months ago. Which findings support that the client is experiencing normal grief reactions rather than clinical depression? 1. The client is experiencing Anhedonia. 2. The client states, "I have good and bad days." 3. The client smiles at the nurse while talking about her grandchild. 4. The client has a persistent state of dysphoria. 5. The client states, "I am having fewer crying spells."
2., 3. & 5. Correct: A client going through a normal grieving process will experience a mixture of good and bad days. The client is able to experience moments of pleasure and cries less. 1. Incorrect: Anhedonia is the inability to experience pleasure seen in clinical depression. 4. Incorrect: Dysphoria is a mood of general dissatisfaction, restlessness, depression, and anxiety. This is often seen in clinical depression.
A client is hospitalized for chronic renal failure. The nurse will need to notify the primary healthcare provider concerning which findings? 1. Sodium 135 mEq/L 2. Potassium 5.8 mEq/L 3. BP 100/70 4. No weight loss 5. Ionized Calcium 4.0 mg/dL
2., 5. Correct: Normal K 3.5-5.0 mEq/L; Normal ionized serum Ca 4.5-5.5 mg/dL. The abnormal lab results need to be reported. 1. Incorrect: Normal sodium 135-145 mEq/L. 3. Incorrect: Hypertension is a potential complication of chronic renal failure. 4. Incorrect: Desired outcome: client exhibits no rapid increases or decreases in weight.
A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse do first? 1. Instruct the child to extend the affected knee 2. Perform range of motion exercise on both knees 3. Compare the appearance of the left knee to the right knee 4. Have the child soak the affected knee in warm water
3. Correct: Comparing the appearance of the left knee to the right knee is the least invasive assessment and allows the nurse to assess if there is a change in the appearance of the affected knee to the unaffected knee. 1. Incorrect: Extending the affected knee may cause further damage. 2. Incorrect: Range of motion exercises may cause further damage to the affected knee. 4. Incorrect: Soaking the affected knee in warm water will not help the nurse assess whether or not an injury occurred.
What is most important for the nurse to teach a client who delivered healthy twin infants about proper feeding? 1. Feed one infant while propping the bottle for the other infant to minimize feeding time, thus allowing the client more time to rest. 2. Add cereal to the nighttime bottle so the infants will sleep longer. 3. Feed each infant individually rather than simultaneously. 4. Warm bottles in the microwave and have more time to bond with the infant.
3. Correct: Each infant should receive individual attention to enhance parent-child bonding , ensure adequate intake, and prevent complications associated with the bottle propping. 1. Incorrect: Does not allow for individual attention and may lead to complications associated with the bottle propping. 2. Incorrect: Cereal in the bottle is not recommended by the American Academy of Pediatrics. 4. Incorrect: Formula can easily be overheated in the microwave leading to injury of the infant.
Two days after a myocardial infarction, a client begins reporting orthopnea and dyspnea. Further assessment reveals bi-basilar crackles, jugular venous distension, an S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90 beats per minute. The urine output has steadily declined over the past 12 hours. What should the nurse do first? 1. Notify the primary healthcare provider. 2. Increase the IV rate. 3. Elevate the head of the bed. 4. Observe for cardiac arrhythmias.
3. Correct: Elevate the head of the bed first. The client is complaining they cannot breathe. (Orthopnea means the client needs to sit up to breathe better.) With ANY client having difficulty breathing, the first intervention for the nurse is to sit the client up. This client is showing s/s of heart failure. 1. Incorrect: Your next step is to call the primary healthcare provider. 2. Incorrect: Increasing the IV rate is contraindicated and would make the problem worse. 4. Incorrect: After an MI, all clients are observed for cardiac arrhythmias. This, however, does not fix the problem.
At a health fair, a nurse encourages an older adult male to be screened for prostate cancer. The client is apprehensive and asks the nurse about the methods used to detect prostate cancer.What should the nurse tell the client about the detection process? 1. Abdominal x-ray to detect lesions and masses. 2. Serum calcium test to detect elevated levels, which may indicate bone metastasis. 3. Digital rectal exam (DRE) and prostate-specific antigen (PSA) test to evaluate the prostate. 4. Magnetic resonance image (MRI) study to detect tumors and other abnormal growths.
3. Correct: Prostate cancer is the second most common type of cancer and the second leading cause of cancer death in men. Early detection improves outcome. DRE and PSA should be offered annually beginning at age 50 to men who have a life expectancy of at least 10 years and at age 45 in high-risk groups. The DRE estimates the size, symmetry, and consistency of the prostate gland while the PSA measures for elevated levels consistent with prostatic pathology, although not necessarily cancer. Declining PSA levels are useful in determining efficacy of treatment for prostate cancer. 1. Incorrect: Radiologic studies are not screening tools for this disease. 2. Incorrect: Hypercalcemia may indicate cancerous bone involvement, but its not a screening tool. 4. Incorrect: MRI is a diagnostic tool, not a screening tool.
A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. EGD, colonoscopy, gallbladder ultrasound and lab results have revealed no physical reason for the complaints. The client tells the nurse, "the pain is so bad some times that I can't function!" What disorder is this client likely experiencing? 1. Conversion disorder 2. Pseudocyesis 3. Somatization disorder 4. Dysmorphic disorder
3. Correct: Somatization disorder is a syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and long-term seeking of assistance from healthcare professionals. Symptoms are vague, dramatized, or exaggerated in presentation. 1. Incorrect: Conversion disorder is a loss of or change in body function resulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder. This disorder affects voluntary motor or sensory functioning suggestive of a neurological disease. 2. Incorrect: Pseudocyesis is false pregnancy that may represent a strong desire to be pregnant. 4. Incorrect: Dysmorphic disorder is characterized by the exaggerated belief that the body is deformed or defective in some way. Most common complaints are slight flaws of face or head, such as thinning hair, acne, wrinkles.
A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM). The newborn weighs 6 pounds (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What should the nurse do? 1. Administer the drug intravenously (IV) since a large volume is required. 2. Choose three injection sites and give the medication as prescribed. 3. Consult with the pharmacy for a different medication concentration. 4. Read the available drug information to determine how to administer the medication.
3. Correct: The nurse must consult with the pharmacy to receive further instructions. The dose is greater than the allowed volume to be given IM, which warrants clarification by the pharmacy. 1. Incorrect: Since the drug is prescribed IM, the route should not be changed to IV administration because this violates the order as written. 2. Incorrect: The dose is greater than the allowed volume to be given IM, which warrants clarification by the pharmacy. You want to avoid having to give three injections. 4. Incorrect: The concern is not drug information on administration, it is the available concentration which can only be provided by the pharmacy.
During a conversation with a client on a psychiatric unit the client tells the nurse, "Everyone here hates me." Which response by the nurse is best? 1. No, they do not hate you. 2. What did you do to make others not like you? 3. Just don't pay attention to what others think of you. 4. I can't speak for the other people, but I don't hate you.
4. Correct: Here the nurse is speaking only for the nurse. The nurse cannot legitimately speak for anyone else. The nurse must model the process of not speaking for anyone else. 1. Incorrect: This is defending which is a non-therapeutic communication technique. The nurse does not know how the others on the unit feel about the client. This may not be a true statement. 2. Incorrect: This is agreeing with the client and putting the client on the defense by implying that the client is at fault. 3. Incorrect: This is using denial. This is where the nurse denies that a problem exists and blocks the discussion with the client and avoids helping the client identify and explore the problem.
A client who has chronic renal failure has been prescribed synthetic erythropoietin for the prevention of anemia. Which assessment findings should be reported to the primary healthcare provider? 1. Hemoglobin level of 10 g/dl (1.6 mmol/L) 2. Blood pressure of 120/84 3. Constipation 4. Swelling of feet and ankles
4. Correct: Swelling of feet and ankles may indicate the beginning of a cardiovascular problem. Clients taking this drug are at risk for myocardial infarctions. 1. Incorrect: The purpose of this drug is to increase hemoglobin levels. A level of 10g/dL (1.6 mmol/L) would be considered favorable. If above 12 g/dl (1.9 mmol/l), the level should be reported. 2. Incorrect: An elevated blood pressure should be reported. This value is within normal limits. 3. Incorrect: Constipation may be caused by iron preparations. Increasing fiber in the diet may improve that symptom.
The nursing supervisor notified the charge nurse on a pediatric unit that a child with a history of developmental delays is being admitted with shingles. The nurses on the floor have the following assignments. It would be inappropriate for the charge nurse to assign the new admit to which nurse? 1. A nurse caring for clients with nephritis, irritable bowel syndrome, and appendectomy. 2. A new nurse just out of orientation caring for clients diagnosed with RSV, asthma and anorexia nervosa. 3. A nurse caring for clients diagnosed with spina bifida, Hirschsprung's Disease, and irritable bowel syndrome. 4. A pregnant nurse caring for clients with cystic fibrosis, myelomeningocele, and rheumatoid arthritis.
4. Correct: The information does not let you know if any of the nurses have had chickenpox or not. If a nurse has not had chickenpox, then they should not care for the client with shingles. The varicella zoster virus is responsible for chickenpox and shingles. The virus is lying dormant in the nerve ganglia and under certain conditions erupts (for example: stress). With the information you have it would be best not to assign the new admit to the nurse who is pregnant. The other set of nurses and clients have no contraindications to taking care of the client with shingles. 1. Incorrect: This is appropriate assignment-the nurse can care for a client with shingles. 2. Incorrect: This is appropriate assignment-the nurse can care for a client with shingles. 3. Incorrect: This is appropriate assignment-the nurse can care for a client with shingles.
