Reduction Risk
A client is admitted with a hip fracture after falling. Based on these lab values, what is the nurse's priority nursing intervention? 1. Provide foods high in iron 2. Increase fluid intake 3. Obtain a urine for culture 4. Measure intake and output
2. Correct: We already know that the question is about what life threatening complication? A pulmonary embolism. And these lab values say that the client is what? Dehydrated! So the only thing that is going to fix that is....... Increasing fluids.
Which assessment findings would the nurse expect to see in a client diagnosed with idiopathic thrombocytopenic purpura (ITP)? 1. Ecchymosis 2. Bleeding gums 3. Palpable spleen 4. Pain 5. Petechiae
1., 2., 3., & 5. Correct: The word thrombocytopenia means low platelets. Any client with low platelets is at risk for bleeding, which is indicated by ecchymosis (bruising), bleeding gums, and petechiae (red to purple dots on the skin, 1-3 mm in size). Spleen and liver are often slightly palpable.
Which immediate action should a nurse take if a client's chest tube is accidentally disconnected from the disposable water-seal system? 1. Have client hold breath 2. Administer oxygen 3. Place the tubing coming from the client into sterile water 4. Raise the head of the bed
3. Correct: The nurse should immediately place the tubing coming from the client into at least 2 cm of sterile water. A disconnected chest tube can allow air to travel into the client's chest cavity and create a life-threatening tension pneumothorax. By putting the end of the disconnected tube into sterile water, a water seal is recreated that will prevent air from entering but will still allow air to escape.
A client was admitted to the unit during the night shift with chronic hypertension. At 0830, the unlicensed assistive personnel (UAP) reports that the client's blood pressure is 198/94. What would be the best action for the charge nurse to delegate at this time? 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm. 3. Have the staff RN recheck the BP. 4. Ask the LPN to recheck the client's BP.
3. Correct: The staff RN will recheck the BP and see what medications may be prescribed for hypertension
The nurse is reviewing sequential lab results on a newly admitted client with multiple health issues. Critical changes in which body system require the nurse to immediately notify the primary healthcare provider? 1. Renal 2. Endocrine 3. Pulmonary 4. Cardiovascular
1. Correct: All lab values are fluctuating, but those most significantly outside of normal range are the BUN and Creatinine levels, reflecting possible renal failure. The nurse would need to immediately notify the primary healthcare provider of possible complications in the client's renal system. The sodium, potassium, and glucose are within normal limits.
A female client has been ordered a radioactive iodine uptake test (RAIU) to evaluate for Graves' Disease (hyperthyroidism). What priority actions should the nurse complete before the test? 1. Insert IV to administer conscious sedation. 2. Remove all jewelry or metal before the test. 3. Obtain urine specimen to check for pregnancy. 4. Confirm client is NPO for two hours before the test. 5. Verify client stopped anti-thyroid meds for one week.
2, 3 & 5. Correct: A radioactive iodine uptake (RAIU) test is utilized to confirm or rule out hyperthyroidism and/or the presence of cancer in the thyroid. A scan of the thyroid is completed using a "gamma probe" on the exterior of the neck. Therefore, all metal or jewelry must be removed to prevent an irregular scan. Radioactive substances cannot be given to pregnant or breast-feeding females so a urine specimen must be obtained to verify possible pregnancy. If the client has been taking anti-thyroid medications, these drugs must be stopped one week prior to the test to prevent inaccurate results.
The nurse is planning care for the prevention of skin breakdown in a client diagnosed with a stroke. What intervention is important for the nurse to include? 1. Massage reddened skin areas located over bony prominences. 2. Place pillows under lower extremities to raise heels off the bed. 3. Position client on paralyzed side for one hour. 4. Apply emollients to dry skin. 5. Place a gel seat cushion on the wheelchair seat. 6. Shift client weight every two hours while sitting in a wheelchair.
2., 4., & 5. Correct: These interventions will decrease the risk of skin breakdown by eliminating sustained pressure to areas at greatest risk of breakdown. 1. Incorrect: Do not massage the damaged area because this may cause additional damage. 3. Incorrect: This is way too long. The client should only be on their paralyzed side for 30 minutes. 6. Incorrect: This is way too long. Skin breakdown can result within this period of time. The client's weight should be shifted within the wheelchair every 15-20 minutes.
A hospitalized client diagnosed with rheumatoid arthritis is receiving IV methylprednisolone every six hours. What is the best method for the nurse to provide client safety? 1. Place "fall precautions" sign above client's bed. 2. Change the intravenous site for steroids daily. 3. Restrict any visitors with visible illnesses. 4. Put client on full contact precautions.
3. CORRECT: Rheumatoid arthritis is an autoimmune disease that affects not only body joints but also organs of the body. Receiving methylprednisolone as treatment further suppresses the immune system, making the client even more at risk of infection. Restricting visitors with colds, respiratory problems and other infectious processes is the best method to protect the client.
Prior to removal of cataracts, the client is to receive eye drops in both eyes. The nurse knows what action takes priority? 1. Remove any exudate around eyes with warm water. 2. Instill exact number of drops into lower conjunctival sac. 3. Instruct client to look upward when drops are instilled. 4. Avoid dropping the medication directly on the cornea.
4. CORRECT: The most important safety consideration when instilling eye drops is to avoid dropping the medication directly onto the cornea. The extreme sensitivity of the cornea before, and after, eye surgery could cause serious eye problems if meds were dropped onto the cornea.
A client has been started on intravenous gentamicin for osteomyelitis. The nurse informs the client frequent blood work will be done to monitor the amount of medication in the body. The nurse knows what labs are a priority to check every three days for the client? 1. BUN and creatinine. 2. Liver function studies. 3. Hemoglobin and hematocrit. 4. Peak and trough levels.
4. Correct: Peak and trough levels help to determine the amount of medication in the body system at specific times. Gentamicin is a very potent antibiotic; therefore, it is crucial to keep track of blood levels of this medication. Too low a level of this drug would be ineffective against the bacteria while too high a level increases the potential for severe side effects or toxicity from this antibiotic.
he nurse suspects a client admitted with myasthenia gravis is going into a cholinergic crisis. Which signs and symptoms would validate the nurse's suspicions? 1. Abdominal cramping 2. Lethargy 3. Salivation 4. Hypertension 5. Lacrimation 6. Miosis
1., 2., 3., 5., & 6. Correct: The signs of cholinergic crisis include Diarrhea and abdominal cramping, Urination increased, Miosis (pinpoint pupils), Bradycardia, Emesis (nausea and vomiting), Lacrimation, Lethargy, Salivation. Remember this: DUMBELLS as a mnemonic to help you recall these signs and symptoms.
An OB/GYN unit has recently discovered an increase in staphylococcus infections among both clients and staff, even though all cleaning procedures have been verified and upgraded. The infection control nurse is attempting to locate the source of the infection. The nurse knows which situations would likely not contribute to this problem? 1. A client in isolation receiving meals on disposable trays and dishes. 2. A client awaiting induction with a bouquet of flowers in the room. 3. A housekeeper sharing cleaning supplies with nighttime personnel. 4. A nurse sharing samples of a new hand cream with staff and clients. 5. A client recovering from a hysterectomy with large number of visitors.
1, 2 & 3. Correct: Certain hospital policies are developed to help eliminate potential danger to the most vulnerable population of clients. Clients in isolation receive food on styrofoam trays with disposable containers and utensils. These items are placed into a biohazard container in the room for safe disposal. A client awaiting induction is permitted to have flowers unless otherwise instructed by the facility, doctor or unit. Cut flowers are usually safer than potted plants, which tend to carry bacteria. Sharing cleaning supplies among personnel does not present an infection hazard.
Two hours post chest tube insertion, the nurse notes 100 mL of dark bloody drainage in the collection chamber of the closed drainage unit (CDU). What action should the nurse take? 1. Document the findings. 2. Notify the primary healthcare provider. 3. Decrease the amount of suction. 4. Use a padded hemostat to clamp the chest tube.
1. Correct: A chest tube is inserted to remove air, blood, or exudate from the pleural space. So 100 mL of dark bloody drainage would not be unusual over the first two hours after insertion. Drainage may range from 100 to 300 mL/hr within the first 2 hours. Documentation is required and continued hourly follow-up.
Which interventions decrease risk of infection or damage to delicate tissue when the nurse is changing a wound dressing? 1. Warm cleansing solutions to body temperature. 2. Clean the wound when there is drainage present. 3. Use cotton balls to clean the suture site. 4. Use sterile gauze squares to dry the wound 5. Use sterile forceps when cleaning the wound.
1., 2. & 5. Correct: Using cleansing solutions at body temperature enhances the healing process by not lowering the temperature of the wound and enhancing circulation to the wound bed. Drainage should be removed so that it does not become infected because drainage and exudate can create an environment where bacteria can thrive. Sterile forceps should be used so that contaminated hands/gloves do not increase the risk of infection at the wound site.
The family of a bedfast 80 year old is providing care in the home. Which reports by the family indicate adequate understanding of interventions that will reduce the risk for skin breakdown? 1. I make sure that the sheets and the foam pad in the chair stay dry. 2. I will not encourage my parent to turn in the bed at night. 3. The perineal area should be kept dry and clean. 4. My parent eats 2 meals per day and drinks a supplement. 5. I may reposition my parent more than every 2 hours if their perception of pressure is intact.
1., 3., 4. & 5. Correct: Keeping moisture from the skin is important for reducing the risk of skin breakdown. Keeping the client dry after using a bedpan is important to maintain healthy skin. As long as the intake of food is adequate, no further action is needed with nutrition. The client who is aware of sensations of pressure on the body has less risk of skin breakdown than those that have lost sensation.
A client is to be discharged following a left modified-radical mastectomy. When reviewing ADL's to be completed at home, the nurse anticipates the client will experience the most difficulty doing what tasks? 1. Cooking a meal. 2. Shampooing hair. 3. Doing the laundry. 4. Vacuuming carpets. 5. Changing bed linens.
2, 3, & 5. CORRECT: The modified-radical mastectomy is a surgical approach to cancer in which the breast tissue, nipple, and axillary lymph nodes are removed but the chest muscles remain intact. Following surgery, individuals usually experience pain and stiffness when resuming normal daily activities, particularly tasks which require stretching the arm above the head. Shampooing or drying hair would be challenging, as would moving loads of heavy laundry between washer and dryer. Also difficult is changing bed sheets because it involves lifting and stretching across the bed. 1. INCORRECT: The process of cooking food can be modified in such a way the client would not need to extend the surgical arm above the head or in a painful position. 4. INCORRECT: Vacuuming carpet does not require lifting or reaching if the client uses an upright sweeper. This task should not present difficult challenges and can be completed with the non-surgical arm.
A toddler with a malfunctioning ventriculoperitoneal (VP) shunt has returned from surgery following new shunt placement. Which post-op assessment finding should the nurse report to the primary healthcare provider immediately? 1. Blood pressure of 90/45 with pulse of 100 2. Urinary output of 30 mL over two hours 3. Sleeping soundly and difficult to arouse 4. Respirations deep and shallow at 20/min
3. CORRECT: Though the toddler is recovering from anesthesia, the nurse should be able to arouse and awaken the client, even expecting some crying. Difficulty arousing this client is one sign of increased intracranial pressure and should be reported immediately.
A client admitted with a diagnosis of portosystemic encephalopathy secondary to Laennec's cirrhosis is scheduled for the insertion of a pigtail catheter. The family asks the nurse the purpose of the catheter. What should the nurse tell the family? 1. Obtains an hourly assessment of urinary output. 2. Instills antibiotics to decrease internal bacteria. 3. Drains excess fluid from the abdominal cavity. 4. Obtains liver tissue for a diagnostic biopsy.
3. Correct: A pigtail catheter, sometimes referred to as a pigtail drain, is inserted for the purpose of either draining fluids from, or introducing fluids into, the body. In this case, the pigtail catheter will be inserted into the abdominal cavity in order to drain the ascites. This type of catheter is often used when the healthcare provider expects to remove abdominal fluid more than one time because the curved tip at the end of this catheter helps it remain secure wherever placed.
The nurse is monitoring the healing of a full-thickness wound to a client's right thigh. The wound has a small amount of blood during the wet to dry dressing change. What action should the nurse initiate next? 1. Notify the primary healthcare provider. 2. Obtain wound culture. 3. Document the findings. 4. Remove dressing and leave open to air.
3. Correct: Look at the clues: full thickness wound, small amount of blood, wet to dry dressing. With a full thickness wound there is destruction of the epidermis, dermis, and subcutaneous tissues going down to the bone. So you would expect to see a small amount of blood or drainage wouldn't you? Yes. This is expected. Simply document this normal finding.
A full term infant is being assessed 12 hours after birth. The infant's respiratory rate is 50 and shallow, with periods of apnea. What action by the nurse takes priority? 1. Apply oxygen by mask at 1 liter. 2. Prepare for emergency intubation. 3. Continue monitoring every 15 minutes. 4. Notify the primary healthcare provider stat.
3. Correct: Normal respirations in the healthy neonate are generally shallow and expected to be between 30 and 50 times per minute with short periods of apnea up to 5 seconds. This infant is displaying a normal respiratory status for the newborn. The nurse should continue to monitor the infant.
A client with a history of angina has returned to the unit following a cardiac catherization. What nursing action has the highest priority? 1. Obtain vital signs every thirty minutes. 2. Assess pedal pulses every ten minutes. 3. Place the call bell within client's reach. 4. Keep affected extremity immobilized for 6 hours.
4. CORRECT: The greatest risk following a cardiac catherization is the potential for hemorrhage, most often from the insertion site. Therefore, the affected extremity must remain straight and immobilized for 4-6 hours after the procedure. 1. INCORRECT: The frequency of vital signs is determined by facility protocol, but generally vital signs are obtained every ten minutes for the first half hour, then every fifteen minutes for another half hour. While vital signs provide valuable information to compare to baseline, another action is more important. 2. INCORRECT: It is vital to assess pedal pulses in order to verify circulation following a catherization. The frequency is based on facility protocol. However, this action is not the highest priority. 3. INCORRECT: Because the client is on bed rest, it is crucial for the client to be able to summon staff when needed. Despite the importance of this action, there is an even more important action.
A client with chronic arterial occlusive disease has a bypass graft of the left femoral artery. Postoperatively, the client develops left leg pain and coolness in the left foot. What is the priority action by the nurse? 1. Elevate the leg. 2. Check distal pulses. 3. Increase the IV rate. 4. Notify the primary healthcare provider.
4. Correct: In this case, there is nothing on the list the nurse can do to fix the problem. The primary healthcare provider must be notified immediately. Anticipate that the client will be returning to surgery because these are symptoms of an arterial problem that needs to be addressed immediately.
Which client should the nurse assign to a room closest to the nurse's station? 1. A multigravida admitted with a new diagnosis of gestational diabetes 2. A primigravida admitted with a diagnosis of placenta previa 3. A primigravida admitted with a diagnosis of complete abortion 4. A pregestational diabetic admitted for glycemic control
2. Correct: A client with a diagnosis of placenta previa is at high risk for bleeding and must be monitored closely. Placenta previa is a complication of pregnancy in which the placenta is either partially or wholly inserted in the lower uterine wall and blocks the cervix. It is the leading cause of antepartum hemorrhage. Clients with this complication will have to have a C-section to prevent harm to the mother and fetus from bleeding.
The nurse is caring for a ventilator-dependent client assisted with positive expiratory end pressure (PEEP). The high-pressure alarm begins sounding. What actions should the nurse initiate? 1. Check to see if client is biting ET tube. 2. Examine tubing for presence of water. 3. Inspect for any loose connections. 4. Reduce the amount of PEEP used. 5. Assess client's need for suctioning.
, 2 and 5. CORRECT: The high-pressure alarm on a ventilator indicates the machine is pushing against excessive resistance while trying to deliver oxygen to the client. There are multiple potential causes for a high pressure alarm. The client could be fighting against the ventilator and thus biting down on the endotracheal tube. Another possible issue may be the water that accumulates in the vent tubing from condensation. Or the client may have excessive mucus in the airways that requires the nurse to suction lungs frequently. Any of these problems could initiate the high pressure alarm.
A client arrives by ambulance after being thrown from a horse. The client is pale, clammy and tachycardic with bruising over left upper abdominal quadrant. The nurse is aware what prescription by the primary healthcare provider takes priority? 1. Obtain blood for type and cross match. 2. Administer hydromorphone IV for pain. 3. Increase Lactated Ringers to 150 mL/hour. 4. Send client to radiology for stat CAT scan.
1. CORRECT: The signs and symptoms displayed by the client suggest a ruptured spleen and shock. The greatest concern in this situation is internal bleeding and possible emergency surgery. The client will need blood; therefore, the nurse should immediately obtain blood for type and cross match. 2. INCORRECT: There is no indication in the scenario the client has pain. Pain medication should never be administered while the client is still being assessed or is in shock. 3. INCORRECT: Fluids are crucial for clients in shock and increasing the Lactated Ringers to 150 mL/hr. is important to help maintain blood pressure. However, this is not the nurse's priority action. 4. INCORRECT: A CAT scan is often prescribed prior to surgery to verify the extent of splenic injury and the amount of blood in the abdominal cavity. Though the order is written as 'stat', this is not the nurse's priority. Transporting an unstable client to another department requires preparation.
A primipara at 36 weeks gestation is seen in the OB/GYN clinic. Which sign/symptom should the nurse immediately report to the primary healthcare provider? 1. Puffy hands and face 2. Reports indigestion 3. Pedal edema 4. Trace proteinurea
1. Correct: Facial and upper extremity edema can be a sign of pre-eclampsia, which can endanger both the mother and fetus. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in a woman whose blood pressure had been normal. Even a slight rise in blood pressure may be a sign of preeclampsia. Left untreated, preeclampsia can lead to serious, even fatal, complications. Signs and symptoms of preeclampsia include hypertension and may include: Proteinuria; Severe headaches; Changes in vision; Upper abdominal pain; Nausea or vomiting; Decreased urine output; Thrombocytopenia; Impaired liver function; Shortness of breath; Sudden weight gain, and edema, particularly in face and hands.
Which finding indicates to the nurse that a client is at risk for skin breakdown? 1. Weakness requiring assistance to move in bed. 2. Daily intake of at least 85 percent of food offered. 3. Occasional forgetfulness. 4. Continent of bowel and bladder.
1. Correct: Immobility or weakness puts a client at risk for skin breakdown, particularly if combined with other indicators such as inadequate nutrition, confusion, incontinence, or limited sensory perception.
A client receiving 50 mL/hr of enteral feedings has a gastric residual volume of 200 mL and is reporting nausea. What is the appropriate nursing intervention? 1. Stop the feeding and assess gastric residual volume in 1 hour. 2. Reduce the infusion rate to 25 mL/ hour and reevaluate residual volume in 4 hours. 3. Change the feeding schedule from continuous to intermittent delivery. 4. Discard the 200 mL and continue the feedings at the same rate.
1. Correct: The safest response is to STOP the feedings and re-assess in 1 hour. Nausea may be a sign of intolerance. Continuing the feeding may also result in vomiting with possible aspiration.
Which food selections would need to be removed from the tray by the nurse for a client recovering from thyroidectomy? 1. Roasted almonds 2. Mashed vegetables 3. Scrambled eggs 4. Ice cream
1. Correct: Too hard and crunchy. Need soft diet because esophagus is right behind the thyroid and trachea. This would be difficult to swallow after surgery due to pain.
A client has been admitted to the unit with acute pyelonephritis. What interventions should the nurse include in this client's plan of care? 1. Observe for changes in mental status. 2. Assist client to restroom. 3. Monitor temperature every 4 hours. 4. Help the client get in a comfortable position to void. 5. Instruct client to void every 30 minutes while ill.
1., 2., 3., & 4. Correct: Changes in mental status may signify septic shock. Help clients to the restroom, use bedpans/urinals, and get in a comfortable position to facilitate urination. Pyelonephritis is a bacterial infection and fever is a clinical manifestation the nurse needs to monitor. 5. Incorrect: Instruct to void every 2-3 hours. This will prevent the buildup of urine in the bladder. Every 30 minutes is excessive.
What information about care of a plaster cast during the first 24 hours should the nurse provide to the client? 1. Keep the cast uncovered until it is completely dried. 2. Use the palms of your hands to position the cast for the first 24 hours. 3. Place an ice pack on top of the cast. 4. Elevate the extremity on a non-plastic pillow. 5. Do not do anything that would cause an indention on the cast.
1., 2., 4. & 5. Correct: The cast will be wet, so it should be left uncovered until completely dry so that moisture does not form between the cast and extremity (think skin breakdown). Using fingertips can cause small indentations, which again can lead to skin breakdown. Elevate extremity to decrease swelling. Avoid plastic as it can create moisture, which can cause skin breakdown. Anything that can indent the cast can cause skin breakdown. 3. Incorrect: We put ice packs on the sides of the cast, not the top.
A child has been diagnosed with varicella in the clinic. What should the nurse tell the parents about home treatment of the child? 1. Apply calamine lotion to affected areas several times a day. 2. Provide cool baths with baking soda. 3. Administer aspirin for fever. 4. Do not allow visitors who have never had varicella. 5. Keep fingernails trimmed short.
1., 2., 4., & 5. Correct: Calamine lotion and cool baths with baking soda will relieve itching. Anyone not vaccinated for chickenpox or who has never had chickenpox should not be exposed. Pregnant women and anyone with a weakened immune system (persons with HIV/AIDS, cancer, had a transplant, receiving chemotherapy, immunosuppressive medications, or long-term use of steroids) should avoid exposure. Keeping fingernails trimmed short may help prevent skin infections caused by scratching blisters. 3. Incorrect: Do not use aspirin or aspirin-containing products to relieve fever from chickenpox. The use of aspirin in children with chickenpox has been associated with Reye's syndrome, a severe disease that affects the liver and brain and can cause death. Instead, use non-aspirin medications, such as acetaminophen, to relieve fever from chickenpox. The American Academy of Pediatrics recommends avoiding treatment with ibuprofen if possible because it has been associated with life-threatening bacterial skin infections.
While preparing an IV in the med room, you observe a new nurse drawing up a dose of insulin in a tuberculin syringe. What is your priority action? 1. Report the incident immediately to the charge nurse. 2. Tell new nurse you will prepare and give the insulin dose. 3. Discuss procedure to prepare insulin with the new nurse. 4. Draw up insulin but let new nurse administer the injection.
3. Correct: This situation is dangerous since the new nurse obviously does not know the proper process or even the correct syringe with which to draw up insulin. This lack of knowledge could lead to serious or even fatal consequences for a client. It is vital the new nurse be properly instructed and then supervised on how to prepare insulin. Additional measures to ensure client safety can then be pursued.
What preferred lab value would the nurse expect to see the primary healthcare provider prescribe for a client admitted with generalized malnutrition? 1. Albumin 2. Prealbumin 3. Iron 4. Calcium
2. Correct: The preferred lab value to screen for generalized malnutrition is prealbumin. This assessment is preferred because it decreases more quickly when nutrition is not adequate. 1. Incorrect: Albumin is a major serum protein that is below normal in clients who have inadequate nutrition. However, it can take weeks to drop. 3. Incorrect: Low serum iron and anemia indicate an iron deficiency. Again, the prealbumin will decrease sooner than other lab values that assess nutrition level. 4. Incorrect: Older women may have low calcium levels which place them at risk for bone demineralization. But, prealbumin provides more data on generalized nutrition.
A client diagnosed with systemic lupus erythematosus (SLE) has been started on hydroxychloroquine sulfate to decrease joint pain and swelling. What statement by the client indicates to the nurse the medication teaching has been effective? 1. "I will be prone to infections while on this medication." 2. "I need to see my eye doctor at least once every year." 3. "I might develop a red rash on my nose and cheeks." 4. "I can stop this medicine after my symptoms are gone."
2. Correct: Hydroxychloroquine sulfate(Plaquenil) is in the category of DMARDs (disease modifying anti-rheumatic drug) and was originally developed to treat or prevent malaria. When taken once or twice daily, this medication reduces swelling and joint pain while also decreasing skin problems in Lupus clients. Though there are relatively few side effects, the most serious is retinal toxicity which requires treatment by an ophthalmologist. It is imperative for clients on this medication to have an eye examination every 6 to 12 months.
A nurse has been educating a client newly diagnosed with diabetes, about proper foot care. The nurse knows teaching will need to be reinforced again when the client makes what statement? 1. "I should cut my toenails with nail clippers." 2. "Drying both feet thoroughly is important." 3. "I should never use nail polish on my toes." 4. "Weekly foot inspection must include the soles of the feet." 5. "I need larger shoes that don't pinch my toes."
3, 4 and 5 CORRECT: The nurse is evaluating the client for an understanding of proper diabetic foot care; therefore, an incorrect statement would require further instruction. There is no reason a client with diabetes could not use nail polish on toenails. Inspection of both feet, including the soles of the feet, must be done daily and not weekly. Most importantly, properly fitted shoes are crucial to prevent complications that might result in a blister or eventually an amputation.
A client has just had a bone marrow biopsy. What is the nurse's priority intervention post procedure? 1. Apply ice pack to needle site. 2. Hold pressure on needle site for at least 5 minutes. 3. Observe needle insertion site every 2 hours. 4. Advise client to avoid activities that may result in trauma to the site for 48 hours.
2. Correct: When you see the word priority, you need to think: "What is the MOST important thing I can do for my client?" If you can only pick one answer, pick the life threatening answer or the answer that will decrease the risk for harm to the client. Here, that answer is hold pressure on the site to prevent bleeding.
A client is admitted to the emergency department after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? 1. Respiratory 2. Cardiac 3. Airway 4. Neurological
3. Correct: A fire in an enclosed area causes concern for carbon monoxide poisoning. In addition to the burns to the chest, there is the added potential for airway damage.
The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation? 1. Clots in urine 2. Bladder pressure 3. Clear urine 4. Bladder spasms
3. Correct: The irrigation is regulated so that the urine is free of clots and slightly pink tinged. When it becomes clear after surgery, the fluid is going too fast and not clearing any blood clots effectively. 1. Incorrect: The irrigation should be increased if you see clots in order to keep the catheter patent. 2. Incorrect: Bladder pressure may mean that the indwelling urinary catheter is obstructed. Either increase flow or manually irrigate catheter to ensure patency and no retention of fluid in the bladder. 4. Incorrect: Bladder spasms occur with clots so you do not want to slow the irrigation if this happens. This would indicate the need for increasing the irrigation fluid rate.
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. Increasing the IV rate of an isotonic solution will help to increase the blood pressure.
The nurse is assessing a client admitted yesterday with a diagnosis of closed head injury and fractured pelvis following a motorcycle accident. Today the nurse observes a small petechial rash on the client's chest. What specific indications of a serious complication should the nurse report immediately to the healthcare provider? 1. An increased blood pressure with tachycardia. 2. A widening pulse pressure with increasing pulse. 3. A petechial rash with an increase in temperature. 4. A rapid respiratory rate with dropping oxygen levels.
3. Correct: The client is experiencing an increase in the systolic blood pressure along with tachycardia and tachypnea. The petechial rash, decreasing oxygen saturation levels and even fever further indicate the client has most likely developed a fat embolism. Fractures or crush injuries of the femur and pelvis places the client at risk for a fat embolism, which can be lethal without immediate intervention.
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 obstruction. 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.
An 18 year old football player is admitted to the ortho unit after a femur fracture. He is scheduled for a rod to be placed in the morning, but suddenly develops severe shortness of breath, a petechial rash on his chest, and unstable vital signs. What should the nurse do first? 1. Decrease rate of IV fluids. 2. Neurovascular checks of affected leg. 3. Elevate the head of the bed. 4. Call the active response team.
4. Correct: The client is exhibiting symptoms of a fat embolism, particularly with the petechial rash on his chest and severe shortness of breath. Due to his age, high risk behaviors with contact sports, and the large long bone fracture, he is the classic example of a client that may experience a fat embolus. This constitutes a medical emergency and activation of the response team.
A client who has a long leg cast is reporting unrelieved pain. What should the nurse do first? 1. Apply a cool compress. 2. Elevate and reposition the leg. 3. Assess for breakthrough bleeding on the cast. 4. Monitor extremity for paresthesia.
4. Correct: Yes, because I am worried about compartment syndrome! Do a complete neurovascular assessment. Remember the 5 Ps: pain, pallor, pulse, paresthesia, and paralysis. 1. Incorrect: A cool compress may be helpful to decrease swelling but monitoring for compartment syndrome takes priority. 2. Incorrect: The nurse should elevate the extremity to decrease swelling, but it is not the priority over assessing neurovascular status. 3. Incorrect: The nurse should assess for breakthrough bleeding on the cast but this is not a priority over neurovascular assessment.
The nurse is preparing to teach a client about post percutaneous transluminal coronary angioplasty (PTCA) care. Which teaching points should the nurse include? 1. Restricting oral fluids until the gag reflex has returned. 2. Encouraging early ambulation and deep breathing exercises. 3. Discontinuing medicines following percutaneous intervention. 4. Reporting any chest discomfort following percutaneous intervention. 5. Avoid lifting more than 10 pounds until approved by healthcare provider.
4., & 5. Correct: The number one thing you are "worried" about post PTCA is re-occlusion or re-infarction, so report chest discomfort at once. Lifting more than 10 pounds can make the client bleed and would be contraindicated until cleared by the primary healthcare provider.
The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse's best action at this time? 1. Warm the room. 2. Submerge the hand in warm water. 3. Order a K pad and apply to hand. 4. Have the client exercise the fingers to increase blood flow.
1. Correct: When caring for clients with skin grafts, we want good circulation, so warm that room up.2. Incorrect: This will not improve circulation and can lead to infection. 3. Incorrect: This will not improve circulation. Someone who has a skin graft doesn't have good sensation so there is risk of another burn to the graft with this. 4. Incorrect: Working those stiff, cold fingers will further imbalance the oxygen supply. This will not help, particularly if the environment remains cool.
The nurse is caring for a client who is scheduled to receive furosemide 40 mg IVP twice daily, as well as 20 meq (20 mmol/l) of potassium chloride twice daily. The client's lab work reveals that the potassium level is 2.4 mEq/L (2.4 mmol/L) this morning. How should the nurse proceed? 1. Notify the primary healthcare provider of the potassium level immediately. 2. Administer the medications as scheduled and notify the primary healthcare provider on rounds. 3. Give the potassium, but hold the furosemide until primary healthcare provider rounds. 4. Assess the client for muscle cramps.
1. Correct: Yes, this is a very low level. Normal values are 3.5-5.0 mEq/L (3.5-5.0 mmol/L). This client will need more potassium and less furosemide (a potassium wasting diuretic). 2. Incorrect: No, potassium is dangerously low. Giving the furosemide will drop the potassium level further since it is potassium wasting. Do not wait for the primary healthcare providers to make rounds as they often do not make predictable rounds. 3. Incorrect: This is delaying care and confuses the issue of how much potassium needs to be administered now. 4. Incorrect: Delays care. What if there are no symptoms? Will you wait for symptoms to treat?
The nurse suspects a client admitted with myasthenia gravis is going into a cholinergic crisis. Which signs and symptoms would validate the nurse's suspicions? 1. Diarrhea 2. Increased urination 3. Dilated pupils 4. Tachycardia 5. Nausea and vomiting
1., 2., & 5. Correct: The signs of cholinergic crisis include Diarrhea and abdominal cramping, Urination increased, Miosis (pinpoint pupils), Bradycardia, Emesis (nausea and vomiting), Lacrimation, Lethargy, Salivation. Remember this: DUMBELLS as a mnemonic to help you recall these signs and symptoms.
A nurse suspects that a client admitted to the emergency department is in diabetic ketoacidosis. What data would lead the nurse to this conclusion? 1. Dry mucous membranes 2. Fruity-smelling breath 3. Biot's respirations 4. Glycosuria 5. Client report of abdominal pain
1., 2., 4., & 5. Correct: The client with diabetic ketoacidosis will have signs of dehydration due to polyuria and includes dry mucous membranes. Fruity breath odor is from the acetone that occurs with breakdown of fats and formation of ketones, which are acids.. With DKA, the client would be spilling glucose into the urine. Vomiting and abdominal pain are frequently the presenting symptoms of DKA.
A client receiving chemotherapy for lung cancer reports increased fatigue. The family confirms client is sleeping most of the day and night. What priority action would the nurse take? 1. Discuss the risks of immobility with client and family. 2. Check current lab values of hematocrit and hemoglobin. 3. Suggest family seek counseling for the client's depression. 4. Request a referral from the healthcare provider for physical therapy.
2. CORRECT: The side effects of chemotherapy can impact all body systems, including the blood and circulatory system. The nursing process requires the nurse to first assess and gather data before proceeding with a plan. Though fatigue in cancer clients can have many causes, the nurse should check current laboratory results for decreased RBCs, hematocrit or hemoglobin caused by chemotherapy. Decreased levels of these elements are a side effect of chemotherapy and could definitely contribute to fatigue or exhaustion. 1. INCORRECT: While the nurse may want to discuss many topics with client or family, effects of immobility does not address the present issue of exhaustion or fatigue. The nursing process always begins with collection of data. 3. INCORRECT: Individuals respond to a terminal disease in different ways but certainly depression is common. Though a possible symptom of depression can be constantly sleeping, the nurse has not collected evidence to support that assumption. Potential physical causes for behavioral changes must be eliminated first. 4. INCORRECT: This action is premature since the nurse has not completed an assessment or collected data. While physical therapy may help to strengthen the client, an exact cause for the fatigue must first be established.
