SAUNDERS WRONG ANSWERS ONLY

The nurse educator is teaching the new registered nurse (RN) how to care for clients with a decrease in blood pressure. Which statement by the new RN indicates the need for further instruction?

"Decreased myocardial blood flow is not a concern." Rationale: The primary effect of a decrease in blood pressure is reduced blood flow to the myocardium. This in turn decreases oxygenation of the cardiac tissue. Cardiac tissue is likely to become more excitable or irritable in the presence of hypoxia. Correspondingly, the heart rate is likely to increase, not decrease, in response to this change. The effects of tissue ischemia lead to decreased contractility over time.

The nurse working in the emergency department has four charts of clients who need to be assessed. Which client should be assessed first?

A client with a history of schizophrenia threatening to harm himself Rationale: The risk of harming oneself or others is an environmental and priority safety issue. To ensure the safety of the client, self, and the safety of others, the client threatening to harm himself is of the utmost importance and should be assessed first. Based on the data identified in the options, the nurse would then assess the client with an open leg wound because this is a physiological concern. Next, the nurse would most likely begin the administration of chemotherapy and finally care for the client with neglect.

A client with benign prostatic hyperplasia undergoes a transurethral resection of the prostate. Postoperatively the client is receiving continuous bladder irrigations. The nurse assesses the client for manifestations of transurethral resection syndrome. Which assessment data would indicate the onset of this syndrome?

Bradycardia and confusion Rationale: Transurethral resection syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure, such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

Exhaling during repositioning Rationale: Activities that increase intrathoracic and intra-abdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. What is the first action by the nurse?

Place the client on the left side in the Trendelenburg's position. Rationale: Although stopping the TPN solution will not treat the problem, it will prevent it from worsening and is a quick action that can be completed first. Lying on the left side may prevent air from flowing into the pulmonary veins. Trendelenburg's position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration. The high-Fowler's position is not helpful at this time. The PHCP should be notified, but this is not the first action.

The nurse is caring for a child following a tonsillectomy. The nurse should reposition the child on return from the operating room if the child is in which position?

Supine Rationale: Supine position should be avoided because it does not facilitate drainage from the oral cavity after tonsillectomy. The child should be placed in a prone or side-lying position following tonsillectomy to facilitate drainage.

Cloxacillin sodium, 200 mg orally every 8 hours, is prescribed for a child with an elevated temperature who is suspected of having a respiratory tract infection. The child weighs 17 lb. The safe pediatric dosage is 50 mg/kg/day. Which conclusion should the nurse draw concerning the dose prescribed?

The dose prescribed is too high. Rationale: The first step is to convert pounds to kilograms by dividing by 2.2. Step 1: 17 lb ÷ 2.2 lb/kg = 7.72 kg The next step is to determine the number of mg/kg the client will receive based on the prescribed dose of 200 mg 3 times a day (every 8 hours). Step 2: 200 mg × 3 = 600 mg The final step is to figure out the maximum dose this client should receive based on his or her weight. Step 3: 50 mg/kg/day × 7.72 kg = 386 mg/day

A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response?

"Take a shower immediately, lathering and rinsing several times." Rationale: When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area by showering immediately and to lather the skin several times and rinse each time in running water. Removing the poison ivy sap will decrease the likelihood of irritation. Calamine lotion may be one product recommended for use if dermatitis develops. The client does not need to be seen in the emergency department at this time.

The nurse is caring for a client admitted to the hospital for an infection who is receiving an aminoglycoside twice a day, intravenously. The nurse is planning to obtain blood for a peak aminoglycoside level. When should the blood be drawn?

30 minutes after completing the infusion Rationale: Peak medication levels are obtained 30 minutes after completing the infusion. Therefore, the times in the remaining options are incorrect.

The nurse caring for a client receiving vincristine is monitoring the client for toxicity. The nurse interprets that the client is experiencing a toxic effect of this medication on the basis of which assessment finding?

Weakness and sensory loss in the legs Rationale: Peripheral neuropathy is the major dose-limiting toxicity associated with vincristine. Nearly all clients exhibit signs and symptoms of sensory or motor nerve injury such as decreased reflexes, weakness, paresthesia, and sensory loss. Nausea and vomiting are rare with the use of this medication. In contrast with most anticancer medications, vincristine causes little toxicity to bone marrow.