uworld-test 1

12. A client with sickle cell crisis reports severe generalized pain. Which intervention is a priority for correcting vasoocclusion? 1. administer high-low iv fluids 2. applying oxygen via nasal cannula. 3. maintaining strict bed rest. 4. transfusing packed red blood cells.

1. Educational objective: Sickle cell crisis results from vasoocclusion of sickled red blood cells in the microcirculation, resulting in severe ischemic pain. The administration of IV fluids reduces blood viscosity and restores perfusion to the areas previously affected by vasoocclusion.

15. The nurse caring for a male client prepares to insert an indwelling urinary catheter. The nurse assesses for allergies, explains the procedure to the client, and asks unlicensed assistive personnel to perform perineal care while equipment is gathered. Place in order the steps the nurse should take when inserting the urinary catheter. All options must be used. -perform hand hygiene and apply sterile gloves -place fenestrated drape with shiny side down -use nondominant hand to grasp penis below lands -use non-dominant hand to cleanse meatus with cotton balls or swab sticks -advance catheter to tubing bifurcation and inflate balloon. -use dominant hand to insert catheter until urine return is observed.

1. perform hand hygiene 2. place fenestrated drape with shiny side down. 3. use nondominant hand to grasp penis below glans 4. use dominant hand to cleanse meatus with cotton balls or swabs. 5. use dominant hand to insert catheter until urine return is observed. 6.advance catheter to tubing bifurcation and inflate balloon.

4. The clinic nurse is assessing a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide? -i lost my imipramine prescription. could i have a refill? -i plan to attend my granddaughter's graduation next month. -i seem to have a lot more energy since i started therapy. 4. i will sin a "no-suicide" contract at today's appointment.

2. Educational objective: Nursing care for clients with suicidal ideation includes assessment of home and work environments, access to psychiatric medications, overall affect, availability of help, access to weapons, and energy level. Clients who articulate long-term personal goals and family milestones are less likely to commit suicide.

11. A nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first? 1.client 2 months post heart transplant with sustained sinus tachycardia of 110/min at rest 2. client 3 hours post coronary artery stent placement via femoral approach and reporting severe back pain. 3.client receiving IV antibiotics for infective endocarditis with a temperature of 101.5F. 4. client who had coronary bypass graft surgery 3 days ago and has swelling in the leg used for the donor graft.

2. Educational objective: Percutaneous coronary intervention via the femoral approach places the client at increased risk for retroperitoneal hemorrhage, which is exacerbated by anticoagulants. Back pain, hypotension, flank ecchymosis (Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention.

6. Based on the nursing assessment progress notes, what is the correct staging of the client's pressure injury? Click on the exhibit button for additional information. Exhibit: progress notes 1300: shallow open area with clean, dark pink wound bed about 1 cm in diameter noted on coccyx. surrounding area is slightly hard and warm to touch wiht erythema. Foam dressing clean, dry, and intact. no drainage noted. Enterostomal consult made. RN 1. Stage 1 2. Stage 2 3.Stage 3 4.Stage 4

2. Educational objective: Stage 2 pressure injuries have partial-thickness skin loss (abrasion, blister, or shallow crater). The skin blisters or forms an open sore, and the area around the sore may be red and irritated. • Stage 1: Intact skin with nonblanchable redness • Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis; the wound bed is red or pink and may be shiny or dry • Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone; tunneling may be present • Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead tissue) may be present; undermining and tunneling may be present • Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or eschar

3. The nurse cares for a client with a terminal disease who has an advance directive supporting a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The client's adult child states, "I changed my mind. Do whatever you can to save him!" Which intervention is most appropriate at this time? 1. call for help to initiate cardiopulmonary resuscitation. 2. call the health care provider to confirm the DNR status. 3. explain the client's wishes to the client's child. 4. offer to call the hospital chaplain to provide support.

3. Educational objective: Advance directives outline the client's choices for medical care at the end of life, including resuscitation status. Client's wishes for medical care are honored over the wishes of family members.

2. the charge nurse is responsible for making room assignments for multiple clients. which pair of client assignments to a shared room is appropriate? 1. client with blood loss anemia and client with intractable diarrhea. 2. client with gastroenteritis and client with chemotherapy-induced nausea and vomiting. 3. client who had a bowel resection 1 day ago and client with asthma exacerbation. 4. client who had a total hip arthroplasty 2 days ago and client with influenza.

3. Educational objective: When preparing room assignments, the nurse should not place a client who has a fresh surgical wound or is immunocompromised in a room with a client who has an active or suspected infection.

1. after listening to the parents' reports and seeing the following pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting? 1. 1 y/o with dyspnea, drooling, and a swollen tongue after eating a houseplant. 2. 2 y/o who is crying and has a large forehead hematoma after falling out of a chair. 3. 3 y/o with second degree burns on the face after pulling a cup of hot coffee off the table. 4. 5 y/o whos x-rays reveals 1 new and 2 healed humerus fractures after falling from a tree.

4. The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated injuries in varied stages of healing, shaken baby syndrome, and injuries to genitalia. Suspicion of abuse necessitates mandatory reporting according to state or provincial laws. injury patterns in nonaccidental truama: -coup-contrecoup -long bone fractures in the humerus of femur -subdural and epidural hematomas -linear-type immersion burns -frenulum tears and gingival lesions -retinal hemorrhage on funduscopic examiniation

5. The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing? 1. BMI of 29.5 kg/m2 2. family history of osteoporosis 3. history of daily glass of wine 4. peripheral arterial disease.

4. Educational objective: Bone healing after fracture depends on multiple factors, including age, nutritional status, and perfusion. A client with peripheral arterial disease is at risk for impaired bone healing.

9. While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority action? 1. Activate the hospital emergency response system. 2. apply supplemental oxygen and quickly transport to the new unit. 3. check the client's respiratory pattern and effort and oxygen saturation. 4. Firmly cover the insertion site with the palm of a clean, gloved hand.

4. Educational objective: Chest tubes are inserted into the pleural cavity to drain air (pneumothorax), blood (hemothorax), or other fluids. If the tube is accidentally dislodged, a sterile occlusive dressing is placed over the site. If such dressings are not immediately available, a clean gloved hand can be placed over the site to prevent air entry into the pleural space. After dressing the site, the nurse should reassess the client and notify the health care provider immediately.

7. A client with type 1 diabetes has prescriptions for NPH insulin and regular insulin. At 7:30 AM, the client's blood glucose level is 322 mg/dL (17.9 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take? Click on the exhibit button for additional information. exhibit: MAR Medications/Time NPH insulin 25 units subcutaneously twice daily - 0739, 2100 Regular insulin: per sliding scale, subcutaneously - AC and HS Sliding-scale blood glucose levels- Regular insulin dose <150 mg/dl (<8.3 mm/L) - 0 units 150-199 mg/dl (8.3-11.0 mmol/L) - 4 units 200-249 mg/dl (11.1-13.8 mmol/L) - 8 units 1. administer 25 unites of NPH insulin now and then 12 units of regular after the morning meal. 2. administer 37 units of insulin: 25 units of NPH and 12 units of regular insulin in 2 separate injections. 3. administer 37 units of insulin: 25 units of NPH mixed wiht 12 units of regular insulin in the same syringe, drawing up NPH into the syringe first. 4. administer 37 units of insulin: 25 units of NPH mixed wiht 12 units of regular insulin in the same syringe, drawing up regular insulin into the syringe first.

4. Educational objective: NPH insulin and regular insulin may be safely mixed and administered as a single injection. Regular insulin should be drawn into the syringe before intermediate-acting insulin to avoid cross-contaminating multidose vials (mnemonic - RN: Regular before NPH).

8. The pediatric nurse plans a home visit for a 2-year-old who will soon be discharged with home health care. Which condition presents the most concern as a safety hazard in the child's home environment? 1. the family lives in a rural area 2. house is heated by a wood-burning area 3. house was built in 1983 4. parents are unemployed with limited financial resources.

2. Educational objective: A wood-burning stove is a fire, burn, and smoke-inhalation hazard with the potential to cause physiological damage. The nurse should assess all clients' access to utilities and resources. Education on lead-based paint should be provided to those living in homes built before 1978.

10. The nurse is caring for a client who had an anterior wall myocardial infarction 2 days ago. The telemetry technician notifies the nurse at 8:30 AM that the client is in ventricular trigeminy. What is the nurse's priority intervention? Click the exhibit button for additional information. 1. administer potassium replacement 2. administer the dose of amiodarone 3. attach cardiac defibrillator pads 4. notify the health care provider.

1. Educational objective: Myocardial injury can predispose a client to premature ventricular contractions (PVCs), placing the client at risk for lethal dysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise. Treatment of the underlying cause is the priority.

13. The charge nurse assists a student nurse preparing to apply knee-length compression stockings onto a client with chronic venous insufficiency. Which actions by the student nurse would cause the charge nurse to intervene? Select all that apply. 1. instructs client that stockings will be worn only at night. 2. measures circumference of both claves at the widest point. 3. rolls down any excess length at the top of the stocking 4. selects a size larger to avoid friction against a leg laceration. 5. smoothes out any wrinkles or creases in the stocking

1. 3. 4. Educational objective: Thromboembolic deterrent stockings (TED hose) promote venous return and reduce the risk of venous thromboembolism. TED hose are worn continually and should be properly sized, free of folds, rolls, or wrinkles.

14. The nurse is caring for a client who has been pronounced brain dead. The client is a registered organ donor. The client's family is voicing concerns about the possibility of disfigurement because they want to have an open casket funeral. How should the nurse respond? 1. if the family is not in complete agreement about organ donation, we won't be able to proceed. 2.once the body is dressed, there is no evidence of organ removal. An open casket will be fine. 3. some organ procurement leaves evidence on the body. You may want to consider a closed casket. 4. your family member consented to be an organ donor. You should really honor this wish.

2. Educational objective: A deceased client who is registered as an organ donor does not need familial consent for organ procurement to proceed. Organ donation does not delay or interfere with funeral arrangements or leave obvious evidence on the body; deceased clients can still be displayed according to their wishes, including open casket funeral services.