15

The nurse is caring for a client who has been involved in a motor vehicle accident. The client's labs indicate a minimally elevated serum creatinine level. The nurse should further assess which body system for signs of injury? A. Renal B. Cardiac C. Pulmonary D. Nervous

A. Renal

A 76-year-old client with Parkinson disease has been admitted with aspiration pneumonia and constipation. Which nursing intervention would help both diagnoses? A. Sitting upright for meals B. Good oral hygiene C. Prolonged laxative usage D. Increase dietary fat

ANS: A Sitting upright for meals is beneficial to both problems. It decreases risk from further aspiration and increases motility. Good oral hygiene promotes gastrointestinal health. Prolonged laxative use and increased dietary fat are not recommended for either condition.

The nurse is admitting a client who is suspected of having heat stroke. What assessment finding would be most consistent with this diagnosis? A. Widening pulse pressure B. Hot, dry skin C. Core body temperature of 99.0°F/37.2°C D. Cheyne-Stokes respirations

ANS: B Rationale: Heat stroke is manifested by hot, dry skin, confusion, bizarre behavior, coma, elevated body temperature (usually 103°F/39.4°C or higher), tachypnea, hypotension, and tachycardia. A widening pulse pressure is more indicative of a heart defect or problem. Cheyne-Stokes respirations, a rare condition characterized by fast, shallow breathing followed by slow heavier breathing, followed by no breathing, are typically seen in clients with heart failure and stroke.

An 80-year-old client is being admitted for dehydration and syncope. The client is found to be hypotensive, and intravenous fluids are ordered. What are some teaching strategies that the nurse should review with this client? A. Before ambulation the client should rise slowly and take mini breaks between lying, sitting, and standing. B. Increase consumption of meals to three times a day, with the largest meal being at breakfast. C. The client must use a rolling walker and call for assistance with any change in position. D. The temperature in the room should stay very hot, and bathing in hot water is appropriate.

ANS: A Rationale: A client experiencing hypotension should rise slowly. The client should consider having five or six small meals a day to minimize hypotension that can occur after a large meal. Extremes in temperature, especially hot showers, should be avoided. Hot temperatures can cause an increase in blood flow and cause dizziness. Every client does not need a rolling walker. Changes in position, especially in bed, should be done independently and often to prevent pressure ulcers

A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood? A. The client is likely experiencing a delayed onset of respiratory complications B. The client has likely developed a systemic infection C. The client's respiratory complications are likely related to psychosocial stress D. The client is likely experiencing an anaphylactic reaction to a medication

ANS: A Rationale: Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. A systemic infection would be less likely to cause respiratory complications. This problem is more likely to be caused by physiologic factors at this phase, not psychological factors. Anaphylaxis must be ruled out, but it is less likely than a response to the initial injury.

A 76-year-old client is in the emergency department with reports of nausea, dyspnea, and shoulder pain. The spouse stated the client woke up confused, slightly unsteady, and pale. Which problem or condition is most likely occurring? A. Myocardial ischemia B. Urinary tract infection (UTI) C. Lung cancer D. Chronic obstructive pulmonary disease (COPD)

ANS: A Rationale: Older adults may have atypical pain or burning that may be in the upper body rather than substernal. Clients may report vague symptoms such as nausea, vomiting, syncope, mental status changes, and dyspnea. A UTI may present with mental status changes, but additional signs and symptoms include frequent, urgent, and/or painful urination. Lung cancer and COPD both usually present with more specific respiratory changes, such as wheezing and persistent coughing.

A public health nurse is educating a group of administrators about decreasing hospitalizations for burns. Which population will the nurse note as the target population for burn injuries? A. Older adults B. Women more than men C. Adults 35-40 years of age D. School-aged teenagers

ANS: A Rationale: The population that is most at risk for hospitalization are older adults. Statistically men have a higher incidence of burns over women. Adults from 35 to 40 years of age are not shown to have a high prevalence. School-aged teenagers do not have a higher prevalence of burns with hospitalization than the aging population

A client with smoke inhalation arrives at the emergency department (ED) after involvement in a house fire and is lethargic with tachypnea and tachycardia. The nurse anticipates what specific intervention(s) for this client? Select all that apply. A. Intubation and ventilator support. B. Treatment in a hyperbaric chamber. C. Hydroxocobalamin medication administration D. Receive nitrate pearls through the ventilator. E. Pralidoxime medication administration.

ANS: A, B, C Rationale: Rapid administration of amyl nitrate, sodium nitrite, and sodium thiosulfate is essential to the successful management of cyanide exposure. First, the client is intubated andplacedonaventilator. Infacilitieswhereahyperbaricchamberisavailable,itmay be used to provide oxygenation before other therapies are initiated. An alternative suggested treatment for cyanide poisoning is hydroxocobalamin (vitamin B12a). Hydroxocobalamin binds cyanide to form cyanocobalamin (vitamin B12).The production of methemoglobin, which is produced by receiving nitrate pearls, is contraindicated in clients with smoke inhalation because they already have decreased oxygen-carrying capacity secondary to the carboxyhemoglobin produced by smoke inhalation. Pralidoxime is a medication for nerve agents that provides an antidote which allows cholinesterase to become active against acetylcholine.

client in the critical care unit is prescribed crystalloid intravenous fluids. The nurse anticipates administering which fluid? Select all that apply. A. Normal saline B. Lactated Ringer C. Dextrose 5% in water D. Albumin E. Hetastarch (TM)

ANS: A, B, C Rationale: These crystalloid solutions in various concentrations and combinations contain electrolytes and sometimes sugars: saline; lactated Ringer; 5% dextrose in water. IV solutions with larger molecules designed to expand IV volume with increased oncotic pressures include: albumin, Hespan, or Hetastarch.

A 55-year-old client is preparing to retire in the next five years. The client has made both financial and social plans to make a successful transition. What are some examples of social change that the client could plan? A. Additional reliance on the spouse and family to fill in leisure time B. Developing routines and friends not associated with work C. Planning several vacations to expand the client's social circle D. Starting an online social network to keep the client connected with co-workers

ANS: B Rationale: Developing routines and friends not associated with work are some health promotion strategies. Other ways to promote successful aging include having an adequate income, and relying on other groups and people, besides the spouse, to spend free time with.

An 80-year-old client has been admitted to the hospital for hypertension and now requires oxygen. The client asks the nurse why oxygen is needed because they have never smoked and feel fine. The client requires oxygen in the hospital because of which respiratory changes or requirements? A. As a therapeutic measure to encourage coughing and deep breathing B. Diminished respiratory efficiency and declining aerobic capacity C. To increase inspiratory and expiratory force of lungs D. Lung mass increases and residual volume decreases

ANS: B Rationale: Diminished respiratory efficiency and declining aerobic capacity are related to age. Older, healthy adults are usually able to compensate for these changes, but stress from illness may increase the demand for oxygen. Oxygen is a drug and not used to encourage cough and deep breathing. Reduced maximal inspiratory and expiratory force may occur in the lungs due to calcification and weakening of the muscles of the chest wall. Lung mass decreases and residual volume increases as the client ages.

A military nurse is treating a soldier after an unexploded ordnance (UXO) was purposely detonated for disposal. The blast radius was larger than anticipated and debris injured the soldier. The nurse anticipates what phase of blast injury occurred to this soldier? A. Primary B. Quaternary C. Secondary D. Tertiary

ANS: C Rationale: A blast may result from terrorism but can also occur anywhere at any time if the right (or wrong) circumstances come together. Secondary blast injuries result from debris from the scene or shrapnel from the bomb that act as projectiles. These injuries may penetrate the trunk, skin, and soft tissue. Secondary blast injuries can also result in fractures and traumatic amputations. A blast injury has both direct and indirect consequences to the body. Identifying the phase of blast injury can help predict needed interventions more effectively and quickly. Primary, quaternary, and tertiary blast injuries are not the result of debris hitting the body. Primary blast injuries occur from the initial blast or air wave, and primarily affect air-filled organs. Quaternary blast injuries occur from pre-existing conditions that are exacerbated by the force of the blast or postblast injury complications. Common pre-existing conditions that can be worsened by blasts include asthma, chronic obstructive pulmonary disease (COPD), cardiac conditions, diabetes, and hypertension, whereas postblast injury complications occur from severe injuries with complex injury patterns such as burns, crush injuries, and head injuries. Tertiary blast injuries occur from the pressure wave that cause victims to be thrown, and often result in head injuries and fractures.

A client has sustained multiple injuries from a gunshot wound while hunting in cold winter weather. The client has waited several hours for rescue and is transported in a helicopter to the emergency department. The nurse recognizes what additional factors are associated with increased mortality for this client? A. Time of injury, hyperhidrosis, and thermal changes B. Comorbidities, location of injury, and gravitational forces C. Hypothermia, acidosis, and coagulopathy D. Venous insufficiency, barometric changes, and fatigue

ANS: C Rationale: Major trauma can cause hypothermia, acidosis, and coagulopathy, sometimes called the "triad of death" because each of these factors is associated with increased mortality. In this case the client was exposed to cold weather for several hours. The client had a gunshot wound that caused bleeding. Coagulopathy likely occurs immediately after massive trauma and shock. As the client with trauma perfusion worsens, lactic acid rapidly accumulates in the tissues, which ultimately results in severe metabolic acidosis. Thermal changes, gravitational forces, barometric changes, and fatigue are all related to stresses of flight, but they are not directly related to an increased mortality. Comorbidities, time, and location of injury can contribute to the client's survivability but are paired with choices that do not. Venous insufficiency and hyperhidrosis (excessive sweating) are not directly linked to this event.

A 54-year-old female client visiting her gynecologist is postmenopausal and reports painful intercourse. What is a physical change that is occurring to the client's reproductive system to account for this problem? A. Thickening of the vaginal wall B. Increased vaginal secretions C. Shortening of the vagina D. Increased pubococcygeal muscle tone

ANS: C Rationale: Ovarian production of estrogen and progesterone decreases with menopause. Changes include thinning of the vaginal wall, decreased vaginal secretions, and decreased pubococcygeal/pelvic floor muscle tone. These changes may cause vaginal bleeding and painful intercourse.

The emergency department (ED) received news of a train derailment locally and the number of clients injured is reported between 50 and 100. The hospital has determined that it can accommodate 50 clients and still remain self-sufficient. What criteria is the hospital using to project the number of clients it can support? A. The understanding that the institution can rely on outside services after 3 days B. Based on the emergency operations plan that incorporates assistance from the Red Cross C. Decided by the institution's ability to sustain core services for at least 96 hours D. Based on the hospital's incident command system that updates the hospital on the severity of injuries

ANS: C Rationale: The emergency preparedness planning committee must have a realistic understanding of its resources. The goal of each health care institution is to remain self-sufficient to provide and sustain core services without the support of external assistance for at least 96 hours from the inception of the incident; ideally, this self-sufficiency should last for 7 days. The institution cannot expect outside services to be available to help until after 96 hours, which is 4 days. The emergency operations plan details how the facility will respond to a mass casualty incident and may include criteria for utilizing external resources, but external assistance from the Red Cross would not be a factor in determining how many clients the facility can realistically care for immediately. External resources such as the Red Cross cannot be accessed and utilized immediately. The field incident command, not the hospital's incident command center, will provide an estimate of number of clients that will be arriving, though severity of injuries and number of clients self-reporting may not be known.

A client is brought by friends to the ED after being involved in a motor vehicle accident. The client sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this client? A. Ambulate the client to expel flatus. B. Place the client in a high Fowler position. C. Immobilize the client on a backboard. D. Place the client in a left lateral position.

ANS: C Rationale: When admitted for blunt trauma, clients must be immobilized until spinal injury is ruled out. Ambulation, side-lying, and upright positioning would be contraindicated until spinal injury is ruled out.

A 69-year-old client is readmitted with heart failure. The client reports taking all medications as prescribed. The client's grandchild usually helps to set up a weekly organizer pill container but is away at college. What should the nurse first do with this information? A. Call the client's home to solicit another family member to help with the medications on discharge. B. Explain the current inpatient orders and make a note on the chart for discharge C. Contact the client's health care provider (HCP) for assistance and direction on how to proceed. D. Complete a comprehensive assessment reviewing the client's medication history, including over-the-counter medications

ANS: D Rationale: A comprehensive assessment begins with a thorough medication history. This is a nursing intervention and part of the admission process. While a note is appropriate, interventions should start before discharge to ensure medication compliance and safety and to decrease readmission. The client's inpatient orders may change once the medication history is reviewed. Until a medication history is obtained, calling the family isn't appropriate. The nurse may need to contact the HCP regarding the client's medication practices, but this should be done after completing a comprehensive assessment of the client's medication history.

A 62-year-old woman started experiencing urinary incontinence six months ago and now wears disposable incontinent panties. The client does not drink any fluids after 5 pm and considers this problem part of aging. What priority modifications and advice should be given to this client? A. "While urinary incontinence is part of the aging process, you should still see your health care provider (HCP) about this condition." B. "You probably have a urinary tract infection and should start drinking cranberry juice." C. "You could purchase pads to place into washable panties. This would decrease costs and feel less like a diaper." D. "Urinary incontinence is not part of the aging process. You should see your HCP and increase your water intake."

ANS: D Rationale: Urinary incontinence affects more women than men under the age of 80. It is not a normal condition due to aging. While embarrassing, the focus should not be on living with it by wearing disposable panties but getting evaluated by a HCP. Adequate consumption of fluids decreases the likelihood of bladder infection.

A client with hypokalemia is to receive intravenous (IV) potassium replacement. Which action should the nurse take when administering potassium intravenously? Select all that apply. A. Administer potassium by IV push. B. Assess blood urea nitrogen (BUN) and serum creatinine prior to potassium administration. C. Monitor complete blood count during potassium infusion. D. Follow the facility policy for infusion of potassium. E. Report a reduced urinary output to the health care provider.

B. Assess blood urea nitrogen (BUN) and serum creatinine prior to potassium administration. D. Follow the facility policy for infusion of potassium. E. Report a reduced urinary output to the health care provider. Rationale: Potassium should be administered by an infusion pump and should never be given by IV push to avoid rapid replacement. Because potassium is excreted by the kidneys, BUN, serum creatinine, and urinary output should be assessed prior to and during administration of IV potassium. Abnormal laboratory results or decreased or absent urinary output should be reported to the health care provider. Because potassium administration does not affect blood cells, the complete blood count does not need to be monitored during administration of potassium. The nurse should check facility policy on the administration of IV potassium to ensure safe care.

The nurse caring for a client post colon resection is assessing the client on the second postoperative day. The nasogastric tube remains patent and is draining moderate amounts of greenish fluid. Which assessment finding would suggest that the client's potassium level is too low? A. Diarrhea B. Paresthesias C. Increased muscle tone D. Joint pain

B. Paresthesias Rationale: Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), and arrhythmias. The client would not have diarrhea because increased bowel motility is inconsistent with hypokalemia. Joint pain is not a symptom of hypokalemia, nor is increased muscle tone.

A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances? A. Maintain a low-sodium diet. B. Encourage the use of over-the-counter calcium supplements. C. Ensure the client has sufficient potassium intake. D. Encourage fluid intake.

C. Ensure the client has sufficient potassium intake. Rationale: Thiazide diuretics, such as hydrochlorothiazide, cause potassium loss, and it is important to maintain adequate intake during therapy. Hyponatremia is more of a risk than hypernatremia, so a low-sodium diet does not address the risk for electrolyte disturbances. There is no direct need for extra calcium intake, and increased fluid intake does not reduce the client's risk for electrolyte disturbances.

The nurse is caring for a client who has a peripheral IV in place for fluid replacement. When caring for the client's IV site, the nurse should: A. ensure that anticoagulants are placed on hold for the duration of IV therapy. B. replace the IV dressing with a new, clean dressing if it is soiled. C. ensure that the tubing is firmly anchored to the client's skin. D. periodically remove hair from 2 cm around the IV site.

C. ensure that the tubing is firmly anchored to the client's skin. Rationale: Anchoring the IV tubing prevents it from being accidentally dislodged. Anticoagulants are not contraindicated during IV therapy. Soiled dressings should be replaced with a new sterile dressing, not a clean dressing. Hair removal is unnecessary.

The intensive care unit nurse is caring for an acutely ill client with signs of multiple organ dysfunction syndrome (MODS). The nurse knows the client is at risk for developing MODS due to all of the following EXCEPT: A. Malnutrition B. Advanced age C. Multiple comorbidities D. Progressive dyspnea

D. Progressive dyspnea Rationale: The client with advanced age is at risk for developing MODS due to the lack of physiological reserve. The client with malnutrition metabolic compromise and the client with multiple comorbidities is at risk for developing MODS due to decreased organ function. Progressive dyspnea is the first sign of MODS.