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Fundamentals: The nurse notes that the client's mechanical ventilator is set to control mode. The nurse understands that this setting will achieve which action? 1.) Allows the lungs to rest 2.) Allows for spontaneous respirations 3.) Hyperventilates the client to ensure adequate oxygenation 4.) Provides some breaths for the client but allows the client to breathe on his/her own also
Answer: 1 Rationale: The control mode setting on a mechanical ventilator is used to allow the lungs to rest. In this setting, all respirations are provided to the client by the ventilator. The assist-control mode allows for spontaneous breathing and will provide breaths from the ventilator if the client's respirations fall below a certain preset amount. Mechanical ventilation is not used for hyperventilation.
Fundamentals: The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which action in the care of this client at this time? 1.) Ensure that the client has voided 2.) Administer all the daily medications 3.) Practice postoperative breathing exercises 4.) Verify that the client has not eaten for the last 24 hours
Answer: 1 Rationale: The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse does not administer all the daily medications just before sending a client to the OR. Rather, the primary health care provider writes a specific prescription outlining which medications may be given with a sip of water. The client is placed on nothing by mouth status for 8 hours before surgery, not 24 hours. The time of transfer to the OR is not the time to practice breathing exercises. This should have been accomplished earlier.
Maternity The nurse understands that an amniocentesis is indicated for which purposes? Select all that apply. 1.) Diagnosis of genetic disorders 2.) Determination of gestational age 3.) Assessment of pulmonary maturity 4.) Assessment of placental placement 5.) Diagnosis of fetal hemolytic disease
Answer: 1, 3, 5 Rationale: Amniocentesis is done to obtain fetal cells, which are contained in amniotic fluid. It is indicated to diagnose genetic disorders (particularly neural tube defects), to assess pulmonary maturity, and to diagnose fetal hemolytic disease. In this procedure, a needle is inserted transabdominally under ultrasonographic visualization to withdraw amniotic fluid. There are methods other than amniocentesis that are less invasive to determine gestational age. This test is not used to determine placental placement.
Management, Prioritization and Delegation The nurse working in the long-term care setting understands that special consents are required in which scenarios? Select all that apply. 1.) Use of restraints 2.) Transferring units 3.) Referral to a specialist 4.) Photographing a client 5.) Performing an autopsy 6.) Donating organs after death
Answer: 1, 4, 5, 6 Rationale: Special consents are required for the use of restraints, photographing a client, performing an autopsy, and donating organs after death. Transferring units and referrals to specialists to not require special consent forms.
Pharmacology math A patient has a BP of 190/128 mmHg Order: Labetolol 2 mg/min, continuous IV Supply: 200 mg/250 mL Calculate the rate for this dose (mL/hr)
Answer: 150 mL/hour Dosage: 2 mg x 60 min= 120 mg/hour Lowest concentration: 200 mg/250 mL = 0.8 mg/mL 120 mg per hour / 0.8 mg x 1 mL= 150 mL/hour (Labetolol is a high alert medication)
Adult Health The nurse is reviewing the laboratory test results for a 68-yr-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. On postoperative day 2, the international normalized ratio (INR) result is 2.7. Which action by the nurse is most appropriate? 1.) Hold the daily dose of warfarin. 2.) Administer the daily dose of warfarin. 3.) Teach the patient signs and symptoms of bleeding. 4.) Call the physician to request an increased dose of warfarin.
Answer: 2 Rationale: The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. To maintain therapeutic values, the nurse will administer the medication as ordered. Holding the medication would lower the INR, which would increase the risk of clot formation. Conversely, the higher the IRN is, the more prolonged the clotting time. Calling the health care provider is not indicated. Although teaching is important, administering the medication is a higher priority at this time.
Maternity The nurse provides instructions to a new mother with hepatitis B regarding breast-feeding her newborn. The nurse determines that the mother understands the instructions if she makes which statement? 1.) "I will not be able to breast-feed at all" 2.) "This infection is not passed through breast milk" 3.) "I will be able to breast feed once my baby is vaccinated" 4.) "I have to wait until the second vaccine is given before I can breast feed"
Answer: 3 Rationale: Hepatitis B can be transmitted via blood, saliva, vaginal secretions, semen, breast milk, and across the placental barrier. Once the infant is delivered, the hepatitis B immune globulin and hepatitis B vaccine is administered. Once vaccinated, the infant can be breast fed. The infant will receive a second vaccination at age 6 months. The mother would be informed that breast-feeding is possible as long as the proper precautions are taken, therefore option 1 is incorrect. Note that the second vaccine is administered at 6 months, at which time initiation of breast-feeding is not feasible; therefore option 4 is incorrect.
Pharmacology The nurse is providing instructions to an adolescent who is taking phenytoin. Which statement by the adolescent indicates a need for further teaching regarding the medication? 1.) "The medication may cause oily skin" 2.) "Drinking alcohol may affect the medication" 3.) "If my becomes become sore, I need to stop the medication" 4.) "Birth control pills may not be effective when I take this medication"
Answer: 3 Rationale: Phenytoin is an anticonvulsant. The adolescent would not stop taking the medication without discussing it with the primary health care provider or nurse because of the risk of recurring seizures. Acne or oily skin may be a problem for the adolescent, and the adolescent is advised to call a primary health care provider for skin problems. Alcohol will lower the seizure threshold, and it is best to avoid the use of alcohol. Birth control pills may be less effective when the client is taking anticonvulsant medication.
Mental Health The nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal? 1.) Constipation, insomnia, and hallucinations 2.) Staggering gait, slurred speech, and violent outbursts 3.) Nausea, vomiting, diarrhea, muscle aches, and diaphoresis 4.) Decreased heart rate and blood pressure and dry nose, mouth and skin
Answer: 3 Rationale: The client who is experiencing opioid withdrawal (such as from heroin) may experience dysphoric mood, nausea, vomiting, diarrhea, abdominal cramping, muscle aches, diaphoresis and piloerection, runny eyes (lacrimation) and nose (rhinorrhea), yawning, low-grade fever, restlessness, insomnia, anxiety, mydriasis, and increased pulse and blood pressure. Therefore, the other options are incorrect.
Management, Prioritization and Delegation The nurse is analyzing laboratory values for assigned clients. Which finding, based on the client's medical history, indicates the need for immediate follow up? 1.) Client with diabetes mellitus and a glycosylated hemoglobin A (HbA1c) of 7% 2.) Client with chronic kidney disease and a serum creatinine of 1.6 mg/dL 3.) Client with heart failure and a B-type natriuretic peptide (BNP) of 140 pg/mL 4.) Client who is male and has anemia with a hemoglobin of 16.5 g/dL
Answer: 3 Rationale: The client with a history of heart failure with a BNP level of 140 pg/mL requires immediate follow-up. Levels above 100 pg/mL indicate the presence of heart failure, and the higher the value the greater the degree of failure. The normal serum creatinine level is 0.5 to 1.2 mg/dL. A serum creatinine of 1.6 mg/dL for a client with chronic kidney disease is expected. An HbA1c level of 7% and below indicates good blood glucose control over a period of 3 to 4 months. The normal hemoglobin is 12-18 g/dL and hematocrit is 37-52% for the male client.
Pharmacology math Order: Pitocin 2 milliunits/min Supply: 20 units/500 mL D5W Calculate rate for this dose....mL/hour
Answer: 3 mL/hour Dosage: 2 milliunits x 60 min= 120 milliunits/hour Lowest concentration: 20 units/500 mL= 20,000 milliunits/500 mL= 40 milliunits/mL 120 milliunits per hour/ 40 milliunits x 1 mL = 3 mL/hour (Pitocin is a high alert medication)
Pediatrics: The nurse monitors a child with increased intracranial pressure for signs of decerebrate posturing. The nurse observes for which characteristic of this type of posturing? 1.) Rigid flexion of all extremities 2.) Flaccid paralysis of all extremities 3.) Abnormal flexion of the upper extremities 4.) Abnormal extension of the upper extremities
Answer: 4 Rationale: Decerebrate posturing is an abnormal extension of the upper extremities with internal rotation of the upper arms and wrists and extension of the lower extremities with some internal rotation. Option 3 describes decorticate posturing. Options 1 and 2 are incorrect descriptions.
Mental Health The nurse should monitor a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal? 1.) Increased appetite, irritability, anxiety, restlessness, and altered concentration 2.) Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and marked tremor 3.) Depression, high drug craving, fatigue, altered sleep patterns, hypertension, agitation, and paranoia 4.) Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis
Answer: 4 Rationale: Opioids are central nervous system depressants. They generally cause drowsiness and the feeling of being out of touch with the world. Withdrawal occurs within 12 hours after the last dose. Option 4 identifies the signs and symptoms associated with opioid withdrawal. Option 1 describes cocaine withdrawal. Option 2 identifies signs associated with nicotine withdrawal. Option 3 describes alcohol withdrawal.
Pharmacology The nurse is speaking with a client taking phenytoin. The client states that she has started using birth control pills to prevent pregnancy. The nurse becomes concerned, knowing that this combination of medications could have which effect? 1.) Increased risk of thrombophlebitis 2.) Severe gastrointestinal side effects 3.) Decreased effectiveness of phenytoin 4.) Decreased effectiveness of birth control pills
Answer: 4 Rationale: Phenytoin is an anticonvulsant and enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. The nurse must tell the client to alert the primary health care provider so that counseling may be done about alternative birth control methods. The other options are incorrect.
Pediatrics: The nurse in the labor room measures an Apgar score on a newborn and notes that it is a 4. The nurse would take which initial action? 1.) Initiates an IV line in the newborn 2.) Places the newborn under a radiant warmer 3.) Places the newborn on a cardiorespiratory monitor 4.) Administers oxygen to the newborn via a resuscitation bag
Answer: 4 Rationale: The immediate nursing action is to administer oxygen via a resuscitation bag. The Apgar score is a measure of the physical condition of a newborn infant, and is obtained by adding points (2, 1, or 0) for heart rate, respiratory effort, muscle tone, response to stimulation, and skin coloration. Newborns with an Apgar score of 5 to 7 often require resuscitative interventions. Scores of less than 5 indicate that the newborn is having difficulty adjusting to extra uterine life and requires vigorous resuscitation. Although the newborn may require a cardiorespiratory monitor and an IV line and may need to be under a radiant warmer, the initial action of the nurse would be to provide resuscitative measures.
Adult Health The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT) who is scheduled for an emergency appendectomy. Vitamin K is ordered for immediate administration. The international normalized ratio (INR) value is 1.0. Which nursing action is most appropriate? 1.) Administer the medication as ordered. 2.) Hold the medication and record in the electronic medical record. 3.) Hold the medication until the lab result is repeated to verify results. 4.) Administer the medication and seek an increased dose from the health care provider.
Answer: B Rationale: Vitamin K is the antidote to warfarin (Coumadin), which the patient has most likely been taking before admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore, it may be necessary to give vitamin K before surgery to reduce the risk of hemorrhage. However, the INR value is normal, and vitamin K is not required, so the medication would be held and recorded in the electronic medical record.