ADAPTIVE QUIZZING

In which process of Swanson's theory is the nurse engaging when explaining neonatal care to a parent?

- Enabling

When the pulse rate for a client with a recent myocardial infarction increases from 70 beats/minute to 135 beats/minute while climbing the stairs, which instruction would the cardiac rehabilitation nurse give to the client?

- "Stand still and rest" An increase in the pulse rate of 20 beats/minute or more indicates an excessive oxygen demand by the heart and that the client should stop and rest before continuing. Cardiac workload and oxygen demand will increase more if the client continues to climb. Though descending the stairs requires less energy than climbing, rest is needed to permit the heart rate to return to normal. Continuing to climb, even at a slower rate, will increase cardiac workload.

Which nursing intervention is appropriate during the first 24 hours after a thyroidectomy when the nurse is concerned about thyroid storm?

- Check vital signs every 2 hours after they stabilize. Checking vital signs helps detect complications such as thyrotoxic crisis, hemorrhage, and respiratory obstruction that may occur early in the postoperative period. Range-of-motion exercises should not begin until 2 to 4 days postoperatively because they can disrupt the suture line. A humidifier can contribute to the spread of bacteria and infection and is contraindicated. Hoarseness and voice weakness usually are temporary and not life threatening; it is appropriate to observe for thyroid storm, hemorrhage, and respiratory obstruction in the first 24 hours.

Which action would the clinic nurse take when a client with chronic obstructive pulmonary disease (COPD) has a 10-mm area of induration after Mantoux testing?

- Document the result as a negative finding A 10-mm induration in a client with COPD would be interpreted as negative and no further action is needed. In this client, a chest x-ray to check for evidence of tuberculosis would be needed for an induration of 15 mm or more. Because the client's Mantoux test is negative, no discussion of latent tuberculosis is needed. The public health department does not need notification for negative Mantoux testing.

Which intervention applies to the care of an infant undergoing phototherapy?

- Exposing as much skin as possible by turning the infant every 2 hours Turning the infant permits optimal skin exposure to the phototherapy lights. The infant's face should not be covered; only the eyes should be covered. Glucose water does not promote excretion of bilirubin in the stools. The supine position would expose only the front of the infant to the lights.

Compromised nutrition during chemotherapy can contribute to an increased risk of infection and other problems. Which actions would the nurse take to offset nutritional deficiencies?

- Provide oral supplements.

The circulating nurse in the operating room recently tested positive for the human immunodeficiency virus (HIV). Which action would this nurse implement regarding participation in exposure-prone procedures?

- Seek approval circumstances and procedures from a review panel Workers who are infected with HIV should seek advice from an expert review panel before performing exposure-prone procedures to determine under which circumstances they may continue to practice these procedures. All health care workers should adhere to standard precautions at all times and not just those who are HIV positive. Workers with exudative lesions or weeping dermatitis should not perform direct client care or handle client care equipment and devices used in invasive procedures. Workers must follow guidelines for disinfection and sterilization of reusable equipment used in invasive procedures.

Which interventions would the nurse implement when administering medications to a 10-year-old child? Select all that apply. One, some, or all responses may be correct.

-Explaining the procedure -Explaining the need to take the medication -Providing activities to relieve the child's aggression

When assessing clients in a mass casualty incident, in which order would the triage nurse assign these clients to be seen by health care providers?

1 Tension pneumothorax 2 Compound fracture of femur 3 Laceration of thigh muscle 4 Severe wrist sprain 5 Crushing head injury In a major disaster, the object is to get the greatest number of survivors treated as rapidly as possible. Critically ill clients who can survive with care are the highest priority to receive services quickly. Tension pneumothorax causes lung collapse and rapid hypoxemia, but can be successfully treated with insertion of a chest tube. Open fractures of long bones are frequently associated with arterial injuries that may result in hemorrhage, but rapid treatment with intravenous solutions and transport to surgery is lifesaving. A laceration of a large muscle is not immediately life threatening and wound care can be delayed. A wrist sprain will result in minimal disability and treatment can be delayed while clients with more severe injuries are managed. A client with a crushing head injury is likely to have had a severe traumatic brain injury and is not likely to survive. In the setting of mass casualty incident, this client would be the lowest priority to be managed.

Which client in the emergency department would the nurse assess first?

1Correct Client with chest pressure and ST segment elevation on the electrocardiogram 2 Client who reports a sharp chest pain with deep inspiration for the past week 3 Client who has history of heart failure with ascites and bilateral 4+ ankle swelling 4 Client with palpitations and paroxysmal atrial fibrillation at a rate of 136 beats/minute

Which intervention would the nurse use for a client taking quetiapine for acute psychosis who develops lead-pipe rigidity, trismus, and tachycardia? Select all that apply. One, some, or all responses may be correct.

Perianal care Correct2 Fall precautions Correct3 Use of a cooling blanket Correct4 Monitoring of intake and output Correct5 Discontinuation of the medication Correct6 Administration of bromocriptine as prescribed The client is demonstrating symptoms of neuroleptic malignant syndrome (NMS). Perianal care would be needed for incontinence. Fall precautions would be instituted for alterations in consciousness. Cooling blankets would be used for pyrexia. Intake and output would be monitored to assess for dehydration caused by diaphoresis, fever, and reduced oral intake because of a change in consciousness. The medication would be discontinued as NMS is a potentially fatal adverse effect of antipsychotic therapy. Symptoms usually last for 5 to 10 days after discontinuation of oral medications and 13 to 30 days with depot antipsychotic medicine. Bromocriptine is a dopamine agonist used to treat NMS.

After hyperbilirubinemia develops in a neonate, phototherapy is prescribed. Which would the plan of care for an infant undergoing phototherapy include?

Taking vital signs every hour Incorrect2 Keeping the eye shields on continuously Correct3 Administering additional fluids every 2 hours 4 Covering the neonate with a lightweight blanket

When an obese client receives a diagnosis of high blood pressure, which topic would be the most important to include in client teaching?

1 Causes of hypertension 2 Symptoms of hypertension Correct3 Effect of weight loss in hypertension 4 Effect of lowering alcohol intake in hypertension

Which child would the nurse plan to start initial tests for lead screening at a scheduled health maintenance visit?

- 18 month old toddler

When writing a disaster plan for implementation during a mass casualty incident (MCI), which percentage of victims often require admission to the hospital for further treatment?

- 30%

A pregnant adolescent reports painful vesicles in the labia minora. The adolescent is diagnosed with a herpes simplex virus infection. Which medication would the nurse expect the primary health care provider to prescribe?

- Acyclovir

Which additional nursing care is needed for the postpartum client after a cesarean birth due to her postsurgical status?

- Administering the prescribed pain medication Because of increased pain and flatus, clients who have had cesarean births require more pain medication than do women who have vaginal births. Wise use of pain medication in the postsurgical client can enable them to be more mobile and to be able to comfortably handle their infants. Early ambulation is encouraged for all postpartum clients. Although this may be difficult because of the incision, palpating the fundus is a necessary part of postpartum care for all clients. Vital signs are checked routinely in all postpartum clients.

The nurse is caring for a child with an exacerbation of leukemia. The nurse would plan to administer the prescribed analgesic for bone pain at which time?

- At scheduled intervals For maximal benefit, the analgesic should be administered at scheduled intervals that are individualized for the child; routine administration manages the pain before it becomes too intense. The goal is to keep the child pain free; by the time the child asks for the analgesic, the pain has returned. It is insensitive to allow the child to be in pain; there should be no pain.

Which factor is most important in predicting a person's reaction to imminent loss and grief?

- Earlier experiences with grief How a person has handled grief in the past provides clues to how she or he will cope with grief in the present. Although family interactions, social support system, and emotional relationships are all important, they are less predictive for a client's reaction to grief.

Which time period would the nurse choose to prepare a preschooler for a surgical procedure before the actual surgery?

- Several days Several days are needed to allow the preschooler to adjust to the idea of and prepare for an intrusive procedure. It provides time to visit the hospital department where the procedure will take place, handle equipment, and engage in therapeutic play. One week is too far in advance; the child may be fearful for an unnecessarily prolonged period. Several minutes is more appropriate for a toddler. Several hours does not allow enough time for adequate preparation.

A client is admitted to the hospital with the diagnosis of cancer of the thyroid, and a thyroidectomy is scheduled. What is important for the nurse to consider when caring for this client during the postoperative period?

1 Hypercalcemia may result from parathyroid damage. 2 Hypotension and bradycardia may result from thyroid storm. 3 Tetany may result from underdosage of thyroid hormone replacement. Correct4 Hoarseness and airway obstruction may result from laryngeal nerve damage

The nurse must administer streptomycin 1 g intramuscularly (IM) to a client. The vial contains 500 mg/mL. How much solution must the nurse administer? Record your answer using a whole number. ___ mL

- 2 The prescribed dose is 1 g. The available concentration is 500 mg/mL. Use the dimensional analysis and/or ratio and proportion methods to determine how many milliliters the nurse would administer. When using the ratio and proportion method, first convert the prescribed dose unit to the available concentration unit.

The client complains of pain in her or his abdomen and nausea at mealtime. An x-ray technician also approaches at the same time for a routine x-ray. Which order of nursing actions is correct?

Correct1. Administering the analgesic as prescribed Correct2. Administering medications to decrease nausea Correct3. Assisting the client with feeding Correct4. Assisting the x-ray technician for the x-ray

In which position would the nurse place an infant who just underwent surgery for a cleft lip?

- Low fowlers The low Fowler or supine position prevents the incision from coming into contact with the mattress and is the preferred position for infants. Lying prone causes frictional contact with the mattress and can result in stress on the suture line. Both the left and right side-lying positions may cause stress on the suture line. Although holding the infant is recommended, positioning the infant on the caregiver's shoulder may cause friction on the suture line if the baby's head should drop forward.

Which information will the nurse consider when planning care for a client with human immunodeficiency virus (HIV) who has been diagnosed with class 3 tuberculosis? Select all that apply. One, some, or all responses may be correct.

Class 3 tuberculosis is a clinically active disease, which is contagious. Tuberculosis is the leading cause of mortality in clients infected with HIV Persons with active tuberculosis are usually treated on an outpatient basis. Class 3 tuberculosis is a clinically active and contagious disease; it is diagnosed either with positive bacteriological studies, or with both a significant reaction to a tuberculin skin test and clinical or x-ray evidence of current disease. Tuberculosis is the leading cause of mortality in clients with HIV infection. Persons with active tuberculosis are usually treated on an outpatient basis, and this does not change based on the client's HIV status. Although clients with HIV are more likely to develop active tuberculosis, they are not more likely to develop multidrug resistant tuberculosis. Immune-compromised clients, such as individuals who are HIV positive, are less likely to have high fever because of a diminished inflammatory and immune response to infection. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation

Postoperative arterial blood gas values for a client in the postanesthesia care unit are pH 7.32, PaCO2 53 mm Hg (7.05 kPa), HCO3 25 mEq/L (25 mmol/L), and PaO2 85 mm Hg (11.3 kPa). Which action would the nurse take?

- Encourage the client to take deep breaths and cough

When a client is admitted to the coronary care unit with a diagnosis of ST segment elevation myocardial infarction, how will the nurse expect the client to describe the pain?

1 Correct Severe, intense chest pain 2 Burning sensation of short duration 3 Sharp, stabbing chest pain with breathing 4 Squeezing chest pain, relieved by nitroglycerin

In which order would the nurse take these prescribed actions when caring for a client with chronic obstructive pulmonary disease (COPD) who is admitted with fever, increased dyspnea, and oxygen saturation of 86%?

1 Start oxygen per nonrebreather mask. 2 Obtain blood and sputum cultures. 3 Infuse ceftriaxone 1 g intravenously 4 Administer acetaminophen for fever

Which intervention would the nurse include in the plan of care for a client admitted with herpes zoster? Select all that apply. One, some, or all responses may be correct.

- Acyclovir - Silvadene - Gabapentin -Wet compresses - Contact isolation A client with herpes zoster would receive antiviral medications such as acyclovir. Silvadene can be applied to open vesicles. Gabapentin can be used to treat the nerve pain associated with herpes zoster. Wet compresses can be applied to the vesicles to relieve discomfort. Herpes zoster is highly contagious, and the client would be placed in contact isolation precautions.

Which parent education would the nurse provide about the preferred carrying position for an infant with cerebral palsy prone to scissoring of the legs?

- Astride one of her hips Muscular hypertonicity often causes scissoring of the legs in infants with cerebral palsy, and prolonged periods in such positions may worsen the infant's musculoskeletal health. Carrying the infant astride the parent's hip prevents scissoring by keeping the infant's legs abducted. An infant seat will not prevent scissoring. Tight wrapping maintains the infant's legs in a scissored position. When the football hold is used, the infant is carried in a supine position with the legs adducted, which promotes scissoring.

Which is the priority nursing action for a client admitted to the hospital in a coma after having a stroke?

- Maintain an open airway