CAI Module 5 Practice Exam
A patient who had a long leg cast applied this morning asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request?
"Excess edema and complications are prevented when the leg is elevated for 24 hours"
When teaching the patient with acute hepatitis C (HCV), which statement demonstrates understanding of the disease process?
"I will need to be monitored for chronic HCV and other liver problems."
During the discharge teaching for the client with Addison's disease, which statement by the client indicates that the nurse needs to do additional teaching?
"If my weight goes down, my dosage of steroid is probably too high" A weight reduction in the client with Addison's disease may indicate a fluid loss and a dose of replacement therapy that is too low rather than too high.
The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which person should the nurse refer for an immunoglobulin (IG) injection?
A caregiver with no history of hepatitis A antibodies who lives in the same household with the patient IG is recommended for persons who do not have anti-HAV antibodies and are exposed because of close contact with persons who have HAV or foodborne exposure. Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG
When providing discharge teaching for a patient after a laparoscopic cholecystectomy, what information should the nurse include?
A low-fat diet may be better tolerated for several weeks
A client with diabetes insipidus is treated with nasal desmopressin acetate (DDAVP). The nurse determines that the drug is not having an adequate therapeutic effect when the client experiences what?
A urine specific gravity of 1.002 Normal range is 1.005 to 1.030
A patient with cholelithiasis is being prepared for surgery. Which patient assessment represents a contraindication for a cholecystectomy?
Activated partial thromboplastin time (aPTT) of 54 seconds An aPTT of 54 seconds is above normal (21-35 seconds) and indicates insufficient clotting ability (significant bleeding complications very likely)
A client with hypoparathyroidism resulting from surgical treatment of hyperparathyroidism is preparing for discharge. What should the nurse teach the client?
Calcium supplements with vitamin D can effectively maintain calcium balance The hypocalcemia that results from PTH deficiency is controlled with calcium and vitamin D supplementation and possibly oral phosphate binders. Replacement with PTH is not used because of antibody formation to PTH, the need for parenteral administration and cost.
A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?
Chvostek's sign
The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What is the nurse's priority?
Control abdominal pain Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated.
The client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What manifestation should the nurse expect to find?
Decreased urine output
When replacement therapy is started for a client with long-standing hypothyroidism, what is most important for the nurse to monitor for in the client?
Dysrhythmias All of these manifestations may occur with treatment of hypothyroidism. However, as a result of the effects of hypothyroidism on the cardiovascular system, when thyroid replacement therapy is started, myocardial oxygen consumption is increased and the resultant oxygen demand may cause angina, cardiac dysrhythmias, and heart failure, so monitoring for dysrhythmias is most important.
A patient has a plaster cast applied to the right arm for a Colle's fracture. Which nursing action is most appropriate?
Elevate the right arm on 2 pillows for 24 hours The casted extremity should be elevated at or above heart level for 24 hours to reduce swelling or inflammation. The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast.
What diagnostic test should the nurse anticipate for an older patient who is vomiting "coffee-ground" emesis?
Endoscopy
The nurse is caring for a patient admitted with a suspected bowel obstruction. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture?
High-pitched and hyperactive above the area of obstruction Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high pitched, sometimes referred to as "tinkling," above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.
A patient with chronic hepatitis B is being discharged with pain medication after knee surgery. Which medication order should the nurse question?
Hydrocodone with acetaminophen The analgesic with acetaminophen should be questioned because this patient has chronic hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because is is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.
A client with Addison's disease comes to the ED with complaints of nausea, vomiting, diarrhea, and fever. What interprofessional care should the nurse expect?
IV administration of hydrocortisone
The client has peritonitis, which is a major complication of ruptured appendix. Which treatment should the nurse plan to include?
IV fluid replacement IV fluid replacement along with abx, NG suction, analgesics, and potential surgery would be expected.
The patient brought to the emergency department after a car accident is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus?
Immobilize the fracture preoperatively The nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus development before surgical reduction. Enoxaparin is used to prevent blood clots, not fat emboli.
A client is scheduled for a bilateral adrenalectomy. During the postoperative period, what should the nurse expect related to administration of corticosteroids?
Increased to promote adequate response to the stress of surgery Although the client with Cushing syndrome has excess corticosteroids, removal of the gland and the stress of surgery require that high doses of corticosteroids be administered postoperatively for several days before weaning the dose.
A patient in the emergency department has just been diagnosed with peritonitis from a ruptured diverticulum. Which prescribed intervention will the nurse implement first?
Infuse metronidazole (Flagyl) 500 mg IV. Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained).
A patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. Which intervention should the nurse include in the patient's plan of care?
Insert an NG tube and maintain NPO status to allow pancreas to rest
The home care nurse visits a 74 y/o man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse?
Left leg externally rotated and shorter than the right leg
A patient underwent amputation below the knee on the left leg after a traumatic accident. Which intervention should the nurse include in the plan of care?
Lie prone with the hip extended for 30 minutes 4 times a day To prevent hip flexion contractures, the patient should lie on the abdomen for 30 minutes 3 or 4 times each day and position the hip in extension while prone. The patient should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.
A patient with a fracture of the proximal left tibia in a long leg cast reports of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority?
Notify the health care provider immediately
Which complication of acute pancreatitis requires prompt surgical drainage to prevent sepsis?
Pancreatic abscess A pancreatic abscess, usually from an infected pseudocyst, is a collection of pus that must be drained to prevent infection of adjacent organs and sepsis. Tetany from hypo Ca is treated w/ IV calcium gluconate. Although pseudocysts usually resolve spontaneously, they may be treated with surgical, percutaneous catheter, or endoscopic drainage to prevent perforation. Pleural effusion is treated by treating the cause (pancreatitis) and monitoring for respiratory distress and O2 sat
An important nursing intervention for a client with a small intestinal obstruction who has an NG tube is to:
Provide mouth care frequently Mouth care should be done frequently for the client with a small intestinal obstruction who has an NG tube because of vomiting, fecal taste and odor, and mouth breathing. The position of the client should be one of comfort.
A patient with a history of peptic ulcer disease presents to the emergency department with severe abdominal pain and a rigid, board-like abdomen. The healthcare provider suspects a perforated ulcer. Which interventions should the nurse anticipate?
Providing IV fluids and inserting a nasogastric (NG) tube
What is one of the most challenging nursing interventions to promote healing in the client with viral hepatitis?
Providing adequate nutrition Adequate nutrition is especially important in promoting regeneration of liver cells, but the anorexia of viral hepatitis is often severe, requiring creative and innovative nursing interventions.
The client comes to the emergency department with intermittent crampy abdominal pain, nausea, projectile vomiting, and dehydration. The nurse suspects a GI obstruction. Based on the manifestations, what area of the bowel should the nurse suspect is obstructed?
Proximal small intestine Intermittent crampy abdominal pain, nausea, and projectile vomiting are characteristics of proximal small intestinal obstruction. Large bowel obstruction is characterized by constipation, low-grade abdominal pain, and abdominal distention. Esophageal sphincter blockage or achalasia feels like food is stuck in the chest. Fecal emesis is seen with distal small intestinal obstruction.
A patient with an intestinal obstruction has a nasogastric (NG) tube to suction but reports of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse?
Reposition the tube and check for placement.
A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take?
Suggest the patient lie on the side, flexing the right leg The client's clinical manifestations are consistent with appendicitis. Lying still with the right left flexed is often the most comfortable position. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe post-op, but coughing will increase pain at this time.
Which assessment should the nurse perform first for a patient who just vomited bright red blood?
Taking the blood pressure and pulse
The nurse is caring for a patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect? SATA
Temperature 99.3 F (37.4 C) Left upper abdominal pain Nausea and vomiting
An injured soldier underwent left leg amputation 2 weeks ago, but now reports shooting pain and heaviness in the left leg. What action by the nurse is supported by research findings?
Use mirror therapy Reduces phantom limb pain in some patients.
