EXAM 2: DAVIS CARDIO MIX
A client is hospitalized for heart failure secondary to alcohol-induced cardiomyopathy. The client is started on milrinone (Primacor®) and placed on a transplant waiting list. The client has been curt and verbally aggressive in expressing dissatisfaction with the medication orders, overall care, and the need for energy conservation. A nurse should interpret that the client's behavior is likely related to the client's: 1. denial of the illness. 2. reaction to milrinone (Primacor®). 3. fear of the diagnosis. 4. response to cerebral anoxia.
ANSWER: 3 A threatening situation (need for heart transplant) can produce fear. Fear and helplessness may cause a client to verbally attack health team members to maintain control. There is no supporting evidence that the client denies the existence of a health problem. Minimizing symptoms or noncompliant behaviors would indicate denial. Milrinone is used in short-term treatment of congestive heart failure unresponsive to conventional therapy with digoxin, diuretics, and vasodilators. It increases myocardial contractility and decreases preload and afterload by direct dilating effect on the vascular smooth muscle. It does not cause behavior changes. Although a low cardiac output may lead to cerebral anoxia, there is insufficient evidence in this situation to support the conclusion of cerebral anoxia causing the client's reaction. ➧ Test-taking Tip: Focus on the issue, the client's reaction to the illness and hospitalizat
A nurse checks on a client following lower lobectomy for lung cancer. The nurse finds that the client is dyspneic with respirations in the 40s, is hypotensive, has a SaO2 at 86% on 10 L close-fitting oxygen mask, has a trachea that is deviated slightly to the left, and notes that the right side of chest is not expanding. Which action should be taken by the nurse first? 1. Notify the physician 2. Give the client whatever medication was ordered to decrease anxiety 3. Check the chest tube to make sure it is not obstructed 4. Turn up the oxygen liter flow
ANSWER: 3 The scenario presented implies that the client is suffering from a tension pneumothorax as a result of a kinking of the tubing or other blockage in the chest tube system. Although notifying the physician would be warranted, unkinking tubing would give some immediate relief and would be the best initial action. Neither turning up the oxygen flow nor treating the client for anxiety would correct this problem. ➧ Test-taking Tip: Use the steps of the nursing process; assessment should be considered as the best answer.
· pt w/ thrill:
assess for murmurs
· med/surge: pt dx w/ bacterial pneumonia. priority:
assess resp rate & depth.
pt w/ chest tube. what should be at bedside?
hemostate
· tachy strip: select all that apply:
hypoxia, anxiety, acute MI, fever, pain
· pt w/ dilated cardiomyopathy. s/s: hypotension & pulmonary edema:
inform him of grave prognosis
· chest tube is pulled out of pleural space:
tape petroleum jelly dressing on 3 sides
The nursing is administering digoxin, a cardiac glycoside, to the client with congestive heart failure. Which interventions should the nurse implement? Select all that apply. 1. Check the apical heart rate for one (1) full minute. 2. Monitor the client's serum sodium level. 3. Teach the client how to take his or her radial pulse. 4. Evaluate the client's serum digoxin level. 5. Assess the client for buffalo hump and moon face.
1. Check the apical heart rate for one (1) full minute.. 3. Teach the client how to take his or her radial pulse. 4. Evaluate the client's serum digoxin level.
26. The client admitted with a diagnosis of pneumonia complains of tenderness and pain in the left calf, and the nurse assesses a positive Homans' sign. Which interventions should the nurse implement? List in order of priority. 1. Notify the health-care provider. 2. Initiate an intravenous line. 3. Monitor the client's PTT. 4. Administer a continuous heparin infusion. 5. Instruct the client not to get out of the bed.
5,1,2,4,3
A normally healthy client has a 5-mm skin induration 72 hours after receiving a tuberculin skin test. Which conclusions should the nurse make regarding the test results? 1. This is negative for a normally healthy person. 2. This indicates that active tuberculosis is present and treatment is needed. 3. This is inconclusive, and a chest x-ray is needed to detect active tuberculosis (TB). 4. This is inaccurate because the assessment was done too long after the injection.
ANSWER: 1 An area of induration measuring 15 mm in diameter or greater in a person with no known risk factors for TB and read 48 to 72 hours after injection is a positive TB test. An induration of 5 mm or greater would be a positive result in HIV-infected persons. A positive test indicates exposure to TB. The result is negative for TB rather than inconclusive. Evidence-based practice guidelines indicate that a reading at 72 hours is more accurate than one at 48 hours. ➧ Test-taking Tip: Note the key phrase "normally healthy" in both the stem and option 1.
. A nurse is caring for a client suspected of pulmonary embolism. The client's arterial blood gas (ABG) results indicate respiratory alkalosis. Which findings support this diagnosis? 1. pH = 7.54; PaCO2 = 25; HCO3 = 24 2. pH = 7.35; PaCO2 = 35; HCO3 = 22 3. pH = 7.50; PaCO2 = 40; HCO3 = 28 4. pH = 7.32; PaCO2 = 48; HCO3 = 24
ANSWER: 1 Because pulmonary emboli interfere with gas exchange, the respiratory center is stimulated to meet oxygenation demands. The tachypnea produces respiratory alkalosis. Thus, the pH is increased above normal of 35 to 45 and the PaCO2 is lower than the normal level of 35 to 45 mm Hg. The HCO3 is normally 22 to 26 mEq/L. The blood gas in option 2 is normal, option 3 represents metabolic alkalosis, and option 4 is indicative of respiratory acidosis. ➧ Test-taking Tip: First look at the pH and eliminate the option with a decreased pH because this indicates acidosis. Of the remaining options, look at the PaCO2 because it is the respiratory component for arterial blood gases (ABG) analysis. Select the option with the decreased PaCO2 because a low PaCO2 is present in respiratory alkalosis.
A client admitted with unstable angina is started on intravenous heparin and nitroglycerin. The client's chest pain resolves, and the client is weaned from the nitroglycerin. Noting that the client had a synthetic valve replacement for aortic stenosis 2 years ago, a physician writes an order to restart the oral warfarin (Coumadin®) 5 mg at 1900 hours. Which is the nurse's best action? 1. Administer the warfarin as prescribed. 2. Call the physician to question the warfarin order. 3. Discontinue the heparin drip and then administer the warfarin. 4. Hold the dose of warfarin until the heparin has been discontinued.
ANSWER: 1 Both heparin and warfarin are anticoagulants, but their actions are different. Oral warfarin requires 3 to 5 days to reach effective levels. It is usually begun while the client is still on heparin. Calling the physician is unnecessary. The nurse's scope of practice does not permit altering medication orders. The nurse should neither discontinue the heparin nor hold the warfarin without a written order. ➧ Test-taking Tip: Use the process of elimination to eliminate options 3 and 4, which alter medication orders, because these are not within the nurse's scope of practice. Of the two remaining options, focus on the action of heparin and warfarin. Recall that warfarin takes 3 to 5 days to reach therapeutic effectiveness, during which time the client will continue to require anticoagulation.
. A hospitalized client is being treated for tuberculosis (TB). When administering medications, which medication on the client's medication administration record (MAR) should a nurse conclude is used for the treatment of TB? 1. Isoniazid (Nydrazid®) 2. Fluconazole (Diflucan®) 3. Azithromycin (Zithromax®) 4. Acyclovir (Zovirax®)
ANSWER: 1 Isoniazid (INH) is an antimycobacterial medication affecting bacterial cell wall synthesis; it is used in the treatment of TB or other mycobacterial infections. Fluconazole is an antifungal agent that inhibits synthesis of fungal sterols, a necessary component of the cell membrane. Azithromycin is a macrolide antibiotic that is bacteriostatic against susceptible bacteria and is usually used for treating lower respiratory tract infections, skin infections, acute otitis media, tonsillitis, or Mycobacterium avium. Acyclovir is an antiviral agent limited to treatment of herpes viruses. ➧ Test-taking Tip: Read each medication name carefully. Use key letters in each medication to determine the medications use ("-azone" is antifungal; "-vira" is antiviral) and eliminate options that do not pertain to a mycobacterium.
. A client is admitted with a diagnosis of acute infective endocarditis (IE). Which findings during a nursing assessment support this diagnosis? SELECT ALL THAT APPLY. 1. Skin petechiae 2. Crackles in lung bases 3. Peripheral edema 4. Murmur 5. Arthralgia 6. Decreased erythrocyte sedimentation rate (ESR)
ANSWER: 1, 2, 3, 4, 5 Vegetations that adhere to the heart valves can break off into the circulation, causing embolism, valve incompetence, and a murmur. A vascular sign of microembolism is skin petechiae. Crackles and peripheral edema occur due to heart failure secondary to IE. Arthralgia (joint pain) can occur from microembolism and inadequate perfusion. The ESR (rate at which red blood cells settle) should increase, not decrease, during an inflammatory process. ➧ Test-taking Tip: The issue of the question is signs and symptoms of infective endocarditis. Recall that the endocardium is the inner surface and cavities of the heart and that in IE microorganisms and debris from the inflammatory process can adhere to heart valves. Select signs and symptoms indicating the heart valves are affected and also those that can occur if portions of the vegetation should break off into the circulation.
A nurse is told by a client of an advance health-care directive that was completed 8 years ago. The nurse looks in the medical record for the advance directive to review its content. Which content should the nurse expect the advance health-care directive to include? SELECT ALL THAT APPLY. 1. Preference for health-care treatment 2. Preference for hospitalization 3. Violation of client confidentiality 4. Do-not-resuscitate orders 5. Notification of next of kin 6. Durable power of attorney for health care
ANSWER: 1, 2, 4, 6 An advance directive is a written document that provides direction for health care in the future, when clients may be unable to make personal treatment choices. Client confidentiality and next-of-kin notification does not pertain to direction for health care. ➧Test-taking Tip: Select options that address wishes pertaining to health care.
. A nurse evaluates that a client understands discharge teaching, following aortic valve replacement surgery with a synthetic valve, when the client states that he/she plans to: SELECT ALL THAT APPLY. 1. use a soft toothbrush for dental hygiene. 2. floss teeth daily to prevent plaque formation. 3. wear loose-fitting clothing to avoid friction on the sternal incision. 4. use an electric razor for shaving. 5. report black, tarry stools. 6. consume foods high in vitamin K, such as broccoli.
ANSWER: 1, 3, 4, 5 A synthetic heart valve requires long-term anticoagulation because of the risk of thromboembolism. Because low-dose aspirin, which prevents platelet aggregation, and oral anticoagulation together are more effective than just oral anticoagulation to reduce the risk of thromboembolism after valve replacement, both are prescribed, which increases the risk for bleeding. Bleeding precautions while on anticoagulation include using a soft toothbrush, avoiding injury (such as can occur with flossing), and using an electric razor. The client will have a sternal incision. Care must be taken to avoid tissue trauma. Black, tarry stools are a sign of bleeding. Flossing should be avoided because it causes tissue trauma, increases the risk of bleeding, and increases the risk of infective endocarditis. The diet should contain normal amounts of vitamin K; excessive amounts antagonize the effects of the anticoagulant. ➧ Test-taking Tip: Focus on the issue: self-care following a synthetic valve replacement. Recall that anticoagulation will be required. Select options that include bleeding precautions and signs of bleeding.
. A nurse is planning care for a client admitted with a new diagnosis of persistent atrial fibrillation with rapid ventricular response. Although the client has had no previous cardiac problems, the client has been in atrial fibrillation for more than 2 days. The nurse should anticipate that the health-care provider is likely to initially order: SELECT ALL THAT APPLY. 1. oxygen. 2. immediate cardioversion. 3. administration of amiodarone (Cordarone®). 4. initiation of a IV heparin infusion. 5. immediate catheter-directed ablation of the AV node. 6. administration of a calcium channel antagonist such as diltiazem (Cardizem®).
ANSWER: 1, 3, 4, 6 The ineffective atrial contractions or loss of atrial kick with atrial fibrillation can decrease cardiac output. Administering oxygen enhances tissue oxygenation. Amiodarone is used for pharmacological cardioversion of the atrial fibrillation rhythm. The client is at risk for thrombi in the atria from stasis. Anticoagulant therapy is used to prevent thromboembolism. Diltiazem, a calcium channel antagonist, is prescribed to slow the ventricular response to atrial fibrillation. An alternative to a calcium channel antagonist would be the use of a beta blocker, such as esmolol, metoprolol, or propranolol. Cardioversion would only be considered if medications were ineffective in converting the client's rhythm and only after the presence of an atrial clot has been ruled out. Ablation of the AV node would only be considered if medications were ineffective in controlling the client's heart rate. ➧ Test-taking Tip: Carefully read the information provided in the stem. The key phrase is "initially order." The nurse should direct interventions at the client's potential complications from the arrhythmia. Note that both options 2 and 5 contain the words "immediate." Eliminate one or both of those options, because both procedures cannot be immediate
. A client on a telemetry unit has a blood pressure (BP)of 88/40 mm Hg, a heart rate of 44 beats per minute, feels faint, and is pale and confused. When caring for this client, which tasks should a registered nurse (RN) delegate to a patient care assistant (PCA)? SELECT ALL THAT APPLY 1. Paging for the charge nurse 2. Paging for a respiratory therapist 3. Applying oxygen per protocol 4. Securing an automatic BP machine 5. Completing a head-to-toe assessment 6. Obtaining a cardiac rhythm strip that the nurse has sent for printing at a central location
ANSWER: 1, 4, 6 Because the client's condition is deteriorating, additional assistance is needed. The PCA should be able to page for the charge nurse, secure an automatic BP machine, and obtain a printed rhythm strip. There is no indication of respiratory distress, so it is unnecessary to page for a respiratory therapist. The RN should apply the oxygen and complete a focused assessment, not a complete head-to-toe assessment. ➧ Test-taking Tip: Focus on the client's symptoms to eliminate options that do not pertain, such as paging a respiratory therapist. RN-only responsibilities, including assessment and evaluation of information, should not be delegated to the PCA.
. An older adult, hospitalized with chest trauma following a motor vehicle accident, has a right femoral arterial line. Because the client has been thrashing about in bed, a physician writes an order for wrist restraints to be applied. Based on this information, which action by a nurse is correct? 1. Apply the wrist restraints as ordered 2. Request an order for a right ankle restraint also 3. Request an order for sedation instead of restraints 4. Question the order because restraints will increase the client's agitation
ANSWER: 2 An ankle restraint will help prevent dislodgement of the arterial catheter and bleeding and injury that could occur from thrashing in bed. While applying wrist restraints will prevent side-to-side movement, it will not keep the client's right leg straight to prevent catheter dislodgement. The client has chest trauma. Sedation may compromise the client's respiratory status. While restraints can increase agitation, especially for an older adult, keeping one leg unrestrained may prevent this from occurring. Safety of the client is priority. ➧ Test-taking Tip: Focus on the information provided in the scenario. The issue is an appropriate restraint for a client with chest trauma who also has a femoral arterial catheter. Select the option that protects the client from injury.
A charge nurse of a step-down unit in a hospital plans bed placement for five male clients transferring from a critical care unit. The clients will be transferred into the three open rooms on the unit. The beds are available in two 2-bed rooms and one private room. Which room assignments should be made by the charge nurse? 1. Client B: private room; clients C and E in same room; clients A and D in same room. 2. Client C: private room; clients A and D in same room; clients B and E in same room. 3. Client E: private room; clients B and C in same room; clients A and D in same room. 4. Client C: private room; clients A and B in same room; clients D and E in same room.
ANSWER: 2 Client C has airborne precautions and requires a private room. Clients A and D have the same organism, may be roomed together, and require contact precautions. Clients B and E may be roomed together since both require only the standard precautions. Transmission of hepatitis C occurs mainly with blood and this is addressed with the standard precautions. The other options list client placements that are not as sound in preventing infection transmission. ➧ Test-taking Tip: Read the chart carefully. Client C with airborne precautions may have infectious tuberculosis and definitely requires a private room. This eliminates options 1 and 3. Determine that clients A and D require contact precautions for the same organism and clients B and E both require standard precautions and select option 2.
In reviewing a physician's orders for a postoperative client who underwent gynecological surgery, which order should a nurse determine is specifically written with the intent to prevent postoperative thrombophlebitis and pulmonary embolism? 1. Have the client dangle the legs the evening of surgery 2. Administer enoxaparin (Lovenox®) 40 mg subcutaneously daily 3. Administer hydromorphone (Dilaudid®) 1 to 4 mg IV every 3 to 4 hours as needed (prn) 4. Encourage coughing and deep breathing (C&DB) every hour while awake
ANSWER: 2 Enoxaparin is an anticoagulant that potentiates the inhibitory effect of antithrombin on factor Xa and thrombin. Early postoperative ambulation instead of dangling is a major preventive technique for thrombophlebitis. Hydromorphone is a narcotic analgesic for pain control. Coughing and deep breathing promote lung expansion and prevent atelectasis and pneumonia. ➧ Test-taking Tip: Note the key words "specifically written," and then eliminate options 1, 3, and 4 because they are not specific to preventing postoperative thrombophlebitis and pulmonary embolism. Knowledge of m
. A client, with a lower leg amputation, is experiencing edema, so a nursing assistant (NA) elevates the client's residual left limb on pillows. What is the most appropriate action by the nurse when observing that the client's leg has been elevated? 1. Thank the NA for being so observant and intervening appropriately. 2. Remove the pillows, raise the foot of the bed, and inform the NA that the limb should not be elevated on pillows because it could cause a flexion contracture. 3. Inform the NA that this was the correct action at this time in the client's recovery, but once the client's incision heals the leg should not be elevated. 4. Report the incident to the surgeon and tell the NA to complete a variance report because the client's leg should not have been elevated.
ANSWER: 2 Flexion, abduction, and external rotation of the residual lower limb are avoided to prevent hip contracture. All other options are incorrect. It is unnecessary for the nurse to report the incident to the surgeon and to complete a variance report unless the client was in the position for an extended period of time. ➧ Test-taking Tip: Select the option that is most complete and yet addresses the issue with the nursing assistant.
A client diagnosed with cardiomyopathy is hyponatremic as a result of fluid volume overload. A fluid restriction of 800 mL/24 hours is ordered by a physician. Which action by the nurse is most appropriate? 1. Provide ice chips and refill the glass every 4 hours. 2. Encourage the client to perform mouth care when feeling thirsty. 3. Offer sugary lozenges for the client to hold in the mouth. 4. Replenish the client's water every 2 hours and have the client take small sips.
ANSWER: 2 Frequent mouth care can help to reduce the sensation of thirst. Ice chips are considered fluid and should be included in the intake volume. A full glass of ice chips is equivalent to 120 mL of fluid. If replaced every
. An 80-year-old client is living in an independent living facility with home health nursing support. The client is diagnosed with pneumonia and started on an oral antibiotic. Which nursing diagnosis would be most appropriate for this client? 1. Risk for imbalanced nutrition 2. Risk for fluid volume deficit 3. Fluid volume deficit 4. Fluid volume excess
ANSWER: 2 The diagnosis of pneumonia may result in fever or increased respiratory rate that increases amount of fluid lost. Additionally, older adults have a decreased sensation of thirst. Nutrition may be affected due to a diagnosis of pneumonia, but fluid volume would be the greatest concern with pneumonia. The client's age and a diagnosis of pneumonia could result in a fluid volume deficit, but there is no information to support that the client is deficient in fluid. There is no information to support an excess fluid volume. ➧ Test-taking Tip:The key phrase is "most appropriate." To have an actual nursing diagnosis, rather than a "risk for," information must be present to support the nursing diagnosis.
A nurse is partnered with a patient care assistant (PCA) on a medical-surgical floor. The PCA provides information about the clients for whom the PCA has been caring. Based on the information from the PCA, which client should the nurse attend to first? 1. The client with a pulmonary embolus who has not had a bowel movement in 2 days 2. The client who underwent a video thoracoscopy with oxygen saturation readings from 88% to 90% on oxygen at 4 L/NC 3. The client who underwent a wedge resection of right lung and has a blood pressure of 100/65 mm Hg 4. The client who has rib fractures and has not voided for 6 hours after the urinary catheter was removed
ANSWER: 2 The most concerning report from the PCA is regarding the client who is not maintaining oxygen saturations despite receiving oxygen. None of the other clients have potentially life-threatening conditions or concerns that could not later be addressed. Although the blood pressure is low in option 3, it is only one data point and obtaining a repeat reading should be delegated to the PCA.
A client has a peripheral intravenous (IV) line with a piggyback line, oxygen at 2 liters per nasal cannula, an as needed (prn) nebulizer treatment, and a chest tube connected to a chest drainage system. Several family members are present, wanting to be very helpful, and have been placing the oxygen back on when the nasal cannula slips, turning the IV pump off when it alarms, and placing the nebulizer tubing in the mouthpiece of the nebulizer. Which action by the nurse is required for the safe care of the client? 1. Inform the family that they are not allowed to touch any medical equipment 2. Inform the family that they must get help from clinical staff when there is a need to connect tubing or devices 3. Thank the family for noticing when tubing is disconnected and getting the client the treatment required 4. Inform the family that they are only allowed to turn off the IV pump alarm
ANSWER: 2 The nurse should inform nonclinical staff, clients, and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions. The family may touch the equipment; however, they should not operate any client care equipment including answering alarms and reconnecting tubing. The potential for incorrect reconnection exists. Tubing misconnections have resulted in death. ➧Test-taking Tip: Apply knowledge of safety policies and guidelines. Note that only option 2 informs the family of the actions to take for tubing disconnections or devices that are alarming.
A nurse is working with a certified nursing assistant (CNA) and a licensed practical nurse (LPN) in providing care to a group of clients. Which tasks should the nurse assign to the CNA and LPN? 1. CNA to perform simple dressing changes; LPN to assess and care for two noncomplex clients 2. CNA to empty and record urinary catheter bag drainage; LPN to administer oral and intramuscular medications 3. CNA to assist clients with hygiene; LPN to provide postmortem care and meet with a deceased client's family 4. CNA to take and document vital signs on all clients; LPN to complete the discharge paperwork to be reviewed with two clients
ANSWER: 2 The scope of practice for a CNA includes measuring and recording intake and output and for the LPN to administer oral and intramuscular medications. A CNA is able in some facilities to perform a simple dressing change, but if the registered nurse (RN) changes it the RN would be able to assess the incision. An LPN should not be assessing clients. A CNA is able to assist with hygiene, but meeting with the family of a deceased client should be completed by the RN and not the LPN. A CNA is able to take and document vital signs, but the RN should be completing discharge paperwork to be reviewed with the clients. The discharge paperwork often includes a review of the care plan and addressing unmet needs of the client. ➧ Test-taking Tip: Eliminate options that include aspects of the RN role that should not be delegated, including assessment, evaluation, and education
A licensed practical nurse is reporting observations and cares to a registered nurse (RN). Based on the report, which client should the RN assess immediately? 1. The client, 2 hours following a total knee replacement, who has 100 mL bloody drainage in the suction container of an autotransfusion drainage system 2. The client with a crush injury to the arm who was given another analgesic and a skeletal muscle relaxant for throbbing, unrelenting pain 3. The client in a new body cast who was turned every 2 hours and supported with waterproof pillows 4. The client with an external fixator on the left leg, having serous drainage from the pin sites
ANSWER: 2 Throbbing, unrelenting pain could be the first sign of compartment syndrome. The neurovascular status of the extremity should be assessed. Unrelieved pressure can lead to compromised circulation and avascular necrosis. Postoperative drainage from a total knee replacement ranges from 200 to 400 mL during the first 24 hours. This amount is neither alarming nor sufficient enough to autotransfuse. The client in a body cast should be turned q2h to promote drying of the cast. To avoid cracking or denting of the cast, the client is supported with waterproof pillows that touch each other without open spaces. Some serous drainage, which is due to tissue trauma and edema, is expected from pin sites of an external fixator. ➧ Test-taking Tip: Focus on the issue, the client that needs immediate assessment, and use the ABCs (airway, breathing, and circulation). Focus on the information in option 2 that suggests circulation is potentially compromised: throbbing, unrelenting pain.
Because a step-down cardiac unit is unusually busy, a nurse fails to obtain vital signs at 0200 hours for a client 2 days postoperative for a mitral valve replacement. The client was stable when assessed at 0600 hours, so the nurse documents the electrocardiogram monitor's heart rate in the client's medical record for both the 0400 and 0600 vital signs. The charge nurse supervising the nurse determines that the nurse's behavior was: SELECT ALL THAT APPLY. 1. the correct action because neither complications nor harmful effects occurred. 2. a legal issue because the nurse has fraudulently falsified documentation. 3. demonstrating beneficence because the nurse decided what was best for the client. 4. an ethical issue of veracity because the nurse has been untruthful regarding the client's care. 5. an ethical legal issue of confidentiality because the nurse disclosed incorrect information. 6. demonstrating distributive justice because the nurse decided other clients' needs were priority.
ANSWER: 2, 4 Documenting vital signs that the nurse did not obtain is both a legal and ethical concern because documents were falsified and the nurse was untruthful regarding obtaining the vital signs. Veracity is telling the truth and not lying or deceiving others. Even if harm had not occurred, the nurse's behavior of falsifying documentation poses an ethicallegal concern and is never the correct action. Beneficence is doing good. There is no information to indicate the nurse did what was best for the client. Confidentiality relates to privacy and not disclosing private information about another. Documenting incorrect vital signs is not disclosing confidential information. Distributive justice is the distribution of resources to clients. There is no information about the resources available to the nurse. ➧ Test-taking Tip: Focus on the nurse's behavior of falsifying documentation. Avoid reading into the question. Despite the unit being unusually busy, there is no information as to what the nurse was doing during the shift. Eliminate the options that are suggestive of nurse actions other than the behaviors
A nurse is planning care for a client being admitted with newly diagnosed active tuberculosis (TB) secondary to AIDS? Which intervention is most important for the nurse to plan? 1. Monitor for signs of bleeding. 2. Teach strategies for skin care. 3. Institute airborne precautions. 4. Assess CD4 and T-lymphocyte counts.
ANSWER: 3 Active TB can be transmitted by airborne droplet nuclei smaller than 5 microns. The client should be in a private room with negative air pressure and 6 to 12 air exchanges per hour. Persons entering the room should wear a N95 respirator. The client should wear a surgical mask when transported out of the room. The client may be at risk for bleeding due to the effects of antiretroviral therapy, but the situation does not note whether or not the client is receiving treatment. Teaching is important, but not the most important. Although it is important to determine the level of immunodeficiency because the client is at risk for infection, initiating airborne precautions is the most important to prevent transmission of TB. ➧ Test-taking Tip: Focus on the client's condition of TB and the key phrase "most important." Select option 3, knowing that TB is transmitted by airborne droplets.
. A registered nurse (RN) assesses that a client is pale,diaphoretic, dyspneic, and experiencing chest pain. Which actions are best for the nurse to take? 1. Stay with the client, call the charge nurse for help, and call the patient care assistant (PCA) to bring an automatic vital signs machine to the room immediately. 2. Call the PCA to take the client's vital signs while the RN leaves to obtain a narcotic analgesic for administration and notify the charge nurse. 3. Apply oxygen, call the PCA to bring an automatic vital signs machine, and call the charge nurse for help and ask to bring the chart and morphine sulfate noted on the medication record. 4. Activate the emergency system for a code to get immediate help, apply oxygen, and send responders for needed equipment and medication.
ANSWER: 3 Because the client is in distress, the RN should stay with the client, apply oxygen, and obtain help from other members of the health-care team. Asking the charge nurse to bring the chart and morphine sulfate, or other medications noted in the chart, will save time in responding to the situation. The charge nurse should delegate locating the chart and obtaining the medication to another nurse. In option 1 the charge nurse is responding, but then either the nurse or the charge nurse would need to leave the room to obtain needed medication, causing a loss of time in treating the client's pain. In option 2 the RN leaves the room but should have stayed, as the client is in distress. In option 4, the code system should only be activated if the client's pulse or respirations are absent because activation will bring members from multiple departments. Some facilities have an acute response team (ART), which has a different composition of personnel who can respond in emergency situations. ➧ Test-taking Tip: Read each option carefully and systematically. Eliminate any options that allow the nurse to leave the room. Use the ABCs (airway, breathing, circulation) to establish the priority intervention for the RN.
A nurse is preparing to discharge a 10-year-old male client who is hospitalized with the diagnosis of rheumatic fever. The nurse's top priority during the client's discharge teaching should be: 1. providing an avenue for verbalization of feelings regarding illness. 2. providing adequate and appropriate pain medications. 3. ensuring that the client is aware of activity restrictions and the need for adherence. 4. emphasizing the need for long-term prophylactic antibiotic therapy.
ANSWER: 3 Rheumatic fever is a serious illness with many major and minor components. This adolescent is at the developmental age and stage at which it is difficult to ensure compliance with activity level, and the child will want to be very active. Options 1, 2, and 4 are all correct, but option 3 is the priority because nonadherence to activity restrictions can impact cardiac function. ➧ Test-taking Tip: Consider the age of the child and the greatest risk upon returning home after being hospitalized.
A registered nurse (RN) is informed by a nursing assistant (NA) that a client, hospitalized last evening with chest pain, plans to leave right now because the pain is gone and "nobody has done anything anyway." Which is the nurse's best action? 1. Thank the NA for the information and then call the client's doctor regarding the situation 2. Tell the NA that the client has the right to leave and send the NA to help the client pack 3. Talk with the client to discuss the client's concerns and explain the plan of care 4. Tell the NA to inform the client that it is unsafe to leave and that the RN will review the test results with the client shortly responsibility.
ANSWER: 3 Seeing the client provides an opportunity for further assessment and client teaching. The nurse's responsibility is to inform clients of the status of their care. Unjustifiable detention is false imprisonment. The client has a right to leave. Sending the NA to assist the client to pack or to speak to the client is inappropriate delegation of the nurse's responsibilities. Telling the client it is unsafe to leave does not explain why the client should remain in the hospital. Calling the physician is premature. ➧ Test-taking Tip: Focus on the option that uses therapeutic communication techniques and correct decision making regarding the RN's
An infection control nurse receives confirmation from a hospital laboratory that a client has sputum cultures positive for Mycobacterium tuberculosis. According to guidelines issued from the Centers for Disease Control and Prevention (CDC), this is a reportable disease. Which action should be taken by the nurse? 1. Issue a press release to the local news agency. 2. Eliminate health-care workers who have negative tuberculin skin tests from caring for this client. 3. Implement measures to notify the local or state health department of the case. 4. Notify the nearest infectious disease facility and prepare to transfer the client so treatment can be initiated. .
ANSWER: 3 The infection control nurse must notify the local or state health department of the case. States mandate which diseases are reportable, and surveillance is managed through local and state health departments. An official report does not involve the local news media. Airborne precautions should already be in place, controlling the risk for transmission of tuberculosis to health-care workers, including those with negative tuberculin tests. Clients diagnosed with respiratory tuberculosis receive treatment in hospitals, clinics, and at home with specific antibiotic and antitubercular medications. Specific tertiary facilities for treatment of clients with tuberculosis are no longer utilized in the United States. ➧ Test-taking Tip: Read the stem carefully and note that the question calls for a definite requirement to report the disease. Select option 3 because the health departments operate under the guidelines of the CDC
. A nurse who is beginning a shift on a cardiac stepdown unit receives shift report for four clients. In which order should the nurse assess the clients? Prioritize the nurse's actions by placing each client in order from most urgent (1) to least urgent (4). ______ A 56-year-old client who was admitted 1 day ago with chest pain receiving intravenous (IV) heparin and has a partial thromboplastin time (PTT) due back in 30 minutes ______ A 62-year-old client with end-stage cardiomyopathy, blood pressure (BP) of 78/50 mm Hg, 20 mL/hr urine output, and a "Do Not Resuscitate" order and whose family has just arrived ______ A 72-year-old client who was transferred 2 hours ago from the intensive care unit (ICU) following a coronary artery bypass graft and has new onset atrial fibrillation with rapid ventricular response ______ A 38-year-old postoperative client who had an aortic valve replacement 2 days ago, BP 114/72 mm Hg, heart rate (HR) 100 beats/min, respiratory rate (RR) 28 breaths/min, and temperature 101.2°F (38.4°C)
ANSWER: 3, 4, 1, 2 The client with new onset atrial fibrillation should be assessed first because it is the most life threatening. The postoperative client with the elevated temperature should be assessed next because the elevated temperature, RR, and HR increase the demands on the heart and could be a sign of pulmonary complications. Third, the nurse should assess the client with the heparin infusion. PTT results should be back, and the dose may require adjustment. Last, the client with end-stage cardiomyopathy should be assessed. The family will have had time alone with the client, and the client and family may need emotional
. A client, hospitalized for a severe case of pneumonia, is asking a nurse why a sputum sample is needed. The nurse should reply that the primary reason is to: 1. complete the first of three samples to be collected. 2. differentiate between pneumonia and atelectasis. 3. encourage expectoration of secretions. 4. help select the appropriate antibiotic.
ANSWER: 4 Culturing the causative organism and testing sensitivities for the most effective antibiotic is the main reason that a sample is collected. Three samples are taken for a client with suspected tuberculosis. A client with atelectasis may get pneumonia, but generally this is not a test used to diagnose atelectasis. Although secretions are expectorated to obtain a sputum sample, the collection itself does not encourage future expectoration of secretions. ➧ Test-taking Tip: Consider the most basic reason why any sample for microorganisms is taken.
A nursing assistant's (NA) job responsibilities include totaling the intake and output (I&O) records for clients at the end of an 8-hour shift. Near the end of the shift, a licensed practice nurse (LPN) reports to the registered nurse (RN) that a new NA on the unit has not completed the task. What is the RN's best action? 1. Ask the LPN to complete this task because the information is needed to give report 2. Remind the NA that the task needs to be completed as quickly as possible 3. Notify the charge nurse that the NA needs additional orientation on job responsibilities 4. Ask the NA what instruction was given on job responsibilities and ask the NA to state how to total I&O records
ANSWER: 4 Delegation of assigned tasks includes determining the delegate's knowledge and ability to perform the task correctly. Asking what instruction was given may also clarify what the NA was told and what the RN perceives to be the task. It may be that the RN or LPN must give the NA the appropriate forms to be completed after recording the amount for intravenous infusions. Delegation of the NA-assigned job responsibilities is inappropriate and can create tension between team members. Reminding the NA may be insufficient if the NA does not know how to total I&O records. Notifying the charge nurse may be premature. Additional information is needed regarding the reason the NA is not performing the task. ➧Test-taking Tip: Focus on the tasks of delegation
An emergency department nurse is assessing a pediatric client suspected of having acute pericarditis. Which assessment finding should the nurse conclude supports the diagnosis of acute pericarditis? 1. Bilateral lower extremity pain 2. Pain on expiration 3. Pleural friction rub 4. Pericardial friction rub
ANSWER: 4 Inflammation of the pericardial sac from acute pericarditis produces a pericardial friction rub. Decreased perfusion to the extremities can cause extremity pain, but this does not occur with pericarditis. Pain on inspiration, not expiration, is present with pericarditis. The friction rub is pericardial, not pleural. ➧ Test-taking Tip: Focus on the word "pericarditis." "Peri-" is around, "cardio-" pertains to the heart, and "-itis" is inflammation. Eliminate options 1, 2, and 3 because option 4 pertains to the heart.
A client is suspected of having a fat embolism following a pelvic fracture from a motor vehicle accident. A nurse should assess for which sign that is specific to a fat emboli? 1. Dyspnea 2. Chest pain 3. Delirium 4. Petechiae
ANSWER: 4 Petechiae (small purplish hemorrhagic spots on the skin) are thought to be due to transient thrombocytopenia. They can occur over the chest, anterior axillary folds, hard palate, buccal membranes, and conjunctival sacs. The other symptoms are not specific to fat emboli but are associated with blood emboli. Dyspnea and chest pain can occur when pulmonary or cardiac vessels are occluded. Cerebral disturbances, due to hypoxia and the lodging of emboli in the brain, vary from headache and mild agitation to delirium. ➧ Test-taking Tip: Note the key word "specific." This should direct you to option 4.
. A nurse is assessing lung sounds on a client with pneumonia who is having pain during inspiration and expiration. The nurse hears loud grating sounds over the lung fields. The nurse should document the client's pain level and should document that: 1. lung sounds were clear upon auscultation. 2. fine crackles were heard upon auscultation. 3. wheezing was heard upon auscultation. 4. pleural friction rub was heard upon auscultation.
ANSWER: 4 The client with pneumonia may have crackles, rhonchi, and wheezes as well as a pleural friction rub. A pleural friction rub has a distinctive sound that tends to be loud and grating and heard easily over the lung fields upon auscultation. Pleural friction rubs are also often associated with painful breathing. Fine or course crackles will have a moist, bubbling, or Velcro-tearing sound. Wheezing tends to have a high-pitched sound. ➧ Test-taking Tip: Consider the expected assessment findings
PT IN ER SUSPECTED OF CARDIAC PROBLEM .WHICH INTERVENTIONS SHOULD RN DO A.OBTAIN MID-STREAM URIE B.ATTACH TELEMETRY MONITOR C.START SALINE LOCK IN R ARM D.DRAW BASIC METABILIC PANEL E.REQUEST STAT ORDER OF 12 ECG
B.ATTACH TELEMETRY MONITOR C.START SALINE LOCK IN R ARM E.REQUEST STAT ORDER OF 12 ECG
1. These four patients arrive in the emergency department after a motor-vehicle crash. In which order should they been assessed? a. A 22-year-old with fractures of the face and jaw b. A 30-year-old with a misaligned right leg c. A 45-year-old complaining of 6/10 abdominal pain d. A 72-year-old with palpitations and chest pain
Correct Answer: A, D, C, B
When a patient requires defibrillation, in which order will the nurse accomplish the following steps? a. Place the paddles on the patient's chest. b. Turn the defibrillator on. c. Check the location of other personnel and call out "all clear." d. Select the appropriate energy level. e. Deliver the electrical charge. Correct Answer: B, D, A, C, E Rationale:This order will result in rapid defibrillation without endangering hospital personnel
Correct Answer: B, D, A, C, E Rationale:This order will result in rapid defibrillation without endangering hospital personnel
· pt w/ pericarditis.
assess for pulsus paradoxus: korotkoff sounds heard during inspiration & expiratioN
· pt w/ acute pericarditis.
call md if: JVD
· pt taking TB med:
check for hx of liver disease
· homless pt w/ PPD 10mm?
class 3. active tb
· pneumonia: s/s vary
depending on organism
· noncompliant tb pt:
directly observe therapy
discharge teaching on pneumonia:
do deep-breathing & coughing for 6 wks
· pt w/ hypertropic cardiomyopathy. important info:
fam hx of cardiomyopathy
· TB of bones:
lungs most common but can spread to bones
· pt w/ end-stage cardiomyopathy ask about transplant?
many factors determine eligibility. not many hearts are available
· chest tube working not working:
no fluctuation in water-seal
· pt w/ cardiomyopathy is put on hep. hep is used to?
prevent thrombus formation in the "L" ventricle
· pt w/ copd and hospital acquired pneumonia:
pseudomonas aeruginosa
· floating nurse assignment?
pt w/ TB
· TB med:
rifampin, ethambutol, isoniazid, pyrazinamide.
· PMI in 6th intercostal space: y
suspect hypertroph
· pt complains that no one has done anything:
talk to pt about his concerns
A nurse is caring for multiple clients in a nursing home. The nurse knows that a competent client's right to autonomy will be limited by health-care providers when the client is diagnosed with which of the following? 1. Medication-resistant tuberculosis and refuses treatment at the nearest health-care facility 2. Entering the end stage of renal failure and refuses to continue dialysis treatments 3. Severe anemia and refuses blood transfusions based upon religious beliefs 4. Having metastases from breast cancer to the brain and refuses chemotherapy
ANSWER: 1 A client's autonomy is limited when the client has a communicable disease that can endanger others. The client must undergo treatment as directed. Pursuant to a client's rights under the Self-Determination Act of 1990, a client's refusal of treatment must be respected unless it endangers others. ➧ Test-taking Tip: Read the situation carefully. Use the process of elimination to eliminate options in which refusal of treatment would not endanger others.
The parent of a child diagnosed with rheumatic heart disease questions the nurse following the doctor's statement that the child has a heart murmur. The nurse explains that a heart murmur is an abnormal or extra heart sound produced by which malfunctioning structure of the heart? 1. Heart valve 2. Heart vessel 3. Heart chamber 4. Heart conduction
ANSWER: 1 A heart murmur is an abnormal or extra heart sound caused by an incomplete closure of the heart valve. In rheumatic fever, the heart valves are damaged by an abnormal response by the immune system. Erosion of the valves makes them leaky and inefficient, and a murmur of backflowing blood will be heard. A malfunctioning vessel, chamber, or conduction would not produce a heart murmur but would likely affect blood flow, contractility, or cardiac rhythm. ➧ Test-taking Tip: Apply knowledge of anatomy and physiology to answer this question.
A 65-year-old female client, who has endstage cardiomyopathy with an ejection fraction of 10%, tells a nurse that she does not want to be resuscitated if she stops breathing. The client currently has a full resuscitation status noted on the medical record. Based on this information, the nurse should first: 1. inform the client's health-care provider of the request. 2. ask the client if she wishes to complete a written advance health-care directive. 3. document the client's statements in her medical record. 4. advise the client to discuss her wishes with her surrogate decision maker who will make healthcare decisions for her when she is unable to make her own decisions.
ANSWER: 1 A written order instructing the health-care team not to attempt CPR is required. The order must be signed by the health-care provider for it to be valid. The client can complete an advanced health care directive to make her wishes known. This is a directive to the health-care provider indicating the client's wishes requiring resuscitation or other life-sustaining measures; a do not resuscitate (DNR) written order is still required. Health-care professionals can improve the end-of-life decision making for clients by encouraging the use of advance directives. The nurse should document the client's statements and advise the client to discuss her wishes with her surrogate decision maker, but neither of these are the first action. ➧Test-taking Tip:The key word is "first
· pt w/ HF & has JVD:
elevate HOB gradually to assess for JVD
· 23 yo w/ RF. most significant info r/t pt is?
upper resp infection 3 wks ago
