FINAL EXAM 1 REVIEW
The nurse is interviewing the parents of the 3 year old newly diagnosed with hypothyroidism. Which question is most important for the nurse to ask?
"Has your child's physical development been delayed?"
The nurse is providing developmentally appropriate care for a toddler hospitalized for observation following a fall down the steps. Which measures might the nurse consider when caring for this child?
- Avoid leaving small objects that can be swallowed in the bed - Encourage parents to stay to prevent seperation anxiety
The nurse is researching behavioral-cognitive pain relief strategies to use on a 5 year old with unrelieved pain. Which methods might the nurse choose?
- Relaxation - Distraction - Thought spacing
A surgical client has been in the PACU for the past 3 hours. What are determining factors for the client to be discharged from the PACU?
- Stable BP - Sufficient oxygen saturation - Adequate respiratory function
The nurse is performing an admission of a 10 year old boy. Which actions will help the nurse establish a trusting and caring relationship with the child and his family?
- The nurse should initiate introductions - The nurse should maintain eye contact at the appropriate level - The nurse should use age appropriate communication with the child
The nurse is consulting with a child life specialist (CLS) to help minimize the stress of hospitalization for a child. Which services would the CLS provide?
-Activities to support normal growth and development -Grief and bereavement support -Emergency room interventions for children and families
The nurse is providing atraumatic care to children in a hospital setting. What are principles of this philosophy of care?
-Avoid or reduce painful procedures -Avoid or reduce physical distress -Use core primary nursing
The PACU nurse in caring for an adult client who had a left lobectomy. The nurse is assessing the client frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU inside what?
-Hypotension -Dysrhythmias -Hypotension
Emergency services brings a 2 month old into the pediatric emergency department. The mother reports that the child has had vomiting and watery diarrhea for the last 24 hours. The nurse assesses the child and finds her very lethargic with a sunken fontanel and dry mouth. The nurse should following interventions in what order?
-Obtain vital signs including weight -Start an IV and begin giving fluids -Apply a urine bag to collect urine -Draw blood for lab tests
The nurse is determining the amount of IV fluids to administer in a 24 hour period to a child who weighs 40 kg. How many milliliters should the nurse administer?
1900 mL
The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that a nurse should perform on this newly admitted client?
Airway patency
The nurse is administering a liquid medication to a 3 year old using an oral syringe. Which action would be most appropriate?
Allow the child time to swallow the medication in between amounts
The nurse is planning client teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during the teaching session. When is the best time for the nurse to provide teaching?
As soon as possible before the surgical procedure
A 7 year old boy has reentered the hospital for the second time in a month. Which intervention is particularly important at this time?
Assessing his parents' coping abilities
A 77 year old client with diagnosis od congestive heart failure has experienced a downward trend in their hemoglobin levels in recent days, and the care team ordered the administration of two unit of packed RBCs. In the hours following the blood transfusion, the client coplained of increasing SOB, and chest auscultation revealed diffuse crackles. The nurse also noted an increase in the client's peripheral edema, and fluid volume excess (FVE) is suspected. What assessment should the nurse prioritize in the care of this client?
Close monitoring of client's I/Os
The nurse is teaching the student nurse how to communicate effectively with children. Which method would the nurse recommend?
Direct questions and explanations to the child
The OR nurse is participating in the appendectomy of a 20 year old female client who has a dangerously low body mass index. What action should the nurse implement to prevent the development of hypothermia?
Ensure that IV fluids are warmed to the client's body temperature
A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances?
Ensure the client has sufficient potassium intake
The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). The plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the client's health?
Fluid volume status
When providing care to a dying child and his family, which would be most important?
Focusing on the family as the unit of care
When planning the care of a client with a fluid imbalances, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?
Hydrostatic pressure resulting from the pumping action of the heart
The nurse is caring for a client who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastasis. The client reports a new onset of weakness with abdominal pain and further assessment suggests that the client likely has fluid volume deficit. The nurse should recognize that this client may be experiencing what electrolyte imbalance?
Hypercalcemia
The nurse is assessing the client for the presence of Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate?
Hypocalcemia
The nurse is working on a burns unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change, the nurse should expect the client to exhibit signs and symptoms of what imbalance?
Hypovolemia
The intraoperative nurse is implementing a care plan that addresses the surgical client's risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication?
Hypoxia
The nurse is performing a cultural assessment of an Asian family that has a child hospitalized for leukemia. What is the best technique for providing culturally competent care for this family?
Just ask the family about their culture and listen
The nurse is caring for a hospitalized 13 year old girl, who is questioning everything the medical staff is doing and is resistant to treatment. How should the nurse respond?
Let's work together to plan your day along with your treatments
The nurse is caring for a client admitting to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning's blood work, the nurse notices that the client's potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance?
Metabolic acidosis
A priority nursing intervention for a client with hypovolemia involves which of the following?
Monitoring respiratory status for signs and symptoms of pulmonary complications
An OR nurse will be participating in the intraoperative phase of a client's kidney transplant. What action will the nurse prioritize in this aspect of nursing care?
Monitoring the client's physiologic status
Match the disease process with the associated symptom or assessment finding
Mumps - Swollen painful parotid glands Rubeola - Koplik's spots Pertussis - Paroxysmal cough Diptheria - Grey psuedomembrane forms over pharynx Fifth Disease - Slapped cheek appearance
A client questioned the nurse's administration of IV normal saline, asking, "Wouldn't sterile water would be a more appropriate choice than saltwater?" Under what circumstances would the nurse administer electrolyte-free water intravenously?
Never, because in rapidly enters red blood cells, causing them rupture
The PACU nurse is caring for a male client who had a hernia repair. The client's blood pressure is now 164/92 mmHg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mmHg. The nurse should assess for what potential causes of hypertension following surgery?
Pain, hypoxia, or bladder distention
The nurse is caring for an 82 year old female client in the PACU. The woman begins to awaken and responds to her name, but is confused, restless and agitated. What principle should guide the nurse's subsequent assessment?
Postoperative confusion is common in the older client, but it could also indicate a significant blood loss
The nurse is providing palliative care for a 9 year old boy in hospice. Which is unique to hospice care for children?
Prolonging treatment that might possibly help
The nurse is caring for a 10-year-old girl who is in an isolation room. Which intervention would be a priority intervention for this child?
Provide age appropriate toys and games
A postoperative client rapidly presents with hypotension; rapid, thready pulse, oliguria and cold, pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action?
Quickly attempt to determine the cause of hemorrhage
A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mmHg, HCO3 24 mmHg. What does this ABG reflect?
Respiratory acidosis
The peri-operative nurse is constantly assessing the surgical client for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the client is developing malignant hyperthermia?
Tachycardia
During the health history, the mother of a 4 month old child tells the nurse she is concerned that her baby is not doing what he should be at this age. What's is nurse's best response?
Tell me what concerns you?
The OR nurse is taking the client into the OR when the client informs the operating nurse that his grandmother spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client?
The client may be at risk for malignant hyperthermia
A nurse educator is reviewing a client's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?
The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance
The nurse is admitting a client who is insulin dependent to the same day surgical suite for carpal tunnel surgery. How should this client's diagnosis of type 1 diabetes affect the care that the nurse plans?
The nurse should assess the client's blood glucose levels vigilantly
The mother of a 15 month old child is questioning the nurse about the need for the hepatitis B vaccination. Which comment provides the most compelling reason for the vaccine?
This protects your child from the infection that can cause liver disease
An adult client is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The client's vital signs and level of consciousness have stabilized, but the client then reports severe nausea and begins to retch. What should the nurse do next?
Turn client completely to one side
A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the client's PaCO2 has been between 56 and 64 mmHg for several months. Why should the nurse be cautious administering oxygen?
Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia
The nurse is preparing to administer an IM injection to an 8 months infant. The preferred appropriate site would be?
Vastus lateralis
The OR nurse is providing care for a 25 year old major trauma client who has been involved in a motorcycle accident. What intra-operative change may suggest the presence of anesthesia awareness?
Vital sign changes and client movement
After teaching the mother about follow-up immunizations for her daughter, who received the varicella vaccine at age 14 months, the nurse determines the teaching was successful when the mother states that a follow-up dose should be given at which time?
When the child is 4 to 6 years of age
