Mastery Level Quizes

The nurse is caring for a group of clients on the psychiatric unit. Which clinical findings will alert the nurse that serotonin syndrome has developed in one of the clients? 1. Continuous involuntary movement of the tongue and jaw 2. Extremely high blood pressure with headache and flushing 3. Blurred vision, urine retention, dry mouth, and constipation 4. Restlessness, tachycardia, fever, diarrhea, and altered mental status

4. Restlessness, tachycardia, fever, diarrhea, and altered mental status

Client A: Elbow Fracture Client B: Lung Abscess Client C: Lobectomy Client D: Leg Sprain Following the three-tiered triage model of care, which of four clients would the nurse care for first?

Client B: Lung Abscess (Client B with a lung abscess should be given emergent care priority because the condition of the client may worsen. Client A with an elbow fracture can be given a nonurgent priority. Client C with a lobectomy can be given an urgent priority because the client needs to be monitored. Client D with a leg sprain can be given a non-urgent priority.)

According to the five-level triage system, in which priority order would clients with four different conditions receive care? 1. Severe respiratory distress 2. Minor burns 3. Closed extremity trauma 4. Gynecologic disorder

1. Severe respiratory distress 3. Closed extremity trauma (Clients with life-threatening complications such as severe respiratory distress are triaged as emergency severity index (ESI) 1, which requires immediate care. Clients with gynecological disorders are triaged as ESI-3, which requires treatment within an hour. Care for clients with closed extremity trauma can be delayed because it is not a life-threatening complication. Clients with minor burns can be provided with care later because it is not a life-threatening complication.)

The nurse evaluates the statements of a client after teaching about hydrocortisone therapy. Which statement made by the client indicates effective learning? 1. "I should report if I experience two to three episodes of vomiting." 2. "I should report if there is swelling in the hands or legs." 3. "I should immediately report if my body temperature crosses 37°C (98.6°F)." 4. "I should immediately report if I experience diarrhea."

2. "I should report if there is swelling in the hands or legs." (Excessive concentration of hydrocortisone causes fluid retention and edema. The client's statement regarding the development of swelling in the hands or legs indicates effective learning. Vomiting, fevers, and diarrhea are associated with prednisone therapy.) (Test-Taking Tip: Recall the side effects of hydrocortisone and relate this knowledge to evaluate the client's statements.)

The nurse is caring for a client after a laparoscopic cholecystectomy. Which nursing action is priority? 1. Perform neurovascular checks. 2. Obtain a pain medication history. 3. Teach about post-discharge activity restrictions. 4. Assess puncture sites for bleeding.

4. Assess puncture sites for bleeding. (The one to four puncture sites used to perform the laparoscopic surgery should be monitored for any possible bleeding. It is unlikely that this type of surgery would cause neurovascular complications; neurovascular checks are not a priority. Although it is important to obtain a pain medication history, this can be evaluated after the essential actions (such as assessing for bleeding) take place. Activity restriction is about 1 week with a laparoscopic cholecystectomy and can be discussed closer to the time of discharge.)

A client is admitted to the hospital for an adrenalectomy. When teaching the client about the prescribed medications, which advice will the nurse emphasize? 1. Medication therapy will be given in conjunction with insulin. 2. Once regulated, the dosage will remain the same for life. 3. Medications will need to be held for surgery or other invasive procedures. 4. Salt intake may have to be restricted.

4. Salt intake may have to be restricted. (Administration of adrenocortical hormones causes sodium retention; dietary intake of salt should be limited. Because pancreatic function is unimpaired, insulin therapy is not indicated. Dosages will likely need to be adjusted over time. The dosage will need to be increased for surgery and severe infections; not doing this can cause a life-threatening crisis.)

After teaching a client about the use of calcitonin (nasal route) as treatment for osteoporosis, which client statement indicates effective learning? 1. "I should expect some nausea when taking this medication." 2. "I should stop the medication when the symptoms subside." 3. "I should not take calcium supplements when taking calcitonin." 4. "I should not spray the medication into the same nostril on 2 consecutive days."

4. "I should not spray the medication into the same nostril on 2 consecutive days." (Clients using a nasal form of calcitonin should spray the medication daily into alternate nostrils. The client's statement regarding the medication should not be sprayed into the same nostril on 2 consecutive days indicates effective learning. Nausea does not occur with the nasal spray. Clients should use the spray as directed and not stop the treatment without informing the primary health care provider. Clients should take calcium supplements during the course of the therapy to prevent secondary hyperparathyroidism.)

Which teaching intervention would be a nursing priority to reduce the risk for bleeding in the client with purpuric lesions on the skin and a thrombocyte count of 100,000 cells per microliter? 1. Drink plenty of fluids. 2. Perform bending exercises. 3. Use superabsorbent tampons. 4. Use alcohol-based mouthwashes.

1. Drink plenty of fluids. (A client with purpuric lesions and a thrombocyte count of 100,000 cells per microliter has thrombocytopenia. Drinking plenty of fluids helps prevent constipation and straining while having a bowel movement, thereby preventing bleeding. Performing bending exercises may lead to bleeding from the nose, and it is contraindicated. Usage of superabsorbent tampons may increase the chance of toxic shock syndrome (TSS) and result in severe infection or death. Usage of alcohol-based mouthwashes can dry the gums and increase bleeding.)

Which actions will the nurse take when caring for a client with a chest tube in place after thoracotomy? Select all that apply. One, some, or all responses may be correct. 1. Administer prescribed analgesic medications. 2. Check around chest tube insertion site for crepitus. 3. Clamp the chest tube before the client ambulates. 4. Add fluid to the suction control chamber as needed. 5. Milk the tubing toward the collection chamber. 6. Check for air bubbling in the water-seal chamber.

1. Administer prescribed analgesic medications. 2. Check around chest tube insertion site for crepitus. 4. Add fluid to the suction control chamber as needed. 6. Check for air bubbling in the water-seal chamber. (Because the intrapleural space has many sensory nerves, the chest tube will be uncomfortable and the nurse will assess for pain and administer analgesics as needed. Crepitus around the chest tube insertion indicates air leakage into the subcutaneous tissue and will be monitored. Fluid in the suction control chamber may evaporate; the fluid level controls the amount of negative pressure applied to the intrapleural space and must be kept at the prescribed level. The water-seal chamber is assessed for bubbling, which indicates that air is exiting the pleural space. Clamping the chest tube is avoided unless there is damage to the drainage system that requires attachment of a new chest drainage system. Milking of the chest tubes is avoided because milking causes increased negative intrapleural pressure that may lead to pleural trauma and bleeding.)

Which emergency assessment has been performed on the client when an emergency management team is removing foreign bodies and performing cricothyroidotomy on a client postburn injury? 1. Breathing 2. Circulation 3. Exposure and environmental control 4. Airway with simultaneous cervical spine stabilization

4. Airway with simultaneous cervical spine stabilization (Emergency assessment of the airway with simultaneous cervical spine stabilization involves removing foreign bodies and performing cricothyroidotomy. It is done in a primary survey to assess patency, respiratory distress, and bleeding. Assessment of breathing is done to check ventilation and respiratory rate and may require ventilating with a bag-valve-mask with 100% oxygen or using needle thoracostomy. Circulation assessment is performed to check capillary refill or measure blood pressure and may require initiating cardiopulmonary resuscitation and advanced life-support measures. Exposure and environmental assessment is done to check the entire body for injuries; it involves removing all clothing and using warm blankets or warmed intravenous fluids to prevent hypothermia.STUDY TIP: Begin studying by setting goals. Make sure they are realistic. A goal of scoring 100% on all exams is not realistic, but scoring an 85% may be a better goal.)

Which are sources of lead the nurse would assess for when providing care to a child who is admitted with lead poisoning? Select all that apply. One, some, or all responses may be correct. Water Pottery Stained glass Collectible toys Vinyl miniblinds

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