Post test review

The nurse is admitting a client diagnosed with chronic bilateral glaucoma and asks about the current health care issues. Which of the following statements made by the client would the nurse anticipate?

"I have to turn my head to see around my room." As intraocular pressure becomes elevated in chronic glaucoma, there is a slow, progressive loss of the peripheral visual field in the affected eye(s); if untreated or uncontrolled, it eventually can lead to blindness. Tiny, painless particles floating inside the eye that are called floaters; retinal detachment can also include floaters but also sparks or flashes of light. Blurred vision can have many causes, including refractive errors, chronic dry eyes, cataracts and macular degeneration

A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client reports having itchy and watery eyes, increased anxiety, and difficulty breathing. What should the nurse anticipate as the first action in the sequence of care for this client?

Administer epinephrine 1:1000 as ordered All of the answers are correct actions to perform under these circumstances; however, the priority is to prevent a full anaphylactic shock response by administering epinephrine. The sudden difficulty breathing is the key that this reaction is anaphylaxis and not just a rapid allergic reaction. Epinephrine will stop the reaction, prevent the airway from closing from swelling, and will prevent the client from going into shock due to cardiovascular collapse. The correct sequence of care is to first administer the epinephrine, then maintain the airway. In the early stages of anaphylaxis, when the client has not lost consciousness and is normotensive, the sequence should be administration of epinephrine, application of the oxygen and then observe for hypotension and shock, both of which are later severe allergic reactions. Diphenhydramine is an antihistamine that blocks a severe allergic reaction when the client has no findings of difficulty breathing or throat swelling.

The nurse is making a home visit to a client diagnosed with chronic pyelonephritis. Which nursing action should have the highest priority?

Ask for a log of the urinary output-The nurse must monitor the urine output because it is the best indictor of renal function.

A nurse is planning care for a client diagnosed with Guillain-Barre syndrome. Which problem should the nurse identify as a priority?

Breathing difficulties Respiratory support is always the priority intervention for clients with Guillain-Barre because respiratory paralysis can occur, requiring mechanical ventilation during the acute phase of the illness. These clients often have an ascending paralysis that begins in the lower part of the extremities. The incorrect responses are potential problems and are not life-threatening. Prioritize using the ABCs

The nurse is providing care to an 80 year-old client with the diagnosis of advanced Parkinson's disease. The nurse should know that the greatest risk to the client is associated with what finding?

Choking on food- A consequence of advanced Parkinson's disease is dysphagia, which results in an increased risk for choking on food. The alternate choices are not uniquely associated as a risk with the diagnosis of Parkinsonism. Falls in persons with Parkinson's are not caused by muscle weakness, but by a loss of balance, limb rigidity or freezing and failure of postural reflexes.

The nurse is providing postoperative care for a client who has undergone a laparoscopic cholecystectomy. Which assessment finding should be reported immediately to the health care provider?

Client reports severe right upper quadrant tenderness Shoulder pain is a common complaint following laparoscopic surgery due to the effects of carbon dioxide gas. Postoperative drowsiness is expected. Although bowel sounds should be assessed after surgery, absence of bowel sounds immediately after surgery is not a cause for alarm. Right upper quadrant pain could be from a retained gallstone or bile duct injury; severe postoperative pain in the right upper quadrant is a medical emergency after a laparoscopic cholecystectomy.

During a dressing change and incision care for a postoperative client, the nurse notes abdominal wound evisceration at the lower half of the incision. What intervention should the nurse implement first?

Cover the wound site with a sterile dressing moistened with sterile 0.9% saline When evisceration occurs, the wound should first be covered with sterile dressings dampened with sterile 0.9% saline using sterile technique. The sequence of steps to be taken next are to minimize tension on the site (by positioning the client flat in bed with the knees bent), treat the pain, and finally, notify the health care provider.

The client is diagnosed with mitral valve regurgitation. The nurse should expect to see which of these findings recorded in the client's medical records?

Exertional dyspnea Mitral valve regurgitation can lead to signs of heart failure with fluid retention and poor cardiac output. These problems cause exertional dyspnea in clients with mitral regurgitation as heart failure worsens. Mitral valve regurgitation (or simply mitral regurgitation) does not cause anemia or a pulse deficit. Ascites is a later finding in heart failure and is less common that dyspnea with exertion.

A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). The nurse should expect which of these findings in the initial documented history?

Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves' disease. It is typically bilateral and may diminish with therapy. Irritability may be present with hyperthyroidism; however, it would not be sudden onset. Weight loss is a more common finding, not weight gain, along with difficulty concentrating, fatigue, heat intolerance and restlessness.

A preterm baby develops nasal flaring, cyanosis and diminished breath sounds on one side of the chest. The health care provider's diagnosis is spontaneous pneumothorax. Which should the nurse prepare for first?

Insertion of a chest tube Because a portion of the lung has collapsed, a chest tube will need to be inserted to restore negative pressure in the chest cavity, which will allow the lung to re-expand. Although the client's findings are an emergency, there is no indication that CPR or assisted ventilation is needed at this time.

The nurse is assessing a client who sustained multiple fractures, contusions, and lacerations in a motor vehicle accident three days ago. The client suddenly becomes confused. Which of the following findings would support the nurse's suspicion that the client has developed a fat embolism? (Select all that apply.)

Low oxygen saturation Correct response Hypertension (does not apply) Dyspnea Correct response Elevated temperature Correct response Petechiae on the upper anterior chest This is a part of the correct response Manifestations of acute confusion, hypoxia, fever and hypotension may indicate fat embolism in a client who has sustained m

The client has been recently diagnosed with gastroesophageal reflux disease (GERD) and is reviewing information about the disease with the nurse. The nurse identifies which area of the gastrointestinal tract as the cause of GERD?

Lower esophagus

A client with renal calculi reports moderate-to-severe right flank pain and continuous nausea. The client's temperature is 100.8 F (38.2 C). What should be the priority nursing intervention for this client?

Manage pain The priority intervention is to manage the client's pain. The other options would be implemented afterwards.

A nurse is assigned to a client with heart failure who develops pulmonary edema and exhibits sudden anxiety, diaphoresis and auditory crackles with breathing. Which nursing intervention should be performed first?

Place the client in a sitting position Placing the client in a sitting position with the legs dangling causes fluid to shift downwards, away from the lungs, making breathing easier. Administration of an intravenous diuretic is a high priority as it will facilitate excretion of the excess fluid. SPO2 assessment will be used to evaluate the effectiveness of therapy in conjunction with oxygen administration. Pulmonary edema is a fluid overload issue, so coughing will not improve the client's respiratory status.

The nurse is caring for several hospitalized children with various medical conditions. Which diagnosis is likely to be associated with metabolic acidosis?

Severe diarrhea- If untreated, severe diarrhea can lead to metabolic acidosis due to excessive loss of bicarbonate in the stool. With metabolic acidosis, the pH is less than 7.35, HCO3 is low (22) and PaCO2 is normal (35-45). As the body compensates by increasing respiratory rate and depth to "blow off" CO2, the PaCO2 will decrease and the pH will rise back toward normal. When reading the options, you can first eliminate the two options that are related to respiratory diseases. You are now left with two issues involving the gastrointestinal system and you need to determine which condition will result in metabolic acidosis: diarrhea or vomiting. Recall that with vomiting, gastric acid is lost, resulting in alkalosis. Diarrhea causes loss of bicarbonate and leads to acidosis.

A nurse admits a client with a three-day history of fever, bilateral flank pain, elevated blood pressure and swelling in the hands and feet. Which data obtained in the admission interview alerts the nurse that this may be acute glomerulonephritis?

Severe sore throat three weeks ago In the many cases of acute glomerulonephritis there is a history of a recent streptococcal infection preceding the onset of the renal infection by two-to-three weeks. The incorrect responses do not suggest acute glomerulonephritis. Travel to a foreign country may result in a gastrointestinal infection such as giardia, dysentery (a severe form of diarrhea), or cholera if contaminated water is ingested. Hypertension is a finding, not a cause, of acute glomerulonephritis.

A nurse is caring for an acutely ill 10 year-old child. Which assessment finding would require the nurse's immediate attention?

Slow, irregular respirations- A slow and irregular respiratory rate is a sign of respiratory fatigue and failure in an acutely ill child. Respiratory failure can rapidly lead to respiratory arrest. Emergency intervention for respiratory support is indicated.

The client is diagnosed with Raynaud's phenomenon. When reinforcing information about self-care and managing the condition, what is the most important point the nurse should make?

Stop smoking Raynaud's phenomenon is a condition that results in poor circulation and bluish discoloration of the fingers and/or toes after exposure to cold temperatures or emotional events. This occurs because of an abnormal spasm of the blood vessels, resulting in decreased blood supply to local tissue. The digits that involved first turn from white to blue and then back to red. The most important teaching for this client is to stop smoking, because the nicotine causes direct arterial vasoconstriction. All alternate options are appropriate in Raynaud's phenomenon, but are not as important as smoking cessation.

A client who had a left arterial revascularization of the leg four hours ago reports increasing pain in the left lower extremity that is not adequately controlled with patient controlled analgesia (PCA). The nurse notes increased swelling and tenderness in the leg, along with other findings that suggest compartment syndrome. Which of these nursing interventions should take priority?

The health care provider should be informed immediately; only quick intervention will prevent the loss of the limb. After notification, the nurse should continue to assess the limb until the surgeon arrives. The client with an arterial disorder should not have the extremity elevated higher than the level of the heart because this type of position will decrease the blood to the distal extremity.

A client that the nurse is caring for has extracellular fluid volume deficit. Which finding should the nurse anticipate?

Urine concentration Kidneys maintain fluid volume through adjustments in urine volume and concentration. By holding onto water in fluid deficit, the urine produced by the kidneys is concentrated. In fluid volume deficit situations, peripheral pulses are weak and neck veins are flattened. Respiratory rate is not a reliable indicator of the fluid volume status. Because the question carefully is asking about fluid volume, you will realize that only urine description is the best fit.