Practice Exam 2

A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse?

Answer: "Tell me what you are feeling." The nurse should ask the client to the them what they are feeling. Asking open-ended questions would encourage the client to verbalize pain. Some clients may not demonstrate their feelings or readily discuss their symptoms due to factors related to cultural norms. Closed-ended questions (answered with "yes" or "no") may block communication

The emergency department nurse is obtaining history from the parents of a 4-year-old child. Multiple bruises and abrasions are noted. The nurse highly suspects child abuse based on which finding?

Answer: The stories about the accident or injury from the parents conflict Conflicting stories about the accident or injury from the parents is a warning sign of abuse. A history consistent with the child's injuries, unkempt appearance, and low socioeconomic status are not indicators of expected or potential abuse. While emotional response of the parents may be concerning, it is not a warning sign of abuse

The nurse is caring for a young child on the oncology unit who has developed thrombocytopenia after cancer treatment. What is the priority action for the nurse to implement when caring for this client?

Answer: Ensure a safe environment Providing a safe environment protects the child from injury. This is important because the child's is at risk for bleeding due to thrombocytopenia. The other options are important for a child with cancer, but are not the priority in relation to thrombocytopenia.

A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus?

Answer: Gently aspirate the I.V. catheter for check for blood return Before administering an IV bolus, the nurse should aspirate the IV catheter for a small amount of blood to ensure correct placement of the IV catheter. The nurse may inject the medication over the recommended time interval. The nurse doesn't need to insert another IV line unless the ordered medication is incompatible with the medicate in the IV solution. Warming the medication could alter the drug's action. Placing a tourniquet on the arm would close off the venous system and prevent drug injection.

A physician orders spironolactone, 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicated that the drug is producing a therapeutic effect

Answer: Loss of 2.2 lbs. (1kg) in 24 hours Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lbs. indicates loss of 1L if fluid. Because spironolactone is a diuretic, weight loss is the best indicator of it effectiveness.

A nurse is working as part of a team on the unit on a performance improvement initiative to address a concern that client's are not receiving adequate preoperative teaching. Now that the problem has been identified, which action would the nurse do next?

Answer: Meet with the parties involved to develop a strategy Performance improvement involves four steps: 1- Discover the problem (which has already by identified) 2- Plan a strategy indicator based on a meeting with the parties involved 3- Implement the change 4- Assess the change, and is the outcome is not met, place a new strategy or refocus the strategy to effect the change

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

Answer: 36% Rule of Nines divides the body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% of each, the anterior legs account for 9% each, the anterior trunk account for 18%. Therefore the client's burns cover 36% of the body surface area.

Which type of restraint is best for the nurse to use for a child in the immediate postoperative period after cleft palate repair?

Answer: Elbow restraints Recommended restraints for a child who has had palate surgery are elbow restraints. They minimize the limitation placed on the child but still prevent the child from injuring the repair with fingers and hands. A safety jacket or wrist or body restraints restrict the child unnecessarily.

A client who is taking olanzapine states he is being poisoned and refuses to take his scheduled medications. The nurse states, "If you don't take you medication, you'll be put into seclusion!" The nurse's statement is an exampled of which legal concept?

Answer: Assault The nurse's statement exemplifies assault, which is the threat of being touched in an offensive way without consent. Battery is touching another person without consent. Malpractice is care below the standard of care that results in injury. Invasion of privacy is a violation of a person's right to be left alone.

What client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the post-anesthesia recovery unit. What should the nurse do FIRST?

Answer: Draw a mark around the stump The priority action is to draw a mark around the site of bleeding to determine the rate of bleeding. Once the area is marked, the nurse can determine whether the bleeding is increasing or decreasing by the size of the area marked. Because the spot is bright red, the bleeding is most likely arterial in origin. Once the rate and source of the bleeding is identified, the surgeon should be notified.

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:

Answer: Rest in an air-conditioned room Fatigue is a common symptoms in clients with MS. Lowering the body temp by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temp, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include: treating depression, using occupational therapy to learn energy-conserving techniques, and reducing spasticity.

The nurse is assessing a client how has a long history of uncontrolled hypertension. The nurse should assess the client for damage in which are of the eye?

Answer: Retina The retina is especially susceptible to damage in a client with chronic hypertension. The arterioles supplying the retina are damaged. Such damage can lead to vision loss. The iris, cornea, and sclera are not affected by hypertension.