QBank Quiz & Evolve Module 2 Quiz

The nurse is planning to educate a client who has a diagnosis of right sided HF. what info should the nurse include? 1. blood backs up in the left upper chamber of the heart 2. your feet, legs and ankles will likely swell bc blood is backing up in your veins 3. activity will increase your HR 4.you might find that you go to the bathroom more often at night 5. weigh yourself daily to monitor for rapid weight gain

2, 3, 4, 5 Congestion is evident by swelling of the lower extremities. ascites may increase pressure on the stomach and intestines causing GI upset with nausea and anorexia. the HR increases in an attempt to increase cardiac output. bedrest induces diuresis. the fluid leaves the extremities and goes back into the vascular space where the kidneys get rid of the excess fluid. daily weights are important to monitor fluid retention. a rapid weight fain is fluid not fat. 1. the blood backs up into the right atrium and venous circulation, not the left upper chamber of the heart

A client from Indonesia is being admitted to the Labor and Delivery unit. Her spouse brought her to the hospital. She is 39 weeks gestation, her contractions are 4 minutes apart, and she experienced spontaneous rupture of the membranes at home. She does not speak English, but a hospital-based interpreter is present. Which questions by the nurse would be appropriate to ask the client when performing the admission assessment? Select all that apply 1. Are there any odd cultural practices that we need to be aware of in caring for you during labor and delivery? 2. In your culture, are fathers generally present for the delivery? 3. Are there any foods that are not permitted or are requested based on your culture or religion? 4. Do you have any personal beliefs or customs prohibiting physical activity during pregnancy, birth and the postpartum period that you will be observing? 5. Will you be observing any special or culturally accepted way for expression of pain? 6. Are there any special considerations that need to be observed for newborn care?

2, 3, 4, 5, 6

the nurse is planning care for a client diagnosed with pyelonephritis. what interventions should the nurse include? 1. advise that urine may turn blue with administration of nitrofurantoin 2. encourage voiding q2h 3. educate the client that phenazopyridine is an antibiotic used to treat pyelonephritis 4. palpate the bladder 14h 5. provide client with at least 1500 m: of water to drink daily

2, 4 2. encourage frequent voiding q2-3h to empty bladder completely bc this can significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection. 4. palpate the bladder q4h to determine bladder distention 1. nitrofurantoin is an antibiotic used to treat most UTIs. the color of urine is not changed 3. Phenazopyridine is an analgesic for urinary pain 5. fluid intake should be increased to 2-3 liters/day unless contraindicated to flush out the kidneys

Which information would the nurse include when participating in community health training about sexually transmitted infections? 1. clients are screened for chlamydial infection and/or gonorrhea only if the client is experiencing cervical discharge, dyspareunia, and dysuria 2. women with chlamydial infection or gonorrhea are likely to be asymptotic 3. in many instances, chlamydia infection and/or gonorrhea will go away without intervention 4. it is only necessary for females to be treated for chlamydial infections and/or gonorrhea due to the potential damage to a female's reproductive system

2. Chlamydial infections of the cervix and gonorrhea often produce no symptoms 1. all sexually active women age 25 and younger should be screened annually 3. if left untreated, chlamydial infections and gonorrhea can result in serious complications 4. partners do need to be treated

A client is undergoing outpatient psychiatric treatment for somatization disorder. Prior to the beginning of group therapy, the client tells the nurse, "I keep having headaches that are killing me! This has never happened to me before." What is the nurse's best response to this client? 1. you need to sit down, because we need to start the group session now 2. I will notify the group leader about your headaches, after the group session 3. I guess we can discuss your pain now. Group therapy will have to start later. 4. Your headaches are not real, so ignore them. Go on into therapy so we can start.

2. Initially, the nurse would fulfill the client's urgent dependency needs, but gradually withdraw attention to physical symptoms. Minimize time given to response to physical complaints. Gradual withdrawal of positive reinforcement will discourage repetition of maladaptive behavior. However, all new symptoms should be reported 1. This is not a therapeutic response. The client's feelings and concerns should not be denied. This will increase the anxiety level of the client. Do not totally ignore the client's complaint. 3. By postponing the group session the nurse is reinforcing the clients somatization disorder. the group session should start on time 4. The pain is real to the client. This response is not therapeutic communication. The direct ignoring of the client's complaint will increase their anxiety level.

a client who was admitted to a coronary care unit with a diagnosis of myocardial infarction is on continuous cardiac monitoring. which cardiac change noted on the monitor would be of GREATEST concern? 1. ventricular tachycardia >100 bpm 2. atrial fibrillation w atrial rate >300 per minute 3. four premature ventricular contractions w/in 1 minute 4. ST segment depression of 0.5 mm

CORRECT: 1. ventricular tachycardia with a ventricular rate greater than 100 bpm can be a precursor to v fib. this rhythm is most life threatening and would be of greatest concern 2. clients diagnosed w a fib are at high risk for formation of thrombus. this is a serious concern, but not as great a concern 3. PVCw that are less than 6 are worrisome but not considered a precursor to v tach or v fib 4. st segment depression of 1 mm or more signifies myocardial ischemia

What test should the nurse use to test a client's gross hearing acuity? 1. Weber's 2. Rinne 3. Audiometry 4. Whisper 5. Monofiliment

1, 2, 3, 4 1. Weber's test uses a tuning fork to assess bone conduction by examining the lateralization of sounds. 2. the Rinne test compares air to bone conduction. 3. Audiometric testing determine the degree and type of heating loss. the audiometer produces pure tones at varying intensities to which the client can respond. the ticking of a watch has a higher pitch than the normal voice. have client occlude one ear. out of the client's sight, place a ticking watch 1 in (2-3 cm) from the unoccluded ear. ask what the client can hear. repeat the other ear. 4. with the whisper test, the examiner stands 12-24 in (30-61 cm) to the side of the client, and after exhaling, speaks using a low whisper. the client is asked to repeat numbers or worlds or answer questions. each ear is tested. 5. monofilament testing idenfies sensory neuropathy, particularly of the feet

what s/s would the nurse expect to assess in a client diagnosed w acute pericarditis? 1. distended neck veins 2. muffled heart sounds 3. narrowed pulse pressure 4. pain worsens when sitting up and leaning forward 5. pulsus paradoxus 6. stabbing chest pain

1, 2, 6 the pericardium is a thin, fluid-filled sac that surrounds your heart. 1. an infection of the pericardium, called constructive pericarditis, can restrict the volume of the heart. as a result, the chambers can't fill with blood properly, so blood can back up into veins, including the jugular veins. 2. muffled heart sounds are indicative of pericarditis. fluid is btwn the heart and chest wall making the heart sounds lowered and distant. 6. the pain is described as stabbing chest pain over the center or left side of the chest 3. narrow pulse pressures occur in several disease such as HF (decreased pumping), blood loss (decreased blood volume), aortic stenosis (reduced stroke volume), and cardiac tamponade (decreased filling time) 4. sitting up and leaning forward tends to ease the pain, while lying down and breathing deep worsens it 5. pulsus paradoxus is an exaggerated decrease in systolic BP during inspiration exceeding 12 mm Hg. it is a hallmark sign of cardiac tamponade

When teaching a client about lactose intolerance, what should the nurse include? 1. common symptoms of lactose intolerance include abdominal bloating, diarrhea, and gas 2. symptoms of lactose intolerance generally occur 3 hr after consuming foods high in lactose 3. calcium rich foods should be consumed 4. the client can drink lactose-free milk 5. Vit D foods should be increased in the diet

1, 3, 4, 5 These statements are all correct. Symptoms include abdominal bloating, pain, diarrhea, and gas. because milk and milk products cause symptoms, the client may not get enough calcium and vit D. supplementing with calcium or foods high in calcium and vitamin D is important to maintain these levels. the client may have lactose-free milk 2. symptoms occur 30 minutes to 2 hours after drinking milk or milk products

a nurse, planning an educational seminar on chronic kidney disease, would invite clients with which medical conditions? 1. diabetes 2. frequent UTIs 3. hyperlipidemia 4. HTN 5. obesity

1, 3, 4, 5 polycystic kidney disease is a genetic condition that causes damage to the kidneys. clients with HTN and diabetes make up more than 67% of clients with CKD. glomerulonephritis damages the kidneys and can lead to permanent damage 2. cystitis is an inflammation of the bladder. inflammation is where your body becomes irritated, red, or swollen. in most cases, the cause of cystitis is a urinary tract infection. acute UTIs do not generally lead to CKD

a nurse is planning care for a newly admitted client diagnosed with acute nephrotic syndrome. what interventions would the nurse include in the plan of care? 1. monitor triglyceride level 2. educate client on a 3 gm sodium diet 3. auscultate lung sounds 4. monitor BP 5. assess for venous thrombosis-embolism (VTE)

1, 3, 4, 5 the liver increases the release of cholesterol and triglycerides while producing more needed albumin. this client is at risk for HF and pulmonary edema so lungs should be auscultated and the BP should be monitored. without proteins, the blood can clot and put the client at risk for thrombosis or embolism 2. the client should be on a low sodium diet (3g is too high) carbohydrate are given liberals to provide energy

a client was admitted two days ago in the oliguric phase of acute kidney injury (AKI). what evaluation by the nurse would indicate that treatment has been effective? 1. variable urine specific gravity 2. serum K+ 5.5 mmEq 3. serum Na+ 140 mEq 4. minimal crackles auscultated in bases of left lung 5. urine output = 1250 mL/24 hr

1, 3, 5 1. a fixed specific gravity indicates the kidneys are not working properly. a variable specific gravity changes based on whether the urine is dilute or concentrated. 3. this is a normal sodium level, which indicates the client is improving. the serum sodium level would be low in the oliguric phase due to increased dilution of the blood. 5. this urine output is adequate to indicate proper kidney function 2. serum K is high. the serum K level is elevated when the client is still in the oliguric phase 4. the lungs would need to be clear to verify that treatment has been effective

the nurse is planning to teach a client about home peritoneal dialysis. what information should the nurse include? 1. after washing hands with soap and water, put on clean gloves and clean the catheter site 2. apply a prescription antibiotic cream to the skin around the catheter with fingers 3. leave crust formed around insertion site alone 4. gently rub the skin dry around the site dry after cleaning 5. wash the skin around the catheter site with antibacterial soap

1, 3, 5 1. before cleaning the area, wash hands with soap and water and put on clean gloves. 3. do not puck at or remove crusts or scabs at the site. 5. the skin around the catheter site should be washed daily or every other day with antibacterial soap or an antiseptic (either povidone iodine or chlorhexidine). the soap should be stored in the original bottle (not poured into another container) 2. apply a prescription antibiotic cream to the skin around the catheter with a cotton-tip swab every time the dressing is changed. 4. pat the skin dry around the site after cleaning. a clean cloth or towel is suggested.

what information should the pre-op nurse include when educating a client about preventing a deep vein thrombus (DVT) formation after abdominal surgery? 1. anticoagulant med may be prescribed 2. caffeinated beverages will be allowed once able to drink in order to promote hydration 3. bed rest will be required for at least 5 days 4. move feet in a circle 10x/hr 5. a sequential compression device (SCD) will be wrapped around the legs

1, 4, 5 anticoagulants can prevent blood clots. simple exercises while you are resting in bed or sitting up in a chair can help prevent blood clots. move your feet in a circle or up and down. do this 10x/hr to improve circulation. SCDs or intermittent pneumatic compression (IPC) are wrapped around your legs and connected to a pump that inflates and deflates the sleeves. this applies gentle pressure to promote blood flow in legs and prevent blood clots 2. alcohol and coffee contribute to dehydration, which can lead to thickened blood and increased risk for clot formation 3. after surgery, a nurse should help the client out of bed, ASAP. moving around improves circulation and helps prevent blood clots

Which client would be appropriate for the RN to assign to the LPN? 1. client requiting enemas and antibiotics 2. newly admitted client with diagnosis of DKA 3. client returning from surgery post-op right upper lobectomy 4. client with frequent reports of nausea and vomiting following chemo 5. client requiring frequent sterile dressing changes

1, 4, 5 1.Administering enemas and antibiotics to a client is within the scope of practice for a LPN. 4. N/V are common side effects after receiving chemo. the LPN can administer antiemetics and monitor fluid status. 5. it is within the scope of practice for the LPN to perform sterile dressing changes 2. this client is a new admit who is in DKA and would be unstable 3. this client will retire frequent assessments and monitoring for post-op complications

The charge nurse is assigning an UAP to take vital signs on a group of adult clients. The charge nurse would instruct the UAP that a rectal temperature is contraindicated for which client? 1. client with thrombocytopenia 2. client with a fractured femur 3. client with an inguinal hernia 4. Client with irritable bowel syndrome

1. client with thrombocytopenia Thrombocytopenia is the deficiency of platelets in the blood. due to the reduced platelet count, the clotting time of the client's blood will be reduced. inserting a rectal thermometer increases the client's risk of rectal trauma. if there is rectal bleeding from the insertion of the rectal thermometer, the client may be experienced increased bleeding due to their decreased platelet count 2. a client with a fractured femur can have their temp assessed by a rectal temp. there are no contraindications for a rectal temp 3. to evaluate a client's temp by inserting a rectal thermometer is acceptable procedure for a client with an inguinal hernia 4. there are no contraindications for clients with IBS to have their temp assessed by a rectal thermometer

While making rounds, the nurse discovers a small fire in a client's room. What should the nurse do first? 1. remove the client from the room immediately 2. leave the client's room to obtain a fire extinguisher 3. instruct the unlicensed assistive personnel (UAP) to pull the fire alarm 4. evacuate all clients from the unit

1. remove the client from the room immediately 1.rescue/remove the client; first step in Rescue, Alarm, Contain, Extinguish (RACE) 2. never leave the client in an unsafe environment. remove the client from the area 3. not first action in RACE. get the client out of the area first. the UAP may help with this. don't send the UAP away 4. Not first action in RACE. remove the client in immediate danger first. all clients may not have to be evacuated if the fire is contained and extinguished

The nurse has been assigned four clients. Who should the nurse see first? 1. A client with diabetes admitted for debridement of a food ulcer 2. a client with epilepsy reporting an odd smell in the room 3. a client with exacerbation of COPD reporting dyspnea 4. an adolescent client post appendectomy reporting pain

2. the client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. the nurse should immediately assess this client, implement seizure precautions and remain with client for safety. 1. although the vascular status of the food needs to be assessed, there is no indication if the debridement has been completed yet. this client is not the nurse's first priority 3. clients with COPD are always SOB and dyspnea is an expected finding during an exacerbation, the client will need to be assessed, but there is no specific indication the respiratory status is presently compromised 4. there is no information regarding how recent was the surgery or the degree of pain being experienced. post-surgical pain is expected and without further parameters, no determination can be made regarding this client. the nurse has another priority

The nurse is caring for a client with acute renal failure. the morning assessment findings indicate the client has become confused and irritable. which finding is most likely responsible for the change in behavior? 1. hyperkalemia 2. hypernatremia 3. elevated blood urea nitrogen (BUN) 4. limited fluid intake

3, a client with acute renal failure will have an increased BUN. significant elevation in BUN may result in N/V, lethargy, fatigue, impaired thought process, and headache 1. hyperkalemia can result from acute renal failure. symptoms do not include confusion or irritability. it may cause muscle weakness, muscle twitching, and flaccid paralysis 2. clients w retail failure retain fluid and are at risk for dilution hyponatremia. increased or decreased sodium levels can cause confusion, but this client is not at risk for hypernatremia 4. clients in acute renal failure should have limited fluid intake. this would not lead to confusion

How should the nurse interpret the arterial blood gas (ABG) results of the client with dehydration? pH: 7.49, PaCO2: 29, HCO3: 25 1. metabolic acidosis 2. respiratory alkalosis 3. metabolic acidosis 4. metabolic alkalosis

4. metabolic alkalosis