Semester 1 EAQ questions

The nurse is assessing the laboratory findings of cerebrospinal fluid (CSF) of four different clients. Which finding is consistent with meningitis?

Client A: Increased pressure >1000 white blood cells >500 protein mg/dL Decreased glucose Cloudy appearance The clinical findings of CSF in client A indicates that he or she has meningitis. Client B's findings indicate encephalitis. Client C's findings indicate a brain abscess. Client D has normal CSF values. The normal values of CSF are a pressure between 70 and 150 mm H2O, white blood cell count between 0 and 5 cells/µL, protein levels between 15 and 45 mg/dL (0.15 and 0.45 g/L), glucose levels between 40 and 70 mg/dL (2.2 and 3.9 mmol/L). In addition the CSF should appear clear.

Which personal protective equipment will the nurse plan to wear when providing central venous access device site care?

Mask and sterile gloves A mask will protect the catheter insertion site from droplet and airborne microorganisms emanating from the nurse, and sterile gloves will protect the insertion site from contact with microorganisms on the nurse's hands. Double gloves and a hair cap are not needed. Gown use is based on facility protocol.

Which part of the brain contains the "central switchboard" of the central nervous system (CNS)?

Diencephalon The thalamus is considered to be the major relay station or "central switchboard" for the CNS. The thalamus, along with the hypothalamus and epithalamus, are located in the diencephalon of the brain. The cerebrum is the largest part of the brain, which has right and left lateral ventricles deep inside and has basal ganglia at its base. The brainstem connects the rest of the brain with the CNS. It is associated with life support and basic functions, such as movement. The cerebellum is concerned with coordination of movement and works together with the brainstem to focus on the functionality of the muscles. This structure is found below the occipital lobe and adjacent to the brainstem.

Which physiological response is the likely cause of a client developing hydrocephalus 2 weeks after cranial surgery for a ruptured cerebral aneurysm?

Locked absorption of fluid from the arachnoid space Residual blood from the ruptured aneurysm may have blocked the arachnoid villi, interrupting the flow of CSF and resulting in hydrocephalus. Vasospasm is a protective response during the active bleeding process; it does not cause hydrocephalus. The Broca center is not directly affected; even if it were, there is no relationship to the development of hydrocephalus. The production of cerebrospinal fluid is not increased in this situation; increased production may result when there is a tumor of the choroid plexus.

The client reports abdominal cramping while undergoing a soapsuds enema. Which action would the nurse take?

Lower the height of the enema bag Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes and then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.

A client is admitted with extensive bone and soft-tissue injuries to the leg and sterile dressings are applied. Two days later, when removing the dressings, the nurse finds that one of the dressings has adhered to tissue in several places. Which action would the nurse take to loosen the dressing?

Moisten the dressing with sterile saline Sterile saline will soften the dried exudates adhered to the dressing, limiting tissue damage when the dressing is removed. The use of hydrogen peroxide can be irritating to the tissues. Pulling off the dressing with steady traction may be painful and cause unnecessary tissue damage. The use of Betadine to remove a dressing is not recommended.

Which complications would the nurse monitor in a client who sustained a transection of the spinal cord, but no other injuries?

Autonomic hyperreflexia Autonomic hyperreflexia, an uninhibited and exaggerated response of the autonomic nervous system to stimulation, results in a blood pressure greater than 200 mm Hg systolic; it is a medical emergency. Although hemorrhage and hypovolemic shock could occur from the trauma, the scenario stated that no other injuries occurred. Although gastrointestinal atony can result from immobility, it is not a medical emergency.

During a tap water enema, a client reports abdominal cramps. Which action would the nurse take?

Clamp the tubing and allow the client to rest Rapid instillation of fluid into the colon may cause abdominal cramps. By clamping the tubing, the nurse allows the cramps to subside so the irrigation eventually can be continued. Emotional support will not interrupt the physical response of abdominal cramps. Although pinching the tubing would lessen the fluid entering the colon and raising the irrigating container to complete the irrigation quickly might reduce the force of the fluid, neither of these will eliminate the flow of fluid completely. Increasing the force of flow will increase abdominal cramps.

During administration of an enema, a client experiences intestinal cramps. Which action would the nurse take?

Stop the fluid until the cramps subside Administration of additional fluid when a client reports abdominal cramps adds to discomfort because of additional pressure. By clamping the tubing for a few minutes, the nurse allows the cramps to subside, and the enema can be continued. Cramps are not a reason to discontinue the enema entirely; temporary clamping of the tubing usually relieves the cramps, and the procedure can be continued. Slowing the rate decreases pressure but does not reduce it entirely. Lowering the height of the container will reduce the flow of the solution, which will decrease pressure but not eliminate it entirely.

Which instruction is important for the nurse to include in discharge teaching for a client who has to perform intermittent urinary self-catheterization?

Wash your hands before performing the procedure To prevent transferring organisms to the urinary system, the client is taught to wash his or her hands thoroughly with soap and water before inserting a clean catheter. Sterile gloves are not required for this procedure in the home care setting. Every 12 hours is too long of a time frame between catheterizations. The client should be taught to recognize when self-catheterization is needed and develop a 2- to 3-hour catheterization schedule. Some home care settings may require the client to clean and reuse catheters.

A high cleansing enema is prescribed for a client. Which is the maximum height at which the container of fluid would be held by the nurse when administering this enema?

18 inches 46 cm For a high colonic enema to be effective, the fluid must extend higher in the colon. If the height of the enema fluid container above the anus is increased, the force and rate of flow also increase. A height of 46 cm (18 inches) is correct. A height of 30 cm (12 inches) is too low for a cleansing enema. Heights of 51 cm (20 inches) and 66 cm (26 inches) are too high and may cause mucosal injury.

An adult client experiences a traumatic brain injury. Which finding identified by the nurse indicates possible damage to the upper motor neurons?

Babinski response A Babinski response (dorsiflexion of the first toe and fanning of the other toes) is a reaction to stroking the lateral sole of the foot with a blunt object; it is indicative of damage to the corticospinal tract when seen in adults. Hyperreflexia is associated with upper motor neuron damage. Increased muscle tone (spasticity) is associated with upper motor neuron damage. The Trousseau sign is indicative of hypocalcemia.

Which is the recommended length of insertion of the enema tube in a child of 3 years?

5-7.5 in For a 3-year-old child, the recommended length of insertion of the enema tube is 5 to 7.5 cm. The length of 1 to 2.5 cm is incorrect, because it is too small. Even the insertion length of the enema tube used in infants is longer than this. For infants, the length of insertion of the enema tube should be 2.5 to 3.7 cm. For adolescents and adults, this length is 7.5 to 10 cm.

The nurse is preparing to change a client's dressing. For which reason would the nurse use surgical asepsis?

Keeps the area free of microorganisms Surgical asepsis means that practices are employed to keep a defined site or objects free of all microorganisms. Confining microorganisms to the surgical site and protecting self from microorganisms in the wound apply to personal protective equipment and medical asepsis. Reducing the risk for growing opportunistic microorganisms applies to medical asepsis.

A client is scheduled for a colonoscopy, and the health care provider prescribes a tap water enema. In which position should the nurse place the client during the enema?

Left sims To take advantage of the anatomical position of the sigmoid colon and the effect of gravity, the client should be placed in the left Sims or left side-lying position for the enema. Back lying, knee-chest, or mid-Fowler positions do not facilitate the flow of fluid into the sigmoid colon by gravity.

The nurse uses the same pair of gloves to remove a soiled dressing and to apply a new sterile dressing. Another nurse is observing the dressing change procedure. Which initial action would the observing nurse take?

Discuss the incident with the nurse Discussing the incident with the nurse is the initial action. The nurse should understand that the technique is not safe and discussing the incident with the nurse provides an opportunity for the offending nurse to correct the technique being used. The dressing should be changed immediately and correctly; the priority is to protect the client. Filing an incident report depends on the policy of the institution and might be done later. Offering to demonstrate the proper technique may or may not be done by the observing nurse; if so, it should be done later. Reporting the individual to the nursing supervisor depends on the policy of the institution and might be done later.

When donning sterile gloves, how would the nurse glove the second hand?

Insert gloved fingers under cuff of second glove and lift glove; then slide unloved hand into glove Sterile gloves can only be handled by sterile equipment, or they are contaminated. The sterile glove that has been donned may touch under the cuff on the sterile surface as the nondominant hand is inserted. The sterile glove may not touch the inside of the glove. Donning a sterile glove and placing below the waist means contamination, because under the waist or in back is contaminated. Grasping by the cuff (folded edge) means the inside of the glove has been touched.

Which evidenced-based nursing intervention links to reducing catheter associated urinary tract infections (CAUTIs) in clients requiring long-term indwelling catheters?

Perform catheter care 2x day A biofilm made up of bacteria develops on long-term indwelling catheters. The best way to eliminate this biofilm is to perform routine perineal hygiene daily. The efficacy of cranberry tablets in decreasing the frequency of urinary tract infections has not been established. Antibiotic therapy may increase the growth of microbes within the biofilm.

Which action would the nurse take when a client reports pain and burning at a peripheral intravenous (IV) site after the nurse has flushed the saline lock with normal saline?

Remove the IV catheter and restart the saline lock in another site The client's report of pain and burning at the site indicates that the tip of the catheter is no longer in the vein and the client needs removal of the current catheter and a new IV access site. Documenting the findings and then reassessing the site in 8 hours would leave the client with no IV access. Flushing vigorously will lead to more pain as more saline is pushed into the infiltrated site. Changing the dressing would leave the client without a patent IV access.

Which basic principles of surgical asepsis must the nurse consider when changing the dressing of a child with severe burns? Select all that apply. One, some, or all responses may be correct.

- a paper field must remain dry to be considered sterile - a 1 in border around a sterile field is considered contaminated - sterile objects in contact with clean objects are considered contaminated Once a sterile paper field becomes wet it allows microorganisms on the surface of the table to contaminate the field. A 1-inch (2.5 cm) border around the outer edge of a sterile field is considered contaminated because the edges touch the table. Once a sterile object comes into contact with any object that is not sterile, it is no longer considered sterile. Sterile objects below the waist are considered contaminated. A fenestrated drape may be considered sterile as long as it has not been contaminated.

The family of an older adult reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter. Which rationale would the nurse manager consider before responding?

A separate signed informed consent or routine treatments is unnecessary This is considered a routine procedure to meet basic physiological needs and is covered by a consent signed at the time of admission. The need for consent is not negated because the procedure is beneficial. This treatment does not require special consent.

A client reports a severe unilateral throbbing headache, nausea, intolerance to light and sound, and double vision. Which phase of this headache involves double vision?

Aura phase The aura phase involves visual changes, flashing lights, or diplopia (double vision). Throbbing and unilateral headaches that are often associated with nausea or sensitivity to light and sound, flashes of light, and double vision may be migraine headaches. There are three types of migraines: migraine with aura, migraine without aura, and typical migraine. The headache phase involves a severe throbbing head ache. The prodromal phase involves specific symptoms, such as food cravings or mood changes. Intensity of the headache will start to decrease in termination phase.

The nurse is reviewing the cerebrospinal fluid (CSF) laboratory findings of four clients. Which client would the nurse suspect has had a previous meningeal hemorrhage?

Brown CSF The brown color of the CSF indicates the client has had a meningeal hemorrhage. A yellow color of the CSF is due to hemolysis of red blood cells (RBC) leading to increased bilirubin. An unclear or hazy appearance of the CSF indicates an elevated white blood cell count. A pink-red to orange color indicates the presence of RBCs in the CSF.

Which technique would the nurse use to maintain surgical asepsis?

Change the sterile field after sterile water is spilled on it A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick and allow microorganisms to contaminate the sterile field. The outsides of containers and packages are not considered sterile and sterile gloves are considered contaminated when touching either of these items. Items on the sterile field should be no less than 1 inch from the outer border or edge of the sterile field; any less is not considered sterile. Surgical areas or wounds should be cleaned from the inside edges to the outside edges to prevent recontamination.

Which procedure is used to verify placement of a newly inserted central venous access device (CVAD)?

Chest x-ray The insertion of a central venous catheter (CVC) into the subclavian vein can result in a pneumothorax, which would be seen on a chest x-ray. Indications of a pneumothorax before the chest x-ray would include shortness of breath and anxiety. If the chest x-ray is negative for pneumothorax, the CVC line may be used. The central line should not be flushed until placement is verified. Blood withdrawal is utilized once placement is verified, but is not used to verify initial placement. Fluoroscopy may be used during placement in certain settings, but not for placement verification.

The nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine. The nurse has a sample of the new product. How would the nurse proceed?

Follow the agency's policy unless it is contraindicated by the primary health care provider's prescription Agency policy determines procedures; if the procedure is out of date or problematic, the nurse would contact the primary health care provider for a change in the prescription. The nurse cannot use another product without a primary health care provider's prescription. The nurse will be risking liability if agency policy is not followed, unless the prescription is changed by the primary health care provider.

A client who sustained a head injury reports bland taste of food. Upon examination, the nurse finds that there is loss of taste perception from the anterior two-thirds region of the tongue. Which origin of the brain is associated with the involved nerve?

Inferior pons Loss of taste perception from the anterior two-thirds of the tongue indicates injury to the facial nerve, which originates from the inferior pons. The medulla is the site of origin for the glossopharyngeal, vagus, accessory, and hypoglossal nerves. The optic nerve and oculomotor nerve originate from the midbrain. The site of origin for the olfactory nerve is the olfactory bulb in the anterior ventral cerebrum.

The nurse is preparing to administer an oil-retention enema and understands that it works primarily by which action?

Lubricating the sigmoid colon and rectum The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces.

Which finding would the nurse expect when assessing a client who has a vertebral fracture at the T1 level?

Normal biceps reflexes in the arms The client will have normal biceps reflexes with a T1 injury. The nerves for arm innervation are at C4, which is above the injury level of T1. Diaphragm innervation is not affected by this injury; the diaphragm is innervated above C4. Innervation of muscles used to move the lower arms is not affected by this injury; these muscles are innervated above C7. Innervation for pain sensation of the hands is not affected by this injury; these nerves are innervated above C7.

A client begins to have difficulty breathing 30 minutes after the insertion of a subclavian central line. Which would the nurse do first?

Raise the head of the bed The priority is to assist breathing. Raising the head of the bed is the least invasive and first action. Assessing for diminished breath sounds and applying oxygen are important but should be done after raising the head of the bed. In addition, requesting a chest x-ray, if not already done, is appropriate, but the priority is to immediately perform nursing interventions that will promote ventilation.

A friend transports an adult client to the emergency department and states, "All of us were partying at a club, and all of a sudden my friend collapsed." The client's vital signs are temperature 99.2°F (37.3°C), pulse 152 beats per minute, respirations 32 breaths per minute, blood pressure 163/92 mm Hg. Which action would the nurse implement next, after completing the physical assessment and health history from the client?

Relay the cleint's status to the health care provider; insert the prescribed IV line 3,4-Methylenedioxymethamphetamine (Ecstasy) is an abused drug that has both stimulant and hallucinogenic properties. Stimulants have the ability to cause dehydration by increasing activity and diaphoresis via increased adrenaline release. The client is displaying symptoms of dehydration; the nurse would inform the health care provider and insert the prescribed IV line. Letting the friend stay and reassessing the client in 1 hour are inappropriate; the client's vital signs indicate the need for immediate attention. Placing the client in a private room with a cool cloth on the head is inappropriate; the client's vital signs are indicative of a problem. Performing a neurological assessment every 15 minutes is inappropriate at this time. The client's vital signs indicate a need for immediate medical attention.

At which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter?

Tubing injection port The appropriate site to obtain a urine specimen for a client with an indwelling catheter is the injection port. The nurse would clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port, and aspirate the quantity desired. The nurse would apply a clamp to the drainage tubing, distal to the injection port, not obtain the specimen from this site. Urine in the bedside drainage bag is not an appropriate sample, because the urine in the bag may have been there too long; thus a clean sample cannot be obtained from the bag. The client's urine will be contained in the indwelling catheter; there will be no urine at the insertion site.

A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching?

Using a back and forth motion wiht the same gauze while cleaning the wound After each swipe, sterile gauze should be discarded, and a new sterile gauze should be used for the next swipe. The other options are correct. Placing the old dressing in a plastic bag confines the soiled dressing to a leak-proof bag and prevents contamination of the environment or others. A mask is not necessary. Nonsterile gloves are acceptable for dressing removal because the dressing is contaminated; sterile gloves may be required for dressing application.