Adaptive Quizzing Review for CAT (102,103,104)

What is a clinical manifestation of hypernatremia in burns? a.Fatigue b.Seizures c.Paresthesias d..Cardiac dysrhythmias

b. Rationale: Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.

A client has symptoms associated with salmonellosis. Which data are most relevant for the nurse to obtain from the client's history? a.Any rectal cancer in the family b.All foods eaten in the past 24 hours c.Any recent extreme emotional stress d.An upper respiratory infection in the past 10 days

b. Rationale: The salmonella organism thrives in warm, moist environments; all foods eaten within the last 24 hours are the most relevant data. Washing, cooking, and refrigerating food limit the growth of or eliminate the organism. Salmonellosis is unrelated to cancer. The salmonella organism, not stress, causes salmonellosis. The salmonella organism is ingested; it is not an airborne or blood-borne infection.

What could be the possible cause of a scald injury? a.Contact with grease b.Contact with hot liquids or steam c.Contact with alkali in oven cleaners d.Contact with open flame in house fires

b. Rationale: scalding injuries usually result from contact with hot liquids or steam. Contact with grease and the alkali in oven cleaners may cause chemical injuries. An open flame in house fires may cause thermal injuries.

Which is a primary glomerular disease? a.Diabetic glomerulopathy b.Chronic glomerulonephritis c.Hemolytic-uremic syndrome d.Systemic lupus erythematosus (SLE)

b. Rationale: Chronic glomerulonephritis is a primary glomerular disease. Diabetic glomerulopathy, hemolytic-uremic syndrome, and systemic lupus erythematosus (SLE) are secondary glomerular diseases.

A client has surgery for the creation of a colostomy. Postoperatively, what color does the nurse expect a viable stoma to be? a.Brick red b.Pale pink c.Light gray d.Dark purple

a. Rationale Brick red describes a stoma that has adequate vascular perfusion. Pale pink indicates inadequate perfusion of the stoma. Light gray is indicative of poor tissue perfusion. Dark purple indicates inadequate perfusion of the stoma.

Which part of the respiratory system is referred to as Angle of Louis? a.Hilum b.Carina c.Alveoli d.Epiglottis

b. Rationale: Located at the level of the manubriosternal junction, the carina is also referred to as the Angle of Louis. The mainstream bronchi, pulmonary vessels, and nerves enter the lungs through a slit called the hilum. Alveoli are small sacs that are the primary site of gas exchange in the lungs. The epiglottis is a small flap located behind the tongue that closes over the larynx during swallowing

The nurse assessed a client's pulse rate and recorded the score as 3+. What is the strength of the pulse? a.Strong b.Bounding c.Expected d.Diminished

a. Rationale A pulse strength of 3+ is considered full or strong. A bounding pulse is 4+. A pulse strength is considered normal and expected when it is 2+. The pulse strength is diminished or barely palpable when the score is 1+.

The nurse is teaching the client about wound healing. Which feature is associated with the "maturation phase" of normal wound healing? a.The scar is firm and inelastic on palpation. b.Fibrin strands form a scaffold or framework. c.White blood cells migrate into the wound. d.Epithelial cells are grown over the granulation tissue bed.

a. Rationale: The maturation phase of normal wound healing involves a mature scar that is firm and inelastic when palpated. In the proliferative phase, the fibrin strands form a scaffold or framework. White blood cells migrate into the wound during the inflammatory phase. In the proliferative phase, the epithelial cells are grown over the granulation tissue bed.

The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take? a.Notify the primary healthcare provider immediately b.Apply a warm, moist compress to the incision site c.Increase the intravenous fluid rate by 20 mL/hr d.Monitor vital signs more frequently

a. Rationale The primary healthcare provider must be notified immediately so that anticoagulation therapy can be instituted. Applying a warm, moist compress to the incision site is inappropriate because it may promote bleeding; if phlebitis occurs, then warm, moist compresses may be applied. Increasing the intravenous fluid rate by 20 mL hourly will not resolve an embolus. Although monitoring vital signs is appropriate, it is an insufficient intervention; the healthcare provider must be notified so that anticoagulants can be prescribed.

A client will be taking nitrofurantoin 50 mg orally every evening at home to manage recurrent urinary tract infections. What instructions should the nurse give to the client? a.Increase the intake of fluids. b.Strain the urine for crystals and stones. c.Stop the drug if urinary output increases. d.Maintain the exact time schedule for taking the drug.

a. Rationale To prevent crystal formation, the client should have sufficient intake to produce 1000 to 1500 mL of urine daily while taking this drug. Straining urine is not indicated when the client is taking a urinary antiinfective. Urinary decrease is of concern because it may indicate renal failure. If fluids are encouraged, the client's output should increase. The drug need not be taken at a strict time daily.

A client begins therapy with a new medication. One month later the client notices blood in the urine. Which drug does the nurse anticipate as the cause? a.Warfarin b.Nifedipine c.Nitrofurantoin d.Phenazopyridine

a. Rationale: Warfarin is an anticoagulant medication and could result in blood in urine, a condition known as hematuria. Nifedipine is a calcium channel blocker that could affect the ability of the urinary bladder or sphincter to contract and relax normally. Nitrofurantoin is used to treat urinary tract infections but can cause alteration in urine color to a dark yellowish-brown. Phenazopyridine, a bladder analgesic used to treat pain associated with urinary tract conditions, changes the color of urine to orange or red.

Which pulse site is used to perform Allen's test? a.Ulnar b.Brachial c.Femoral d.Dorsalis pedis

a. Rationale The ulnar pulse site is used to perform Allen's test. The brachial pulse site is used to assess the status of circulation to the lower arm and to auscultate blood pressure. The femoral site is used to assess the character of the pulse during physiological shock or cardiac arrest. The dorsalis pedis site is used to assess the status of circulation in the foot.

Which retrograde procedure involves the examination of the ureters and the renal pelvises? a.Cystogram b.Pyelogram c.Urethrogram d.Voiding cystourethrogram

b. Rationale: A pyelogram is a retrograde examination of the ureters and the pelvis of both kidneys. A cystogram is a retrograde examination of the bladder. An urethrogram is a retrograde examination of the urethra. A voiding cystourethrogram is used to determine whether urine is flowing backward into the urethra.

A client with cancer of the colon is admitted to the hospital for a hemicolectomy. What does the nurse expect the preoperative plan of care to include? a.Giving oil-retention enemas daily for two days preoperatively b.Administering cleansing enemas and then neomycin c.Having a Sengstaken-Blakemore tube at the bedside d.A high-protein and high-carbohydrate regular diet for two days preoperatively

b. Rationale After the bowel is cleansed, neomycin is given to decrease gram-negative bacteria in the colon, which should limit postoperative infection. Oil-retention enemas are used to alleviate constipation; oil-retention enemas are not prescribed before surgery because they contaminate the bowel with oil. A Sengstaken-Blakemore tube is used for a client with ruptured esophageal varices, not for a client having a hemicolectomy. A diet to decrease bulk and empty the colon generally is prescribed; usually it is a clear liquid diet.

A spouse of a client with pulmonary tuberculosis (TB) receives a tuberculin skin test. The nurse reads the test and identifies an area of induration greater than 10 mm. What does this result indicate to the nurse? a.No further action is required. b.Additional tests are necessary. c.Repeating the skin test is indicated. d.Results are positive, indicating infection.

b. Rationale The test does not indicate whether TB is dormant or active. However, a client with an induration of 5 mm or greater is considered positive if there is repeated close contact with a person diagnosed with pulmonary tuberculosis or if the client has a disease causing decreased resistance; this requires further diagnostic study, such as chest x-rays and sputum culture. A newly infected client will receive preventive therapy with isoniazid (INH). Isoniazid will be continued for 6 months if chest x-rays are normal, or 12 months if chest x-rays are abnormal. Repeating the skin test is not necessary; the test is considered positive.

A client injures an amphiarthrodial joint. Which joint did the client injure? a.Knee joint b.Pelvic joint c.Elbow joint d.Cranial joint

b. Rationale Amphiarthrodial joints are those that permit slight movements. The pelvic joint is an example of amphiarthrodial joint. Knee and elbow joints are the examples of diarthrodial joints, which are freely movable. A cranial joint is an example of a synarthrodial joint, which is immovable.

A client newly diagnosed with type 1 diabetes is taught to exercise on a regular basis. What is the primary reason for instruction on exercise? a.To decrease insulin sensitivity b.To stimulate glucagon production c.To improve the cellular uptake of glucose d.To reduce metabolic requirements for glucose

c. Rationale Exercise increases the metabolic rate, and glucose is needed for cellular metabolism; therefore, excess glucose is consumed during exercise. Regular vigorous exercise increases cell sensitivity to insulin. Glucagon action raises blood glucose but does not affect cell uptake or use of glucose. Cellular requirements for glucose increase with exercise.

Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients? a.Analysis b.Inference c.Explanation d.Interpretation

c. Rationale Explanation requires knowledge and experience for choosing strategies for care of clients. Analysis is a critical thinking skill that requires open-mindedness while looking at the client's information. The skill of inference is associated with noticing relationships in the findings. Interpretation is associated with an ordered data collection.

A client who had a myocardial infarction receives a prescription for a nitroglycerin patch. What does the nurse identify as the purpose of the nitroglycerin patch? a.Decreased heart rate lowers cardiac output. b.Increased cardiac output increases oxygen demand. c.Decreased cardiac preload reduces cardiac workload. d.Peripheral venous and arterial constriction increases peripheral resistance.

c. Rationale Nitroglycerin reduces cardiac workload by decreasing the preload of the heart by its vasodilating effect. It decreases blood pressure, not heart rate (which may increase to compensate for the decreased blood pressure). It decreases, not increases, oxygen demand. Nitroglycerin dilates, not constricts, peripheral veins and arteries.

A healthcare provider prescribes enalapril for a client. Which is the most important nursing action? a.Assess the client for hypokalemia. b.Ensure that the medication is ingested with food. c.Monitor the client's blood pressure during therapy. d.Teach that a missed dose can be doubled at the next scheduled time.

c. Rationale Enalapril is an antihypertensive. A lowering of the client's blood pressure reflects a therapeutic response and needs to be monitored frequently. The client may be at risk for hyperkalemia, not hypokalemia. Enalapril may be taken without regard to meals. Doubling a dose is unsafe as it may cause an extreme lowering of blood pressure. A missed dose can be taken as long as it is not close to the next scheduled dose.

Which complication may be caused by sepsis in burns? a.Diarrhea b.Constipation c.Paralytic ileus d.Curling's ulcer

c. Rationale: Paralytic ileus, or hypoactive bowel, is a complication caused by sepsis in clients with burns. Diarrhea can be caused by the use of enteral feedings or antibiotics. Constipation can occur as a side effect of opioid analgesics, decreased mobility, and a low-fiber diet. Curling's ulcer is a type of gastroduodenal ulcer characterized by diffuse superficial lesions. It is caused by a generalized stress response to decreased blood flow to the gastrointestinal tract in clients with burns.

Which is the definition of photophobia? a.Double vision b.Foreign body sensation c.Persistent abnormal intolerance to light d.Gradual or sudden inability to see clearly

c. Rationale: Photophobia is a persistent abnormal intolerance to light. Diplopia is double vision. Foreign body sensation results in pain. A gradual or sudden inability to see clearly is called blurred vision.

Which hormone is crucial in maintaining the implanted egg at its site? a.Inhibin b.Estrogen c.Progesterone d.Testosterone

c. Rationale: Progesterone is necessary to maintain an implanted egg. Inhibin regulates the release of follicle-stimulating hormone (FSH) and gonadotropin-releasing hormone (GnRH). Estrogen plays a vital role in the development and maintenance of secondary sexual characteristics. Testosterone is important for bone strength and development of muscle mass.

A client is diagnosed as having invasive cancer of the bladder, and brachytherapy is scheduled. What should the nurse expect the client to demonstrate that indicates success of this therapy? a.Decrease in urine output b.Increase in pulse strength c.Shrinkage of the tumor on scanning d.Increase in the quantity of white blood cells (WBCs)

c. Rationale: Brachytherapy, in which isotope seeds are implanted in the tumor, interferes with cell multiplication, which should control the growth and metastasis of cancerous tumors. Radiation affects healthy as well as abnormal cells; urinary output will increase with successful therapy. With brachytherapy of the bladder, increase in pulse strength is not a sign of success. Bone marrow sites may be affected by radiation, resulting in a reduction of WBCs.

A client is instructed to avoid straining on defecation postoperatively. Which food item chosen by the client indicates successful learning? a.Ripe bananas b.Milk products c.Green vegetables d.Creamed potatoes

c. Rationale: Green vegetables contain fiber, which promotes defecation. Bananas, milk products, and creamed potatoes have a constipating effect, which results in straining at stool.

A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response? a."Your primary healthcare provider must have forgotten to prescribe it." b."Your condition is not severe enough to have physical therapy approved." c."Your joints are still inflamed, and physical therapy can be harmful." d."Physical therapy is not helpful for persons who suffer from RA."

c. Rationale: Rest is required during active inflammation of the joints to prevent injury; once active inflammation has receded, an activity and exercise regimen can begin. Physical therapy is not prescribed during a period of exacerbation because it can traumatize already inflamed joints. The extent of the arthritis is not the determinant; whether the process is in exacerbation or remission is the deciding factor. Physical therapy is helpful, but it is not performed during an acute exacerbation of the arthritis.

A nurse teaches a client with type 2 diabetes how to provide self-care to prevent infections of the feet. Which statement made by the client shows that teaching was effective? a."I should massage my feet and legs with oil or lotion." b."I should apply heat intermittently to my feet and legs." c."I should eat foods high in protein and carbohydrate kilocalories." d."I should control my blood glucose with diet, exercise, and medication."

d. Rationale Controlling the diabetes decreases the risk of infection; this is the best prevention. Oil or lotion that is not completely absorbed may provide a warm, moist environment for bacterial growth. Coexisting neuropathy may result in injury from heat application. Protein, carbohydrates, and fats must be in an appropriate balance; high carbohydrate intake can provide too many calories.

Which caring intervention helps to provide comfort, dignity, respect, and peace to a client? a.Listening b.Spiritual caring c.Providing presence d.Relieving pain and suffering

d. Rationale Relieving pain and suffering is not just about giving medications but providing comfort, dignity, respect, and peace to a client. Listening helps to obtain meaningful interactions with clients. Spiritual caring helps clients find balance between their own life values, goals, and belief systems. Providing presence helps to convey closeness and a sense of caring.

The nurse assesses a client for orthostatic hypotension. The results are: Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider? a.Increase furosemide from 20 mg by mouth (PO) to 40 mg PO daily b.Give 1 L of 0.9% normal saline (NS) bolus over 4 hours c.Start intravenous (IV) infusion of D5 ½ NS to run at 150 mL/hr d.No prescription change

d. Rationale The assessment findings do not indicate postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure). There is no indication from the data that a prescription change is needed for this client. Increasing the furosemide or giving intravenous fluid to this client could result in a fluid imbalance.

In a clinical study, subjects were given chlorhexidine and betadine as antiseptics. How will a nurse researcher categorize this research? a.Evaluation research b.Descriptive research c.Correlational research d.Experimental research

d. Rationale The nurse will categorize this study as experimental research. In experimental research, the investigator gives variables randomly to the subjects. In this case, subjects are given chlorhexidine and betadine to test their efficacy in reducing infection. Evaluation research is an initial study that refines a hypothesis, such as testing a new exercise in older dementia clients. In a descriptive study, the characteristics of a person or a situation are measured. For example, a researcher may examine the nurses' bias while caring for obese clients. Correlational research is used to find out the relationship between different variables without the interference of a researcher. An example would be determining the educational status of nurses and their satisfaction with the job provided.

Why is Phalen's test performed in a client? a.To diagnose atrophy b.To diagnose bone tumor c.To detect rotator cuff injuries d.To detect carpal tunnel syndrome

d. Rationale: Phalen's test is used to detect carpal tunnel syndrome. A muscle biopsy is done for the diagnosis of atrophy. A computed tomography scan is done to diagnose a bone tumor. The drop arm test is performed to detect rotator cuff injuries.

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take? a.Take the client's vital signs. b.Inform the healthcare provider. c.Turn the client to the unaffected side. d.Check the tube to ensure that it is not kinked.

d. Rationale Once the drainage tube is patent, the fluctuation in the water column will resume; a lack of fluctuation because of lung reexpansion is unlikely 36 hours after a traumatic open chest injury. Taking the client's vital signs may be done eventually but is not the priority at this time. Informing the healthcare provider is unnecessary at this time; the chest tube is occluded, and nursing interventions should be attempted first. Turning the client to the unaffected side will compromise aeration of the unaffected lung.

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? a.Dull sound on percussion b.Vocal fremitus on palpation c.Rales with rhonchi on auscultation d.Absence of breath sounds on auscultation

d. Rationale: The left lung is collapsed; therefore, there are no breath sounds. A tympanic, not a dull, sound will be heard with a pneumothorax[1][2]. There is no vocal fremitus because there is no airflow into the left lung as a result of the pneumothorax. Rales with rhonchi will not be heard because there is no airflow into the left lung as a result of the pneumothorax.

The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? a.Increased appetite b.Clubbing of the nail beds c.Hypertension d.Weight gain

d. Rationale The most common signs and symptoms of right-sided heart failure are hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients with right-sided heart failure often have decreased appetites. Clubbing is indicative of hypoxemia. Hypertension is associated with left-sided heart failure.

The nurse is presenting information about hyperthermia to a group of nursing students. Which activities put a client at risk for this condition? a.Snowmobiling b.Skiing in the winter c.Hiking Alaskan mountains d.Performing strenuous activity in high humidity

d. Rationale: When a client performs strenuous activity in high humidity, it reduces heat loss from the body and results in hyperthermia. Activities such as snowmobiling, skiing, and hiking in cold weather may cause hypothermia because they occur in cold temperatures and may lower the body temperature.

Which interview technique is the nurse using when asking a client to score the pain on a scale from 0 to 10? a.Probing b.Back channeling c.Open-ended questioning d.Closed-ended questioning

d. Rationale: Asking a client to score pain on a scale of 0 to 10 is a type of closed-ended question. These types of questions specify the cause of the problem or the client's experience of the illness. Asking whether anything else is bothering the client is an example of probing. A response by the nurse such as "All right," or "Go on," when a client says something is called back channeling. This interview technique encourages a client to provide more details. The nurse asks open-ended, nonspecific questions such as "What brought you to the hospital today?" to elicit the client's side of story. Such questions are related to the client's health history and can strengthen the nurse-client relationship.

Which diagnostic test may be used to distinguish vascular from nonvascular structures? a.Chest X-ray b.Pulmonary angiogram c.Computed tomography d. Magnetic resonance imaging

d. Rationale: Magnetic resonance imaging is used for distinguishing vascular from nonvascular structures. An X-ray is useful to screen, diagnose, and evaluate changes in the respiratory system. A pulmonary angiogram is used to visualize pulmonary vasculature and locate obstruction of pathologic conditions. Computed tomography is performed for diagnosis of lesions difficult to assess by conventional X-ray studies.

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan? a.Kidney dysfunction b.Cardiovascular diseases c.Eye problems, such as glaucoma d.Accidents, including their prevention

d. Rationale: Accidents are common during young adulthood because of immature judgment and impulsivity associated with this stage of development. Kidney dysfunction is not a problem specific to any one stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma is a common health problem in older adults.

A nurse is caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency? a.Hemorrhage b.Hypovolemic shock c.Gastrointestinal atony d.Autonomic hyperreflexia

d. Rationale: 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. While 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.