EAQ 8: Care Competencies
The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco2 of 45 mm Hg, HCO3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support which diagnosis? 1 Hypocapnia 2 Hyperkalemia 3 Metabolic alkalosis 4 Respiratory acidosis
3 Elevated plasma pH and elevated bicarbonate levels support metabolic alkalosis. The arterial carbon dioxide level of 45 mm Hg is within the expected value of 35 mm Hg to 45 mm Hg; no hypocapnia is present. The client's serum potassium level is within the expected level of 3.5 mEq/L to 5 mEq/L (3.5-5 mmol/L). With respiratory acidosis the pH will be less than 7.35 and the Pco2 will be elevated.
A client had part of the ileum surgically removed. The nurse monitors the client closely for anemia based on which rationale? 1 Folic acid is absorbed in the ileum. 2 Cobalamin is absorbed in the ileum. 3 Iron absorption is dependent on simultaneous bile salt absorption in the ileum. 4 Copper, cobalt, and nickel are dependent on simultaneous bile salt absorption in the ileum.
2 Vitamin B12 (cobalamin) combines with intrinsic factor, a substance secreted by the parietal cells of the gastric mucosa, and is absorbed in the ileum. Cobalamin is needed to make red blood cells. Folic acid and iron are not absorbed. Copper, cobalt, and nickel are not absorbed in the ileum.
Which priority interventions would the nurse follow when caring for a client with malignant hyperthermia? Select all that apply. One, some, or all responses may be correct. 1 Administer 100% oxygen (O2). 2 Prepare for endotracheal intubation 3 Monitor the core body temperature. 4 Stop all inhalation anesthetic agents. 5 Insert an indwelling urinary catheter.
1,2,4 The client should be ventilated with 100% O2 using the highest possible flow rate when malignant hyperthermia is evident. The nurse would prepare the client for endotracheal intubation. All inhalation anesthetic agents should be stopped immediately because the client's condition may worsen. The core body temperature should be monitored on an ongoing basis. An indwelling urinary catheter is inserted to monitor urine output, which is part of ongoing monitoring.
Which is the priority nursing intervention, after collaborating with the emergency response team, for a group of clients admitted to the emergency department after a radioactive explosion in a uranium mine? 1 Arranging blood transfusions for the clients immediately 2 Starting intravenous fluid administration immediately 3 Removing client's clothes and showering clients immediately 4 Performing total body assessment of clients immediately
3 Clients who have been exposed to a radioactive explosion may carry radioactive substances along with them and pose danger to other clients and hospital staff. The emergency department staff should first implement decontamination measures such as removing the clothes and showering the clients to reduce the risk. The emergency department nurse can arrange blood transfusions for the clients, but only after implementing the decontamination measures. The emergency department team can start intravenous fluids to the clients only after showering the clients. The emergency department staff can perform total body assessments to clients only after implementing decontamination measures.
A client enters the emergency department reporting shortness of breath and epigastric distress. Which would be the triage nurse's first intervention? 1 Assess the pain level. 2 Insert an intravenous (IV) saline lock. 3 Provide the client with oxygen. 4 Draw blood for troponin levels.
3 Treating the client's shortness of breath is the priority. Providing the client with oxygen should take place before the other interventions. Assessment of pain is important, but improving oxygenation should be done first. Although inserting an IV saline lock may be done, it is not the priority. Although drawing blood for troponins may be needed, it is not the priority.
Which is the priority in preparing health care professionals for any type of disaster? 1 Identification of hazards 2 Cooperation with state authorities 3 Collaboration with local authorities 4 Implementation of federal mandates
1 Identification of hazards is the priority in the preparedness of health care professionals in any type of disaster plan. Although cooperation with state authorities, collaboration with local authorities, and implementation of federal mandates also play a role in being prepared for a disease, these are not the priority because it is essential to identify the specific hazard to implement the most appropriate portion of the disaster plan.
Which test would be used to determine fetal lung maturity in a client in preterm labor? 1 Amniocentesis 2 Ultrasonography 3 Measurement of human gonadotropin hormone 4 Chorionic villus sampling
1 The presence of phosphatidylglycerol and a 2:1 lecithin to sphingomyelin ratio in the amniotic fluid confirm fetal lung maturity. Ultrasonography cannot be used to determine fetal lung maturity. The measurement of human chorionic gonadotropin hormone is most commonly used to diagnose pregnancy. Chorionic villus sampling, a diagnostic screening test, is done between the 8th and 12th weeks of pregnancy to determine fetal chromosomal status.
The nurse is taking care of a client who has chronic back pain. Which nursing considerations would be made when determining the client's plan of care? Select all that apply. One, some, or all responses may be correct. 1 Ask the client about the acceptable level of pain. 2 Eliminate all activities that precipitate the pain. 3 Administer the pain medications regularly around the clock. 4 Use a different pain scale each time to promote patient education. 5 Assess the client's pain every 15 minutes.
1,3 The nurse works together with the client to determine the tolerable level of pain. Considering that the client has chronic, not acute, pain, the goal of pain management is to decrease pain to a tolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide a stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level because it helps ensure consistency and accuracy in the pain assessment. Only management of acute pain, such as postoperative pain, requires pain assessment at frequent intervals.
Which would the nurse expect to see when reviewing the results of a complete blood count for an infant with tetralogy of Fallot? 1 Anemia 2 Polycythemia 3 Agranulocytosis 4 Thrombocytopenia
2 The body responds to the chronic hypoxia caused by the heart defect by increasing the production of red blood cells (RBCs) in an attempt to increase the oxygen-carrying capacity of the blood. The RBC count will be increased because the body increases erythrocyte production in an attempt to make more cells available to carry oxygen. Agranulocytosis does not result from hypoxia; it occurs when the white blood cell count decreases to a very low level and neutropenia becomes pronounced. Leukopenia occurs when the white blood cells become low and is not associated with tetralogy of Fallot.
Which observations would alert the nurse to suspect maltreatment in an 11-month-old infant who is brought to the pediatric clinic weighing 9 lb, 3 oz (4167 g)? Select all that apply. One, some, or all responses may be correct. 1 Stranger anxiety 2 Inappropriate clothing 3 Social unresponsiveness 4 Frequent rocking motions 5 Adequate personal hygiene
2,3,4 The following would alert the nurse to maltreatment in an infant: inappropriate clothing, social unresponsiveness, and frequent rocking motions. A typical sign of physical neglect is the wearing of dirty clothes or clothing that is not suitable to the environment (inappropriate clothing). The infant who has not experienced social responsiveness from the caregiver has not learned how to be socially responsive to others. Infants who experience emotional deprivation resort to self-stimulating behaviors in an effort to meet their emotional needs (frequent rocking motions). Stranger anxiety begins around 5 to 6 months, when infants become responsive to the caregivers who have met both physical and emotional needs. When strangers speak to them or reach out to hold them, they seem fearful, cling to the caregiver, and cry. Infants whose needs have not been met adequately have no reason to be fearful of others. An infant with adequate personal hygiene does not indicate maltreatment. Infants who experience physical neglect are more likely to be unclean, with signs of unattended skin lesions such as diaper rash or bruises.
The nurse manager asks the nurse, "How would you implement clinical decision-making in a group of clients?" Which answer(s) provided by the nurse show(s) effective critical thinking? Select all that apply. One, some, or all responses may be correct. 1 "I will avoid involving clients as decision-makers and participants in care." 2 "I will discuss complex cases with other members of the health care team." 3 "I will identify the nursing diagnoses and collaborative problems of each client." 4 "I will consider the time it takes to care for clients whose problems have higher priority." 5 "I will decide to perform activities individually to resolve one client problem at a time."
2,3,4 The nurse would discuss complex cases with the other members of the health care team. It ensures a smooth transition in the care requirements. As a part of effective critical thinking, the nurse would diagnose the collaborative problems of each client. The nurse would consider the care time for the clients having problems that require high priority. Effective critical thinking requires the nurse to involve clients as decision-makers or participants in care. The nurse would decide on combining activities to resolve more than one client problem at a time.
Which is the most important need for a newly pregnant client receiving phenytoin for seizures? 1 Discussing the need to increase protein requirements 2 Providing a referral for immediate termination of the pregnancy 3 Stressing the need to decrease phenytoin to prevent fetal phenytoin toxicity 4 Explaining why it is extremely important to take the prescribed folic acid supplements
4 Phenytoin therapy interferes with folate absorption, which increases the risk of neural tube deformities in the developing fetus; therefore it is a priority for this client to take folic acid supplements. Although all pregnant clients have increased protein needs, phenytoin therapy does not cause a need for additional protein. Before termination of any pregnancy, it is important to ensure that the client receives appropriate counseling to make an informed decision. Fetal phenytoin toxicity is not an issue of concern; however, the effect of phenytoin on the fetus is, so rather than decreasing phenytoin, the more appropriate choice would be to discuss a different antiepileptic with the provider.
Leucovorin calcium is prescribed and is to be administered immediately after an infusion of methotrexate. Which result of laboratory testing indicates that leucovorin has been effective? 1 Potassium level normalizes 2 Folic acid level within normal limits 3 Improved white blood cell count 4 Decreased methotrexate level
4 The laboratory measurement of the client's methotrexate level is the most objective measure of leucovorin calcium's effectiveness. Leucovorin calcium is considered a "rescue" medication because it minimizes the effects of methotrexate on healthy cells by competing with methotrexate at the cellular level, thus neutralizing it and causing it to be excreted. Its purpose is not to affect folic acid levels nor to affect potassium or white blood cell counts.
The nurse discovers the client with antisocial personality disorder and visitors are smoking marijuana in the hall. Which response would the nurse make when the client responds, "I'm celebrating. I went to trial today and just got put on probation"? 1 "You were lucky you just got probation, so don't get right back into trouble." 2 "I understand your relief about the trial, but smoking pot is against the rules." 3 "It's important that you and your friends join the other visitors in the dayroom." 4 "If you can't follow the rules against drug use on the unit, your visiting privileges will be canceled."
4 The nurse would respond with, "If you can't follow the rules against drug use on the unit, your visiting privileges will be canceled." This client needs firm, realistic limits set on behavior. This response permits the client to make the choice and clearly states the consequences of behavior. Clients with this diagnosis (antisocial) do not learn from past errors so saying, "You were lucky you just got probation, so don't get right back into trouble," will be ineffective and it is nontherapeutic. The response "I understand your relief about the trial, but smoking pot is against the rules," states the limits but does not inform the client of the consequences if the limits are broken. Clients with the diagnosis of antisocial personality disorder do not care about rules. The client and visitors will probably refuse to socialize with other clients and visitors and it is not appropriate at this time to send them to dayroom after smoking marijuana.
The nurse identifies a small amount of bile-colored drainage on the dressing of a client who has had a liver biopsy. How would the nurse interpret this finding? 1 Fluid is leaking into the intestine. 2 The pancreas has been lacerated. 3 This is a typical, expected response. 4 A biliary vessel has been punctured.
4 The flow of bile through the puncture site indicates that a biliary vessel was punctured; this is a common complication after a liver biopsy. Fluid will leak through the puncture site or into the peritoneum, not the intestine. The pancreas does not contain bile; it is in the upper left, not upper right, quadrant. This is a complication, not an expected outcome.
The client with a seizure disorder receives intravenous (IV) phenytoin. The nurse will monitor closely for which condition? 1 Cardiac dysrhythmias 2 Hypoglycemia 3 Polycythemia 4 Paradoxical excitation
1 IV phenytoin was once used to treat dysrhythmias until better medications were developed. It depresses both atrial and ventricular conduction, and so it can cause significant dysrhythmias. It can also cause hyperglycemia (not hypoglycemia) and pancytopenia (not polycythemia). Paradoxical excitation is not a known issue; it has a depressant effect resulting in drowsiness.
The registered nurse (RN) measures the blood pressure in a client as 130/80 mm Hg. When the student nurse is measuring the blood pressure in the same client, it is found to be 120/90 mm Hg. Which could be the possible reasons for this difference? Select all that apply. One, some, or all responses may be correct. 1 Poor fitting of the cuff 2 Inflating the cuff too slowly 3 Deflating the cuff too quickly 4 Inflating the cuff inadequately 5 Applying the stethoscope too firmly
1,3 Poor fitting of the cuff or deflating the cuff too quickly causes false low systolic and false high diastolic readings. Inflating the cuff too slowly results in false high diastolic readings. Inflating the cuff inadequately yields false low systolic readings. Applying the stethoscope too firmly against antecubital fossa yields false low diastolic readings.
Which would the nurse instruct the parents to do to enhance their toddler's need for autonomy? 1 Help the child learn society's roles. 2 Teach the child to share with others. 3 Help the child develop internal controls. 4 Teach the child to accept external limits.
4 Appropriate limit setting and discipline are necessary for children to develop self-control while learning the boundaries of their abilities. Roles within society are learned by the school-aged child. Learning to share develops during the preschool years. Internal controls begin to develop in the preschool years.
2 The signs/symptoms and history suggest possible physical neglect. If physical neglect is occurring, measures to prevent dehydration, weight loss, or falls will not correct the underlying safety issue.
Based on the assessment data in the client's chart, which need is the priority for a cognitively impaired older adult who has a cut on the forehead? 1 Adequate fluid to prevent dehydration 2 Assessment for possible physical neglect 3 Nutrition adequate to prevent weight loss 4 Implementation of fall-prevention interventions
A client has cholelithiasis with possible obstruction of the common bile duct. Before surgery is scheduled, which consideration would the nurse make when determining the client's nutritional status? 1 Is the client deficient in vitamins A, D, and K? 2 Does the client eat adequate amounts of dietary fiber? 3 Does the client consume excessive amounts of protein? 4 Are the client's levels of potassium and folic acid increased?
1 Bile promotes the absorption of fat-soluble vitamins; an obstruction of the common bile duct limits the flow of bile to the duodenum, limiting absorption of fat-soluble vitamins A, D, and K. Vitamin K helps with clotting; surgery can be postponed if bleeding problems exist. Knowing whether the client eats adequate amounts of dietary fiber is not relevant to the situation. Knowing whether the client consumes excessive amounts of protein is unnecessary; however, protein is desirable for wound healing. Increases in potassium and folic acid are not expected with this disease.
A client is admitted for surgery and appears apprehensive and withdrawn. Which is the nurse's best action? 1 Orient the client to the unit environment. 2 Have a copy of hospital regulations available. 3 Explain that there is no reason to be concerned. 4 Reassure the client that the staff is available if the client has questions.
1 Orienting the client to the hospital unit provides knowledge that may reduce the strangeness of the environment. Having a copy of hospital regulations available and reassuring the client that the staff is available to answer questions are part of orienting the client to the unit. Explaining that there is no reason to be concerned may be false reassurance because no one can guarantee that there is no reason to be concerned.
A parent asks the nurse, "The doctor said my baby has something called pulmonic stenosis. What does that mean?" Which is the best response by the nurse? 1 "What else did the doctor say?" 2 "Your baby has a heart problem." 3 "Are you concerned about the baby?" 4 "I'll page your doctor so that you can discuss this again."
1 The nurse would need to know how much information the parent has before responding. Pulmonic stenosis, a narrowing of the pulmonic valve at the entrance to the pulmonary artery, may vary in severity. Treatment may vary from balloon angioplasty to valvotomy. The mother likely knows by this time that her infant has a heart problem; telling the mother this is too vague yet too blunt. The parent is obviously concerned, or she would not have asked the question. Referring the mother back to the health care provider may be necessary, but first the nurse would assess the parent's level of understanding and provide education, if indicated.
Which clinical finding would indicate possible meningitis in an infant with an infected ventriculoperitoneal shunt? Select all that apply. One, some, or all responses may be correct. 1 Fever 2 Lethargy 3 Stiff neck 4 Poor feeding 5 Depressed fontanels
1,2,3,4 A low-grade fever progressing to a high fever occurs in meningitis. An infectious process that causes meningitis may result in rigidity and hyperextension of the neck (opisthotonos). Central nervous system irritation results in irritability, lethargy, and anorexia. The fontanels will be tense or bulging as intracranial pressure increases.
Which education would the nurse provide the parent of a hospitalized 3-year-old child undergoing chemotherapy who is asking for fried chicken? 1 Fried foods might cause nausea and vomiting during chemotherapy. 2 Any food that is requested should be offered because the child needs calories. 3 The coatings on fried foods may irritate the child's mouth and cause bleeding. 4 Foods from outside should not be brought to the unit because of the potential for infection.
2 Because chemotherapy can cause nausea, vomiting, and anorexia, the child should be offered any food that is requested. Even if the nutritional quality is minimal, any caloric intake is encouraged. Fried foods can usually be eaten because they generally do not cause nausea and vomiting or irritate the mouth. Food prepared adequately should not be contaminated and should not cause problems for a child undergoing chemotherapy.
When evaluating for nerve injury after a thyroidectomy, which action would the client be asked to do? 1 Speak 2 Swallow 3 Purse the lips 4 Turn the head
1 The laryngeal nerve is close to the operative site and can be damaged inadvertently. Loss of the gag reflex occurs with general anesthesia; the ability to swallow signifies its return. The ability to purse the lips tests the seventh cranial (facial) nerve, which is not affected in thyroid surgery. The nerves involved in turning the head are not near the thyroid gland.
Which foods should be avoided by children with celiac disease who recently started on a gluten-free diet? 1 Steamed rice 2 Mashed corn 3 Fresh applesauce 4 Grilled frankfurter
4 Frankfurters usually have grain fillers; parents should read labels and, unless they are sure of the ingredients, refrain from feeding the food to their child. Steamed rice does not contain gluten. Mashed corn does not contain gluten. Applesauce does not contain gluten.
2 According to a 3-tiered triage system, the client with unstable vital signs is categorized under the emergent tier level. Normal respiratory rates and heart rates are in the range of 12 to 20 breaths per minute and 70 to 100 beats per minute, respectively. Client B first has normal values for respiratory rate and heart rate and then shows markedly elevated values for respiratory and heart rates. Client B should be treated first. Clients A, C, and D do not have any fluctuations from normal values for respiratory and heart rates. Clients A, C, and D can be treated after client B is treated.
The client with which change in vital signs measurements would be treated first to ensure safety? 1 A 2 B 3 C 4 D
A client is discharged with a prescription for sustained-release nitroglycerin. Which information will the nurse provide to the client? 1 Swallow the capsule whole. 2 Take the medication with milk. 3 Place the capsule under the tongue. 4 Crush the capsule and mix with soft food.
1 The sustained-release capsule should be swallowed whole on an empty stomach. The capsule should not be chewed or crushed because the "beads" within the capsule are activated on a time-release schedule. Taking the capsule with milk isn't necessary; a full glass of water is sufficient. The sustained-release capsule is taken on an empty stomach. A sublingual tablet is held under the tongue, not swallowed; sustained-release nitroglycerin is a capsule that needs to be swallowed. A stinging feeling when the medication is under the tongue may occur with a sublingual nitroglycerin tablet; sustained-release nitroglycerin is a capsule that should be swallowed whole.
Place the nursing interventions in the appropriate order to best ensure milieu safety for when a client begins to demonstrate aggressive behavior toward a visitor. 1. Suggesting to the client, "Walk with me to your room." 2. Calmly addressing the individual by name to redirect the client's attention 3. Explaining that the client will be placed in seclusion if the aggressive behavior continues 4. Reassuring the client that the staff will help control the aggressiveness if the client is unable to do so 5. Firmly stating that aggressive behavior like this cannot be tolerated because "someone may get hurt"
1st. Calmly addressing the individual by name to redirect the client's attention2nd. Suggesting to the client " Walk with me to your room."3rd. Firmly state the aggressive behavior is not tolerated4th. Explaining that the client will be placed in seclusion if the aggressive behavior5th. Reassuring the client that the stuff will help control the agressiveness. The initial action is to redirect the client's attention (calmly addressing the individual by name). The second action is to remove the client to a safe low-stimulus environment ("walk with me to your room"). The third action is to set limits by explaining why the behavior cannot be tolerated ("someone may get hurt"). The fourth action is to describe the outcome of not complying (will be placed in seclusion if the aggressive behavior continues). Finally, the client must be assured that if the client is unable to control the behavior, staff will help do so.
A client states, "I keep my insulin in the refrigerator because that is where my parents kept it." Which reason will the nurse include when explaining why insulin should be stored at room temperature? 1 Its potency and effectiveness are maximized. 2 Absorption is enhanced and local irritation is decreased. 3 It is more convenient and drawing insulin into the syringe is facilitated. 4 Adherence of insulin to the syringe and resistance upon injection are decreased.
2 Insulin that is close to body temperature prevents vasoconstriction at the site and decreases irritation of tissues. Insulin can be stored at room temperature for up to 1 month but must be kept away from heat or sunlight. Inappropriate storage of insulin can decrease its stability and decrease, not increase, its therapeutic action. Although it may be more convenient to keep insulin in the refrigerator, this is not a valid rationale; temperature of the solution does not increase the viscosity of insulin. Neither adherence of insulin to the syringe nor decreased resistance upon injection occurs.
