M2 Quiz
A client returns to the unit after having extracorporeal lithotripsy. Which would be the best indicator that the treatment has been effective? 1. The client is relieved of the pain. 2. The urine is free of red blood cells. 3. The urinary output has increased since return to the unit. 4. There is sediment in the urinary catheter drainage bag.
1. The client is relieved of the pain. 2. The urine is free of red blood cells. 3. The urinary output has increased since return to the unit. 4. There is sediment in the urinary catheter drainage bag.
A client has been admitted with advanced cirrhosis. The nurse's assessment verifies an increase weight of 6 lbs. (2.71 kg) since yesterday's weight and an abdominal girth increase of 5 inches (12.7 cm). What is the priority assessment? 1. Urinary Output 2. Daily weight 3. Blood pressure 4. LOC
1. Urinary Output 2. Daily weight 3. Blood pressure 4. LOC
What would the nurse include in the teaching plan for a client with right sided heart failure? 1. There is a backup of blood in the right upper chamber of the heart. 2. There is swelling of lower extremities. 3. The heart rate decreases. 4. You may experience fatigue and depression. 5. You may have nausea and anorexia.
1., 2. 4. & 5. Correct: The blood backs up into the right atrium and venous circulation. Vascular congestion is evident by swelling of the lower extremities. Clients usually experience fatigue and depression. Ascites may increase pressure on the stomach and intestines causing GI upset with nausea and anorexia. 3. Incorrect: The heart rate increases in an attempt to increase cardiac output.
The nurse is monitoring the client's heart rhythm. The monitor shows sinus tachycardia. What is expected with this assessment finding? 1. Regular rhythm 2. Rate of 101-200 3. P wave normal 4. P-R interval not measurable 5. QRS complex normal
1., 2., 3. & 5. Correct: Sinus tachycardia indicates a regular rhythm, although the rate is elevated. The term tachycardia is defined as a heart rate above 100. The P-wave is normal in a sinus rhythm. Sinus rhythms have a normal QRS complex. 4. Incorrect: P-R interval is not measurable in atrial flutter, atrial fib, PVCs, V tach or V fib.
A nurse, planning an educational seminar on chronic kidney disease, would invite clients with which medical conditions? 1. Polycystic kidney disease 2. Diabetes 3. Hypertension 4. Glomerulonephritis 5. Acute urinary tract infections (UTI)
1., 2., 3., & 4. Correct: Polycystic kidney disease is a genetic condition that causes damage to the kidneys. Clients with diabetes and hypertension make up more than 67% of clients diagnosed with chronic kidney disease. Glomerulonephritis damages the kidneys and can lead to permanent damage. 5. Incorrect: Acute UTIs do not generally lead to chronic kidney disease.
In order to maintain asepsis, what would the nurse teach the client on home peritoneal dialysis? 1. Drink only bottled water. 2. Cap Tenckhoff catheter when not in use. 3. Soak the dialysate in warm water. 4. Clean the arteriovenous fistula with hydrogen peroxide twice a day. 5. Wash around the catheter insertion site daily.
2., & 5. Correct: Capping the Tenckhoff catheter prevents dialysate leakage and bacterial invasion. Clean around insertion site to decrease risk of bacterial infection. 1. Incorrect: What does drinking bottled water have to do with it? Nothing 3. Incorrect: Soaking the bags of solution in warm water can introduce bacteria to the exterior of the bags of solution . 4. Incorrect: Do you have an arteriovenous fistula? Not with peritoneal dialysis.
What signs/symptoms would the nurse expect to assess in a client diagnosed with acute pericarditis? 1. Petechiae on trunk 2. Muffled heart sounds 3. Pericardial friction rub 4. Pulsus paradoxus 5. Chest pain on deep inspiration
2., 3., & 5. Correct: Muffled heart sounds are indicative of pericarditis. Fluid is between the heart and the chest wall; heart sounds are lowered and distant. A pericardial friction rub is a classic symptom of acute pericarditis. Chest pain is the most common symptoms of pericarditis, and is aggravated by deep inspiration, coughing, position change, and swallowing. 1. Incorrect: Petechiae on the trunk, conjunctiva, and mucous membranes are indicative of endocarditis. 4. Incorrect: Pulsus paradoxus is an exaggerated decrease of systolic blood pressure during inspiration exceeding 12 mm Hg. It is the hallmark of cardiac tamponade.
The nurse is caring for a client who is receiving enoxaparin after a diagnosis of deep vein thrombosis of the left leg. Which nursing interventions would be appropriate for this client? 1. Monitor PT and aPTT 2. Initiate bedrest 3. Elevate left leg 4. Monitor closely for bleeding 5. Monitor complete blood count
2., 3., 4. & 5. Correct: The main complication of anticoagulant therapy is bleeding. Periodic complete blood counts, including platelet count, and stool occult blood tests are recommended during the course of treatment with enoxaparin sodium Injection. Bedrest will reduce the risk of a clot dislodging. Elevate left leg to decrease swelling and promote venous return. 1. Incorrect: When administered at recommended prophylaxis doses, routine coagulation tests such as Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are relatively insensitive measures of enoxaparin
What should the nurse instruct a client to avoid when prescribed digoxin? 1. Corn 2. Apples 3. Black licorice 4. Milk
3. Correct: Black licorice can deplete the body of potassium which can result in digoxin toxicity. 1. Incorrect: Corn is a vegatable that can be eaten when digoxin is prescribed. 2. Incorrect: Apples can be eaten when digoxin is prescribed. 4. Incorrect: Milk can be consumed when digoxin is prescribed.
A construction worker comes into the occupational health nurse's clinic reporting chest heaviness. The nurse should assess for what additional signs and symptoms? 1. Headache 2. Dry, flushed skin 3. Lightheadedness 4. Dyspnea 5. Irregular pulse
3., 4. & 5. Correct: The nurse should be thinking myocardial infarction (MI)! All of these are signs of an MI. 1. Incorrect: Headaches do not commonly occur with MI. 2. Incorrect: Skin would be cool and clammy.
A client has sublingual (SL) nitroglycerin prn added to their medication regimen. Which statements made by this client indicates teaching has been effective? 1. "I will take this medication if I have an episode of chest pain." 2. "I will wait at least 1 hour after I take my erection agent before using Nitroglycerin." 3. "I can take up to 3 tablets every 10 minutes if my angina occurs." 4. "I know that I must put this tablet under my tongue for it to work." 5. "I will keep my medication handy, in a pocket."
1. & 4. Correct: Nitroglycerin should be used for chest pain and sublingual should be placed under the tongue. 2. Incorrect: Nitroglycerin should not be used with erection agents, as extreme hypotension may occur. 3. Incorrect: Take one tablet every 5 minutes x 3 doses. 5. Incorrect: Nitroglycerin should be keep in a cool, dark place.
A nurse is caring for a client post heart catheterization with a left femoral stick. What signs and symptoms would indicate to the nurse that the primary healthcare provider should be notified? 1. Capillary refill of 6 seconds to left toes. 2. Epigastric discomfort 3. Paresthesia to left leg 4. Left pedal pulse 0/4; Right pedal pulse 2+/4 5. Temperature of 99.9º F (37.72º C)
1., 2., 3., & 4. Correct: These signs and symptoms indicate an emergency with loss of circulation to the extremity. This is an emergency, and the primary healthcare provider is the only one that can save this foot from ischemia. Don't delay. Epigastric pain could indicate the client is having an MI. Always assume the worse! 5. Incorrect: Temperature of 101º F (38.3º C) or more indicates a problem.
A client who has been diagnosed with chronic venous insufficiency has received teaching regarding how to prevent venous stasis ulcerations. Which statements by the client indicate to the nurse that teaching has been effective? 1. "Stationary standing should be kept to a minimum." 2. "It is important to avoid wearing constricting clothes longer than 2 hours." 3. "Protecting my legs from trauma is very important." 4. "I will wear compression stockings every day." 5. "I will elevate the foot of my bed 6 inches (15.24
1., 3., 4., & 5. Correct: Minimize stationary standing as much as possible. Protect legs from trauma as this can lead to ulcerations. Elastic compression stockings are recommended for clients with chronic venous insufficiency to prevent pooling and promote venous return. Leg elevation decreases edema, promotes venous return, and provides symptomatic relief. Legs should be elevated frequently throughout the day (for at least 15-30 minutes every 2 hours). During the night, the client should sleep with the foot elevated approximately 6 inches (15.24 cm). 2. Incorrect: The client should avoid wearing any constricting clothing, even for short periods of time. This will decrease blood flow.
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. Fixed urine specific gravity 2. Serum K+ 4.9 mEq (4.9 mmol/L) 3. Serum Na+ 143 mEq (143 mmol/L) 4. Minimal crackles auscultated in bases of left lung 5. Urine output = 1250 mL/24 hours
2., 3. & 5. Correct: The serum potassium is within normal range. The serum potassium level would be elevated if the client was still in the oliguric phase. This is a normal sodium level, which indicates that the client is improving. The serum sodium level would be low in the oliguric phase due to increased dilution of the blood. This urine output is adequate to indicate proper kidney perfusion. 1. Incorrect: A fixed specific gravity indicates that the kidneys are not working properly. 4. Incorrect: The lungs would need to be clear to verify that treatment has been effective.
What assessment finding would the nurse expect when evaluating whether treatment has been effective for a client hospitalized with systolic heart failure? 1. S3 heart sound 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.91 kg) 4. Hepatomegaly 5. Increasing BNP level 6. Urine output at 50 mL/hr
2., 3. & 6. Correct: Normal CVP is 2-6 mm Hg. This CVP is within normal range so treatment is effective. Weight loss indicates that fluid is being removed and a urine output of 50mL/hour indicates that renal perfusion is adequate. All three assessments indicate improvement. 1. Incorrect: S3 would indicate that the client is not better. S3 is heard when the client is in fluid overload. 4. Incorrect: Hepatomegaly and tenderness in the right upper quadrant of the abdomen result from venous engorgement of the liver. The client is not better. 5. Incorrect: An increase in BNP level would indicate that the heart failure was getting worse, not better.
A client is admitted with arterial disease of the lower extremities. Which client teachings would the nurse initiate? 1. Elevate extremities above the level of the heart. 2. Discourage use of caffeine. 3. Protect extremities from cold exposure. 4. Maintain a warm environment at home. 5. Encourage isometric exercise.
2., 3., 4., & 5. Correct: Caffeine, stress, and nicotine cause vasoconstriction and vasospasm, which impedes peripheral circulation. Warmth promotes arterial flow by preventing the vasoconstriction effects of chilling. Vasodilation will be increased by providing warmth in the environment. Cold causes vasoconstriction. Isometric exercise and walking promote the development of collateral circulation. 1. Incorrect: Lower the extremities below the level of the heart for arterial problems. Dependent extremities enhance arterial blood supply.
When an explosion occurs at a local shopping center, an off-duty nurse quickly begins to triage those injured. The nurse knows which client needs immediate attention? 1. An elderly adult with a traumatic left eye enucleation. 2. A child with an open, compound fracture of the femur. 3. An adult with a head laceration bleeding profusely. 4. An adolescent with a rigid, board-like lower abdomen.
4. CORRECT: This client's symptoms indicate the presence of internal bleeding. Without emergency surgery, this client will quickly develop hypovolemic shock and may not survive. 1. INCORRECT: This client has lost the left eye due to trauma. Despite the fact that this client is elderly and may have other co-morbidities, the eye injury is not considered life-threatening. 2. INCORRECT: A fractured femur can lead to other issues, such as blood loss or fat emboli; however, even an open, compound fracture is not considered the most life-threatening injury here. 3. INCORRECT: Lacerations of the face, head or hands generally do bleed profusely because the vessels are near the surface of the skin. However, this represents capillary blood and is not critical.
A client who was admitted to 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 with atrial rate > 300 per minute 3. Four premature ventricular contractions within one minute 4. ST segment depression of 0.5 mm
1. Correct: Ventricular tachycardia with a ventricular rate greater than 100 per minute can be a precursor to ventricular fibrillation. This rhythm is the most life threatening and would be of greatest concern. 2. Incorrect: Clients diagnosed with atrial fibrillation are at high risk for formation of thrombus. This is a serious concern, but not as great a concern as ventricular tachycardia. 3. Incorrect: Premature ventricular contractions (PVCs) that are less than 6 are worrisome but not considered a precursor to ventricular tachycardia or ventricular fibrillation. 4. Incorrect: ST segment depression of 1 mm or more signifies myocardial ischemia.
What should a nurse include when planning an educational program for a group of women on how to prevent a urinary tract infection (UTI)? 1. Increase daily intake to at least 9 cups (2160 mL) of water. 2. Urinate within one hour after sexual intercourse. 3. Take a low dose antibiotic. 4. Urinate at least twice a day.
1. Correct: Water helps to dilute urine and flush out bacteria. 2. Incorrect: Urination should occur within 15 minutes after sexual intercourse. 3. Incorrect: A low dose antibiotic taken for several months may be prescribed but only when the client has multiple UTIs. 4. Incorrect: Prevent UTIs by drinking plenty of water and urinating often. This will help to flush bacteria out of the bladder.
Which signs and symptoms experienced by the client correlate with chronic renal failure diagnosis? 1. Fatigue 2. Anorexia 3. Dark skin pigmentation 4. Swollen extremities 5. Hyperkalemia
1., 2., 4. & 5. Correct: The client will have fatigue from anemia and anorexia from toxins. Fluid volume excess leads to swollen extremities. Hyperkalemia can be caused by reduced renal excretion or excessive intake. 3. Incorrect: The client may have an uremic frost not dark skin pigmentation.
A nurse is attempting to help a client who has self-care difficulty due to left-sided hemiparesis. Which interventions should the nurse plan to include? 1. Provide the client with a button hook for dressing. 2. Discourage use of electric razors and toothbrushes. 3. Have client comb own hair. 4. Offer to take the client to the toilet every four hours. 5. Avoid relying on furniture for support when walking.
1., 3. & 5. Correct: The use of a button hook or loop and pile closure on clothes may make it possible for a client to continue independence in this self-care activity. This is a one handed task that will enable the client to maintain autonomy for as long as possible. Having client comb own hair helps maintain autonomy. The client should use prescribed assistive devices for ambulation. Furniture may move or not be in the correct place for support while walking. 2. Incorrect: The client can be helped by using an electric razor and toothbrush. These will improve client safety during self care. 4. Incorrect: Offer bedpan or place client on toilet every 1 to 2 hours during the day and three times during the night.
After assessing a client, the nurse determines that the client has incomplete emptying of the bladder with reports of dribbling, hesitancy, and frequency. Which interventions would the nurse include for this client? 1. Have client attempt to void again (double voiding). 2. Encourage the client to void every 8 hours. 3. Perform Credé method. 4. Have client listen to sound of running water. 5. Teach intermittent catheterization for retention, if needed.
1., 3., 4. & 5. Correct: Have client attempt to void again. This is called double voiding. This can improve bladder emptying. Place bedpan, urinal, or bedside commode within reach. Provide privacy. Have client listen to sound of running water or place hands in warm water and/or pour warm water over perineum to stimulate urination. Offer fluids before voiding. Perform Credé method over bladder to increase bladder pressure. If these methods are unsuccessful, the client will need education on intermittent catheterization. 2. Incorrect: Encourage client to void every 4 hours. We do not want urine to sit in the bladder for long periods of time. Stagnant urine can create infection.
As a member of the emergency preparedness planning team at the hospital, which action should the nurse encourage the team to implement? 1. Develop a response plan for each potential disaster. 2. Provide education to employees on the response plan. 3. Practice the response plan on a regular basis. 4. Evaluate the hospital's level of preparedness. 5. Coordinate with neighboring hospitals regarding different
2., 3., 4., & 5. Correct: Developing a single response plan, educating individuals to the specifics of the response plan, and practicing the plan and evaluating the facility's level of preparedness are effective means of implementing emergency preparedness. Consideration must be given to the proximity of chemical plants, nuclear facilities, schools, and areas where large groups gather. 1. Incorrect: One good response plan should be developed rather than multiple plans.
A client arrives to the emergency department with reports of palpitations, chest discomfort, and light-headedness. The nurse connects the client to a cardiac monitor and notes a weak, thready pulse, and a BP of 90/50. What actions should the nurse take? 1. Administer Lidocaine 50 mg intravenous push (IVP). 2. Initiate oxygen at 2 liters per nasal cannula. 3. Apply oxygen saturation monitor to client. 4. Prepare for immediate synchronized cardioversion. 5. Perform carotid massage. 6. Begin cardiopulmonary resuscitation.
2., 3., & 4. Correct: This client has a rapid heart rate of 188/min. The actual rhythm is atrial tachycardia but can also be identified as supraventricular tachycardia because the heartrate is greater than 150/min. This client is considered unstable so requires oxygen therapy, with O2 saturation monitoring, and synchronized cardioversion. 1. Incorrect: Lidocaine is not indicated for an atrial or supraventricular dysrhythmia. 5. Incorrect: Carotid massage is not within the scope of practice of the nurse. Asystole could result. 6. Incorrect: This client has a pulse, so CPR is not needed at this time.
A community health nurse is presenting a seminar to a group of senior citizens on ways to reduce the risks of peripheral artery disease (PAD). What topics should the nurse include? 1. Anti-embolic stockings 2. Smoking cessation 3. Moderate exercise 4. Application of heat 5. Low cholesterol diet 6. Decrease blood pressure
2., 3., 5. & 6. Correct: Senior clients are at increased risk for peripheral artery disease for a variety of reasons, though many erroneously believe that this process is an unavoidable part of the aging process. Educating clients on preventative activities will help reduce incidence of atherosclerosis and improved mobility along with quality of life. Smoking is a major risk factor in developing PAD by contributing to arterial constriction. Clients can increase collateral circulation with a moderate exercise program of at least 30 minutes three times a week. A low cholesterol, heart healthy diet with more fruits and vegetables helps reduce cholesterol while decreasing blood pressure, both important goals towards controlling PAD. 1. Incorrect: Increasing arterial blood flow is important in the prevention or management of peripheral artery disease; however, anti-embolic stockings are designed to improve venous return in clients with decreased mobility. The use of these stockings would actually hinder arterial flow in lower extremities. 4. Incorrect: Clients with PAD often complain of cold extremities secondary to decreased arterial blood flow. But the application of heat such as use of a heating pad is unsafe and is always contraindicated in the elderly with PAD. Inability to sense temperature extremes may result in serious burns to lower extremities. Additionally, clients with PAD do not heal as well from injuries or wounds.
