Med surg Lewis Test 3

While working in the emergency department, the RN admits a patient with extensive burn injuries caused by a fire at the patient's home. Which assessment should the RN accomplish first? A) TBSA burned B) Breath sounds C) Pain level D) Blood pressure

(B) B) Breath sounds Rationale: Respiratory complications are a major cause of death in patients who have burn injuries. Adventitious breath sounds such as wheezes or decreased breath sounds may indicate the need for immediate intubation or tracheotomy.

A nurse is assigned to care for a client who sustained a burn injury. The nurse reviews the physician's orders and should question the registered nurse about which order? 1. Monitor weight daily 2. Monitor urine output hourly 3. Maintain the nasogastric tube to intermittent suction 4. Administer morphine sulfate intramuscularly every 3 hours as needed for pain

4. Administer morphine sulfate intramuscularly every 3 hours as needed for pain Rationale: Oral, subcutaneous and intramuscular routes for administering medications are contraindicated in the burned client because of the poor absorption factor. When fluid balance is stabilized, oral narcotic agents can be used. Options 1, 2 and 3 are all appropriate interventions for the client with a burn.

A nurse is observing a nursing assistant talking to a client who is hearing impaired. The nurse should intervene if which of the following were performed by the nursing assistant during communication with the client? 1. The nursing assistant is speaking in a normal tone 2. The nursing assistant is speaking clearly to the client 3. The nursing assistant is facing the client when speaking 4. The nursing assistant is speaking directly into the impaired ear

4. The nursing assistant is speaking directly into the impaired ear Rationale: When communicating with a hearing impaired client, the nurse should speak in a normal tone to the client and should not shout. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express the statement differently. Moving closer to the client and toward the better ear may improve communication, but the nurse should avoid talking directly into the impaired ear.

What is the best method to prevent autocontamination for the client with burns? A) Change gloves when handling wounds on different areas of the body. B) Ensure that the client is in isolation therapy. C) Restrict visitors. D) Watch for early signs of infection

A) Change gloves when handling wounds on different areas of the body. Feedback: CORRECT Correct: Gloves should be changed when handling wounds on different areas of the body and between handling old and new dressings. B) Ensure that the client is in isolation therapy. Feedback: INCORRECT Incorrect: Isolation therapy methods are used to prevent cross-contamination rather than autocontamination. C) Restrict visitors. Feedback: INCORRECT Incorrect: Restricting visitors helps prevent cross-contamination, not autocontamination. D) Watch for early signs of infection. Feedback: INCORRECT Incorrect: Watching for early signs of infection does not prevent contamination.

Situation: Your patient is a 27-year-old man who fell into a bonfire while drinking with his friends. He sustained a 55% total body surface area burn. He was fluid resuscitated using Parkland formula guidelines. It is 1 day after the injury, and he is intubated and sedated. Sedation has not been effective, and his pulse oximeter reading is dropping as his agitation increases. The physician prescribes vecuronium (Norcuron) to be administered. You note that the patient's urine output has dropped significantly over the past 4 hours. A physician prescribes IV furosemide (Lasix). Why is this incorrect? A) Diuretics actually decrease circulating volume. B) Mannitol (Osmitrol) is a more appropriate medication. C) Lasix is administered only to older burn patients with a history of heart failure. D) Lasix should be administered only if the patient sustained a myocardial infarction.

A) Diuretics actually decrease circulating volume. Rationale: It is a common mistake to prescribe a diuretic rather than to change the amount and rate of fluid administration. Diuretics reduce blood flow to other vital organs and increase the risk for hypovolemic shock. Mannitol is often used when the burn is caused by electrical energy but is given after adequate urine output has been established. p.534 Click to flip

The nurse is providing teaching to a patient regarding pain control after surgery. The nurse informs the patient that the best time to request pain medication is: A. Before the pain becomes severe. B. When the patient experiences a pain rating of 10 on a 1-to-10 pain scale. C. After the pain becomes severe and relaxation techniques have failed. D. When there is no pain, but it is time for the medication to be administered.

A) The question states that the patient is being instructed on when to "request" pain medication. If a pain medication is ordered PRN, the patient should be instructed to ask for the medication before the pain becomes severe.

Situation: The 27-year-old man from the bonfire remains intubated and sedated. It is 3 days after the burn injury, and he is entering the acute phase of his injury. You are reviewing the medication record with the physician. Antimicrobial agents such as sulfadiazine (Silvadene) are applied to burn wounds. What is the goal of topical antimicrobials? A) To reduce bacterial growth in the wound and prevent systemic sepsis B) To prevent cross-contamination from other patients in the unit C) To enhance cell growth D) To minimize the need for a skin graft

A) To reduce bacterial growth in the wound and prevent systemic sepsis Rationale: The use of topical antimicrobials is an important intervention for infection prevention in burn wounds.

The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implantation. Which home care measures will the nurse include in the plan? Select all that apply. A. Avoid activities that require bending over B. Contact the surgeon if eye scratchiness occurs C. Place an eye shield on the surgical eye at bedtime D. Episodes of sudden severe pain in the eye are expected E. Take acetaminophen (Tylenol) for minor eye discomfort

A. Avoid activities that require bending over C. Place an eye shield on the surgical eye at bedtime E. Take acetaminophen (Tylenol) for minor eye discomfort

The nurse should assess an older adult with macular degeneration for.... A. Loss of central vision B. Loss of peripheral vision C. Total blindness D. Blurring of vision

A. Loss of central vision assessment

A nurse is discussing treatment options for retinal detachment with a client. Which of the following are options? Select all that apply a. Observation b. Sealing breaks c. Vitrectomy d. Injections

a. Observation b. Sealing breaks c. Vitrectomy

Which medication is used to treat a patient suffering from severe adverse effects of a narcotic analgesic? A) naloxone (Narcan) B) acetylcysteine (Mucomyst) C) methylprednisolone (Solu-Medrol) D) protamine sulfate

A: Naloxone is the narcotic antagonist that will reverse the effects, both adverse and therapeutic, of opioid narcotic analgesics.

Situation: The 27-year-old man from the bonfire remains intubated and sedated. It is 3 days after the burn injury, and he is entering the acute phase of his injury. You are reviewing the medication record with the physician. The physician decides to change the sulfadiazine (Silvadene) to topical gentamicin. Neither of these worked well, so the physician changed the medication to mafenide acetate (Sulfamylon). Based on this change, what lab values should be monitored? A) Blood glucose and CBC B) Blood gases and electrolyte levels C) Electrolytes and sedimentation rate D) CBC and sedimentation rate

B) Blood gases and electrolyte levels Rationale: Monitor blood gas and serum electrolyte levels. Mafenide acetate may cause metabolic acidosis. p. 542, Chart 28-5

Situation: The 27-year-old man from the bonfire remains intubated and sedated. It is 3 days after the burn injury, and he is entering the acute phase of his injury. You are reviewing the medication record with the physician. Why did this patient receive a tetanus toxoid injection on admission? A) His last tetanus injection was less than 5 years ago. B) Burn wound conditions promote the growth of Clostridium tetani. C) The wood in the fire had many nails, and the patient was cut as he fell. D) It was prescribed in error.

B) Burn wound conditions promote the growth of Clostridium tetani. Rationale: Burn wound conditions promote the growth of Clostridium tetani, and all burn patients are at risk for this dangerous infection. Tetanus toxoid, 0.5 mL given IM, enhances acquired immunity to C. tetani. This agent is routinely given when the patient is admitted to the hospital. Administration of tetanus immune globulin (human) (Hyper-Tet) is recommended when the patient's history of tetanus immunization is not known.

Situation: The 27-year-old man from the bonfire remains intubated and sedated. It is 3 days after the burn injury, and he is entering the acute phase of his injury. You are reviewing the medication record with the physician. Antimicrobial agents such as sulfadiazine (Silvadene) are applied to burn wounds. What changes in the wound might indicate infection? A) Redness and pain B) Soupiness of the wound area C) Development of a rash encircling the wound D) Development of granular tissue within the wound

B) Soupiness of the wound area Rationale: Watch for signs of infection, such as soupiness of the wound area. p. 542, Chart 28-5

The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnosis should receive priority? A. Alteration in comfort B. Alteration in mobility C. Alteration in skin integrity D. Alteration in O2 perfusion

B. Alteration in mobility priority

A patient has the following preoperative medication order: morphine 10 mg with atropine 0.4 mg IM. The nurse informs the patient that this injection will A. decrease nausea and vomiting during and after surgery. B. decrease oral and respiratory secretions, thereby drying the mouth. C. decrease anxiety and produce amnesia of the preoperative period. D. induce sleep, so the patient will not be aware during transport to the operating room.

B. decrease oral and respiratory secretions, thereby drying the mouth. Atropine, an anticholinergic medication, is frequently used preoperatively to decrease oral and respiratory secretions during surgery, and the addition of morphine will help to relieve discomfort during the preoperative procedures. Antiemetics decrease nausea and vomiting during and after surgery, and scopolamine and some benzodiazepines induce amnesia. An actual sleep state is rarely induced by preoperative medications unless an anesthetic agent is administered before the patient is transported to the operating room.

While admitting a patient for treatment of an acetaminophen overdose, the nurse prepares to administer which of the following medications to prevent toxicity? A) naloxone (Narcan) B) acetylcysteine (Mucomyst) C) methylprednisolone (Solu-Medrol) D) vitamin K

B: Acetylcysteine is the antidote for acetaminophen overdose. It must be administered as a loading dose followed by subsequent doses every 4 hours for 17 more doses and started as soon as possible after the acetaminophen ingestion (ideally within 12 hours

The nurse is preparing to administer an injection of morphine to a patient. Assessment notes a respiratory rate of 10 breaths/min. Which action will the nurse perform? A) Administer a smaller dose and record the findings B) Notify the physician and delay drug administration C) Administer the prescribed dose and notify the physician D) Hold the drug, record the assessment, and recheck in 1 hour

B: Respiratory depression is a side effect of narcotic analgesia. Therefore since the patient's respiratory rate is below normal, the nurse should withhold the morphine and notify the physician.

Massage therapy is ordered as adjunct treatment for a patient with musculoskeletal pain. The patient asks the nurse how "rubbing my muscles" will help the pain go away. The nurse responds based on the knowledge that A) massaging muscles decreases the inflammatory response that initiates the painful stimuli. B) massaging muscles activates large sensory nerve fibers that send signals to the spinal cord to close the gate, thus blocking painful stimuli from reaching the brain. C) massaging muscles activates small sensory nerve fibers that send signals to the spinal cord to open the gate and allow endorphins to reach the muscles and relieve the pain. D) massaging muscles helps relax the contracted fibers and decrease painful stimuli

B: The gate theory of pain control identifies large sensory nerves that, when stimulated, send signals to the spinal cord to close the gate, blocking pain stimuli from reaching the brain. Therefore the patient is not having the sensation of pain even if the stimulus is still present. Click to flip

A 5-year-old child was recently diagnosed with having bacterial conjunctivitis in both eyes. The nurse is teaching the mother the best way to prevent the spread of infection to the child's siblings. The best way to prevent the spread of infection is: a) wash both eyes with soap and water frequently b) use regular eye drops 3 times per day until the infection clears c) apply antibiotic eye drops as prescribed, wash hands frequently, and keep the child from touching the eyes until the infection has cleared d) do nothing because this infection is not contagious at all so there is nothing to worry aboutsafety

C

Situation: Your patient is a 27-year-old man who fell into a bonfire while drinking with his friends. He sustained a 55% total body surface area burn. He was fluid resuscitated using Parkland formula guidelines. It is 1 day after the injury, and he is intubated and sedated. Sedation has not been effective, and his pulse oximeter reading is dropping as his agitation increases. The physician prescribes vecuronium (Norcuron) to be administered. What is your understanding of vecuronium? A) It improves pulmonary functioning. B) It is a potent sedative. C) It is a paralytic agent that removes all breathing control from the patient. D) It improves oxygenation.

C) It is a paralytic agent that removes all breathing control from the patient. Rationale: Vecuronium makes ventilation easier. Any patient receiving a neuromuscular blockade (paralytic) must also receive sedation, analgesia, or antianxiety medication unless clinically contraindicated. p. 535

Situation: The 27-year-old man from the bonfire remains intubated and sedated. It is 3 days after the burn injury, and he is entering the acute phase of his injury. You are reviewing the medication record with the physician. The physician decides to change the sulfadiazine (Silvadene) to topical gentamicin. Based on this change, what lab values should be monitored? A) Blood glucose B) CBC C) Serum and urine creatinine D) Platelet count

C) Serum and urine creatinine Rationale: Monitor serum and urine creatinine clearance before and during treatment. p. 542, Chart 28-5

The client has had a cataract removed. The nurse's discharge teaching should include which of the following: A) Keep the head aligned straight B) Utilize bright lights in the home C) Use an eye shield at night D) Change the eye patch as needed

C) Use an eye shield at night teach

A nurse is showing a young student nurse the appropriate way to conduct an assessment using an otoscope on an elderly male client. Indicate in which order the nurse should conduct assessment of this client: 1. Choose the largest speculum that will fit comfortably. 2. Pull the pinna up and back to straighten the S-shape of the canal. 3. Tilt the clients head slightly away from you toward the opposite shoulder. 4. Hold the otoscope and use the dorsum of your hand along the person's cheek to steady the otoscope. A. 1, 2, 3, 4 B. 2, 1, 4, 3 C. 1, 3, 2, 4 D. 4, 3, 2, 1

C. 1, 3, 2, 4 Choose the largest speculum that will fit comfortably. , Tilt the clients head slightly away from you toward the opposite shoulder., Pull the pinna up and back to straighten the S-shape of the canal., Hold the otoscope and use the dorsum of your hand along the person's cheek to steady the otoscope.)

The nurse has been assigned to a client who is hearing impaired and reads speech. Which of the following strategies should the nurse incorporate when communicating with the client? (Select all that apply) 1. Avoiding being silhouetted against a strong light. 2. Not blocking out the person's view of the speaker's mouth. 3. Facing the client when talking. 4. Having a bright light behind the client so the individual can see. 5. Ensuring the client is familiar with the subject material before discussing. 6. Talking to the client while performing other nursing procedures. A. All options should be included B. 2, 3, 4,6 C. 1,2,3,5 D. 2, 4. 6 E. 1, 3, 6

C. 1,2,3,5 1. Avoiding being silhouetted against a strong light. 2. Not blocking out the person's view of the speaker's mouth. 3. Facing the client when talking 5. Ensuring the client is familiar with the subject material before discussing. Click to flip

A client with conjunctivitis has to administer an eye ointment for several days. Indicate the order the client should take to administer the ointment 1. Pull down the lower lid, creating a pocket 2. Wash hands 3. Place a thin ¼" strip of ointment into the conjunctival sac 4. Look up 5. Gently close eyes for several minutes A. 1, 2, 4, 5, 3 B. 4, 5, 2, 1, 3 C. 2, 4, 1, 3, 5 D. 2, 1, 3, 5, 4

C. 2, 4, 1, 3, 5

The nurse is developing a teaching plan for the client with glaucoma. Which of the following instructions would the nurse include in the plan of care? A. Avoid overuse of the eyes B. Decrease the amount of salt in the diet. C. Eye medications will need to be administered for the client's entire life. D. Decrease fluid intake to control the intraocular pressure.

C. Eye medications will need to be administered for the client's entire life. teach

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks the nurse to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take? A.) Assist patient to bathroom and stay next to door to assist patient back to bed when done. B. Allow patient to go to the bathroom since the onset of the medication will be more than 5 minutes. C. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. D. Ask patient to hold the urine for a short period of time since a urinary catheter will be placed in the operating room.

C. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance. Click to flip

A sixty year old blind man has been admitted to your floor. As the nurse what is your primary responsibility? A. Let the other nurses know he is blind B. Tell the charge nurse your safety concerns C. Orient the patient to the room D. Keep the door open so you can watch the patient

C. Orient the patient to the room safety

The client arrives in the emergency room with a penetrating eye injury from wood chips while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? A. Remove the piece of wood using a sterile eye clamp. B. Apply an eye patch. C. Perform visual acuity tests. D. Irrigate the eye with sterile saline

C. Perform visual acuity tests teach

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse tells the client that: A. The medication will help dilate the eye to prevent pressure from occurring. B. The medication will relax the muscles of the eyes and prevent blurred vision C. The medication causes the pupil to constrict and will lower the pressure in the eye D. The medication will help block the responses that are sent to the muscles in the eye.

C. The medication causes the pupil to constrict and will lower the pressure in the eye pharm

A 75 year old male client has a history of macular degeneration. While he is in the hospital, the priority nursing goal will be: A. To provide education regarding community services for clients with adult macular degeneration (AMD). B. To provide health care related to monitoring his eye conditions C. To promote a safe, effective care environment D. To improve vision

C. To promote a safe, effective care environment priority

A patient has been admitted after overdosing on acetaminophen (Tylenol), with a total ingested dose of 14 g over a period of 1 hour. The nurse plans to monitor this patient for development of which of the following signs and symptoms related to the overdose? A) Renal failure B) Kidney stones C) Acute hepatic necrosis D) Metabolic alkalosis

C: Acetaminophen in large doses over a short period is extremely hepatotoxic. The long-term ingestion of large doses of acetaminophen is more likely to result in nephropathy.

In monitoring a patient for adverse effects related to morphine sulfate, the nurse assesses for stimulation of A) autonomic control over circulation. B) cough reflex center. C) chemoreceptor trigger zone. D) respiratory rate and depth.

C: Morphine sulfate can irritate the gastrointestinal tract, causing stimulation of the chemoreceptor trigger zone in the brain, which in turn causes nausea and vomiting

The nurse teaches a patient prescribed the fentanyl (Duragesic) transdermal delivery system to change the patch at what interval? A) When pain recurs B) Every 24 hours C) Every 72 hours D) Once a week

C: The fentanyl transdermal delivery system is designed to slowly release analgesic over a 72-hour time frame

In developing a plan of care for a patient receiving morphine sulfate, which nursing diagnosis is a priority? A) Acute pain B) Risk for injury related to central nervous system side effects C) Impaired gas exchange related to respiratory depression D) Constipation related to gastrointestinal side effects

C: Using Maslow's hierarchy of needs and the ABCs of prioritization, impaired gas exchange is a priority over pain, constipation, and a risk for injury. If a patient cannot oxygenate sufficiently, all of the other problems will not matter because the patient will not live to worry about them.

The nurse plans pharmacologic therapy for a patient with pain based on the knowledge that A) narcotic analgesics should not be used for more than 24 hours secondary to the risk of addiction. B) analgesics should be administered as needed (prn) to minimize side effects. C) pain relief is best obtained by administering analgesics around the clock. D) patients should request analgesics when the pain level reaches a "6" on a scale of 1 to 10.

C: When pain is present, analgesic dosages are best administered around the clock and not "as needed," but dosages should always be within the dosage guidelines for each drug used. The around-the-clock (or "scheduled") dosing allows steady states of the medication and prevents drug dosage "troughs" and escalation of pain. Click to flip

The nursing student is caring for the client with open wound burns. Which priority nursing interventions does the nursing student include for this client? (Select all that apply.) A) Provides cushions and rugs for comfort B) Cleans equipment daily C) Performs frequent handwashing D) Provides fresh fruits and vegetables E) Performs gloved dressing changes F) Provides plants and flowers in the room G) Uses disposable dishes

Correct: (B, C, E, G) B) Cleans equipment daily Rationale: Daily cleaning of the equipment and general housekeeping are essential for infection control. C) Performs frequent handwashing Rationale: All isolation methods use proper and consistent handwashing as the most effective technique for preventing infection transmission. E) Performs gloved dressing changes Rationale: Use of asepsis requires all health care personnel to wear gloves during all contact with open wounds. G) Uses disposable dishes Rationale: Disposable items (e.g., pillows, syringes, and dishes) are used as much as possible. Incorrect: A) Provides cushions and rugs for comfort Raitonale: Rugs and upholstered articles are difficult to clean and may harbor organisms. Their use is also restricted. D) Provides fresh fruits and vegetables Raitonale: Some burn units do not permit clients to eat raw foods (e.g., salads, fruit, pepper) to reduce exposure to organisms. F) Provides plants and flowers in the room Raitonale: Because Pseudomonas has been found in plants, the presence of plants and flowers is prohibited. Click to flip

A clinic nurse is providing instructions to a client with a diagnosis of conjunctivitis. Which statement by the client indicates a need for further instruction? A. "I should apply warm compresses before instilling the antibiotic drops if purulent drainage is present in my eye." B. "I can use saline eye irrigations before instilling antibiotics in my eye if drainage is present." C. "If I have any eye discomfort, I can use the eye analgesic ointment that my physician has prescribed." D. "Sharing washcloths and towels is acceptable because this condition is not contagious."

D. "Sharing washcloths and towels is acceptable because this condition is not contagious." safety

You are assigned a client with conjunctivitis. When preparing to give the meds for your patient, you realize you must apply ophthalmic antibiotic ointment. Indicate which order signifies the proper procedure for administration and infection control: 1. Administer eye ointment 2. Don gloves. 3. Assist pt to high-Fowler's position with head slightly tilted back. 4. Cleanse the edges of eyelids from inner to outer if needed. 5. Pull down eyelid with non-dominant hand to expose the conjuctival sac. 6. Ask patient to gently close eyes and move them around. A. 1, 2, 3, 4, 6, 5 B. 2, 4, 3, 1, 5, 6 C. 2, 3, 4, 1, 5, 6 D. 3, 2, 4, 5, 1, 6

D. 3, 2, 4, 5, 1, 6

A fifty-year-old blind and deaf patient has been admitted to your floor. As the charge nurse your primary responsibility for this patient. A. Let others know about the patient's deficits B. Communicate with your supervisor your concerns about the patient's deficits C. Continuously update the patient on the social environment D. Provide a secure environment for the patient

D. Provide a secure environment for the patient safety

A nurse manager is planning assignments for a registered nurse and two unlicensed assisted personnel. Which of the following is an appropriate assignment for one of the UAP's? A. Perform the Snellen test on a client. B. Observe drainage from the conjunctival lining of a client C. Document the results of a Snellen Test. D. Reinforce an eye bandage for a post-op client.

D. Reinforce an eye bandage for a post-op client management of care

A patient needs to switch analgesic drugs secondary to an adverse reaction to the present regimen. The patient is concerned that he will not receive an effective dose of a new drug to control pain. The nurse responds based on knowledge that potencies of analgesics are determined using an equianalgesic table comparing doses with that of A) meperidine. B) fentanyl. C) codeine. D) morphine.

D: The equianalgesic table identifies dosages of various narcotics that are equal to 10 mg of morphine

You are teaching a client diagnosed with chronic open angle glaucoma how to administer their eye drops, Pilocarpine HCl. Teaching is a success when the client states: a. "The eye drops are used to cause pupil dilation and help decrease pressure in the eye" b. "Vision may be blurred 1 to 2 hours after administration of pilocarpine" c. "Nausea, vomiting, and diarrhea are normal side effects of the medication" d. "Dark environments should not be a problem while I am using my eye drops"

b. "Vision may be blurred 1 to 2 hours after administration of pilocarpine"

The nurse is caring for client who underwent surgical repair of a detached retinal of the right eye. Which of the following interventions should the nurse perform? Select all that apply. a. Place the client in a prone position b. Approach the client from the left side c. Encourage deep breathing and coughing d. Discourage bending down e. Orient the client to his environment f. Administer the client to a stool softener

b. Approach the client from the left side d. Discourage bending down e. Orient the client to his environment f. Administer the client to a stool softener

A nurse is caring for a client with moderate hearing and vision loss. The client has fallen three times since her last visit. Upon visiting the client's home, the nurse notes that the client has lot of clutter inside the house. Of the following the nurse would do all of the following except? a.) Providing adequate lighting b.) Placing a rug in the middle of the hall leading to the client's bedroom c.) Removing objects that could cause the client to slip d.) Providing no slip socks for the client to move around in

b.) Placing a rug in the middle of the hall leading to the client's bedroom safety

A nurse is asked to check the corneal reflex on an unconscious client. The nurse should use which of the following as the safest stimulus to touch the client's cornea?

1. Sterile glove 2. Wisp of cotton 3. Sterile drop of saline 4. Tip of a 1 mL syringe3. Sterile drop of saline Rationale: The client who is unconscious is at risk of corneal abrasion. The safest way to test the corneal reflex is by using a drop of sterile saline. Options 1, 2 and 4 can cause injury to the cornea.

A nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Teaching for this client will include which of the following statements? a. Drive only when feelings of dizziness have not been experienced for several hours b. Go to the bedroom and lie down when vertigo is experienced c. Remove throw rugs and clutter in the home d. Turn the head slowly when spoken to

c. Remove throw rugs and clutter in the home teaching

The potential for injury during an attack of Meniere's disease is great. The nurse should instruct the client to take which immediate action when experiencing vertigo? a. "Place your head between your knees." b. "Concentrate on rhythmic deep breathing." c. "Close your eyes tightly." d. "Assume a reclining or flat position

d. "Assume a reclining or flat position." prevention

The ER nurse has had several patients arrive to the hospital simultaneously. Which of these clients represents the nurse's first priority. a. 5 year old client complaining of inner ear pain b. 72 year old female complaining of worsening cloudy vision with history of cataracts c. 83 year old male who claims he has a decrease in his ability to hear d. 23 year old male who was struck in the eye with a baseball and has complete loss of vision in right eye and bleeding.

d. 23 year old male who was struck in the eye with a baseball and has complete loss of vision in right eye and bleeding. priority

A newly hired nurse at a busy ENT's office is asked to keep an eye on things while the doctors and staff eat lunch. Which of the following indicate a need to call the doctor immediately? a. A 68 year-old man who had eye surgery two days ago and still has some bruising b. A 35 year-old woman with a small cut on her upper eyelid c. A 15 year-old boy who got an eraser stuck in his nose during a dare d. A 52 year-old man with atherosclerosis who recently changed his aspirin dosage and complains of tinnitus

d. A 52 year-old man with atherosclerosis who recently changed his aspirin dosage and complains of tinnitus

A female client complains of periorbital arching, tearing, blurred vision, and photophobia in her right eye. Opthalmologic examination reveals a small, irregular, nonreactive, pupil- a condition resulting from acute iris inflammation (iritis). As part of the client's therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification? a. Parasympathomimetic agent b. Sympatholytic agent c. Adrenergic blocker d. Cholinergic blocker

d. Cholinergic blocker pharm

50-year-old male has been taking aspirin regularly for 6 months to prevent a heart attack. He informs the nurse that he has noticed a constant "ringing" in both ears. How should the nurse respond to the client's comment? a. Tell the client that "ringing" in the ears is associated with the aging process. b. Inform the client he needs a Weber test done. c. Schedule the client for audiometric testing. d. Explain to the client that the "ringing" may be related to the aspirin he has been taking for his heart.

d. Explain to the client that the "ringing" may be related to the aspirin he has been taking for his heart. pharm

client has been diagnosed w/ acute angle-closure glaucoma. what medications/therapies would be appropriate for this emergency? a. cholinergic agents b. hyperosmotic agents c. laser surgery to create an opening in the iris d. all of the above

d. all of the above (cholinergic agents, hyperosmotic agents, laser surgery to create an opening in the iris) pharmacological & parenteral therapies

A 65-year-old male has hearing loss and a sensation of fullness in both ears. The nurse examines his ears with the understanding that a common cause of hearing loss in older adults is related to: A. Accumulation of cerumen in the external canal. B. Accumulation of cerumen in the internal canal. C. External otitis D. Exostosis

A. Accumulation of cerumen in the external canal. prevention

In caring for a person receiving an opioid analgesic through an epidural catheter, the nursing responsibility of prime importance is A. assessing for respiratory depression. B. establishing a baseline laboratory profile. C. inspecting the catheter insertion site hourly. D. ensuring that the patient remains on strict bed rest.

A. assessing for respiratory depression. Possible side effects of epidural opioids are pruritus, urinary retention, and delayed respiratory depression, occurring 4 to 12 hours after a dose. Establishing a baseline laboratory profile is outside the scope of practice for a nurse. Hourly inspection of the catheter insertion site is an unnecessary nursing intervention. In general, the site is assessed once a shift unless unexpected complications occur. Strict bed rest is not necessary for the patient with an epidural catheter; however, assistance with getting out of bed could be necessary related to effects of the opioid analgesic.

When assessing for the most serious adverse reaction to a narcotic analgesic, the nurse is careful to monitor the patient's A) respiratory rate. B) heart rate. C) blood pressure. D) mental status.

A: The most serious side effect of narcotic analgesics is respiratory depression.

When administering eye drop medication is important that the nurse following standard precautions. Which of the following should be done? A. Dawn gown B. Wash hands and wear gloves C. Have patient shield unaffected eye D. Not take any precautions

B. Wash hands and wear gloves infection control

A patient is admitted to the psychiatric unit for treatment of narcotic addiction. The nurse would anticipate administration of which medication? A) Morphine B) Methadone C) Meperidine D) Naloxone

B: Methadone is a synthetic opioid analgesic with gentler withdrawal symptoms and is the drug of choice for detoxification treatment.

When teaching a patient about risk factors for glaucoma, the nurse knows that more teaching is needed when the patient states: A. I have a higher chance of glaucoma because both my mother and grandfather had it B. I should ask my doctor of pharmacist about medications I'm taking because some medications can cause glaucoma C. I should be tested for glaucoma periodically because I have a history of sinus infections D. I'm at higher risk because of the accident I had when a firework hit me in the eye

C. I should be tested for glaucoma periodically because I have a history of sinus infections infection control

The potential for injury during an attack of Meniere's disease is great. The nurse should instruct the client to take which immediate action when experiencing vertigo? A. "Place your head between your knees" B. "Concentrate on rhythmic deep breathing" C. "Close your eyes tightly" D. "Assume a reclining or flat position

D. "Assume a reclining or flat position" safety

A patient receiving narcotic analgesics for chronic pain can minimize the gastrointestinal (GI) side effects by A) taking Lomotil with each dose. B) eating foods high in lactobacilli. C) taking the medication on an empty stomach. D) increasing fluid and fiber in the diet

D: Narcotic analgesics decrease intestinal motility, leading to constipation. Increasing fluid and fiber in the diet can prevent this.

What drug classes are used as adjuncts to general anesthesia?

Opioids, Benzodiazepines, Neuromuscular Blocking Agents, & Antiemetics

treating different visual disorders it is important to administer eyedrops/ointments appropriately. list the following actions in order of how you would perform them. 1. wash hands & put on gloves 2. have client keep eyes closed for several minutes 3. press nasolacrimal canthus 4. evert lower lid 5. apply medication in the conjunctival sac a. 1,2,3,4,5 b. 5,4,3,2,1 c. 1,4,5,3,2 d. 5,1,2,3,4

c. 1,4,5,3,2 (wash hands & put on gloves, evert lower lid, apply medication in the conjunctival sac, press nasolacrimal canthus, have client keep eyes closed for several minutes) Click to flip

In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the physician's orders, expecting which type of eye drops to be prescribed? a. a miotic agent b. a thiazide diuretic c. can osmotic diuretic d. an mydriatic medication

d. an mydriatic medication management of care

When assessing a patient for adverse effects related to morphine sulfate, which effects would the nurse expect to find? (Select all that apply.) A) Decreased peristalsis B) Diarrhea C) Delayed gastric emptying D) Urinary retention

When assessing a patient for adverse effects related to morphine sulfate, which effects would the nurse expect to find? (Select all that apply.) A) Decreased peristalsis B) Diarrhea C) Delayed gastric emptying D) Urinary retention

A patient with partial-thickness wounds of the face and chest caused by a campfire is admitted to the burn unit. All of these actions have been prescribed by the physician. Which one should the nurse accomplish first? A) Give oxygen per non-rebreather mask at 100% FiO2. B) Infuse lactated Ringer's solution at 150 mL/hr. C) Give morphine sulfate 4 to 10 mg IV for pain control. D) Insert a 14-Fr retention catheter.

(A) A) Give oxygen per non-rebreather mask at 100% FiO2. Rationale: Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the patient's tissue oxygenation at an optimal level. The other actions should be implemented as quickly as possible after the oxygen therapy is initiated.

A patient is admitted with a full-thickness scald burn over the abdomen and thighs, and all of these physician orders are received. Which order should be implemented first? A) Place two large-bore IV lines. B) Insert a 16-Fr retention catheter. C) Obtain a complete blood count. D) Administer tetanus toxoid 0.5 mL.

(A) A) Place two large-bore IV lines. Rationale: The priority nursing actions at this time are ensuring adequate oxygenation and tissue perfusion. Because there is no indication that the patient is having respiratory difficulties, the initial nursing action should be to start fluid resuscitation, which will require large-bore IV lines. The other actions should also be implemented rapidly but are not the highest-priority actions

Situation: Your patient is a 27-year-old man who fell into a bonfire while drinking with his friends. He sustained a 55% total body surface area burn. He was fluid resuscitated using Parkland formula guidelines. It is 1 day after the injury, and he is intubated and sedated. Sedation has not been effective, and his pulse oximeter reading is dropping as his agitation increases. The physician prescribes vecuronium (Norcuron) to be administered. The patient is receiving morphine sulfate for pain management. What is your understanding of the use of opioid analgesics for burn patients? Select all that apply. A) They depress respiratory function. B) They increase intestinal motility. C) They provide little more than moderate relief. D) They are most often given by the IV route.

(A, C, D) A) They depress respiratory function. C) They provide little more than moderate relief. D) They are most often given by the IV route. Rationale: Opioid analgesics rarely offer more than moderate relief during acutely painful procedures. They are given IV because of problems with absorption from the muscle and stomach. p. 536

The nurse on a burn unit has just received change-of-shift report about these patients. Which patient should be assessed first? A) A 20-year-old patient admitted a week ago with deep partial-thickness burns over 35% of the body who is complaining of pain at a level 7 (0-to-10 scale) B) A 26-year-old firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers "I can't catch my breath!" C) A 50-year-old electrician who suffered external burn injuries a month ago and is requesting that you call the doctor immediately about discharge plans D) A 60-year-old patient admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr

(B) B) A 26-year-old firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers "I can't catch my breath!" Rationale: Smoke inhalation and facial burns are associated with airway inflammation and obstruction. The patient with difficulty breathing needs immediate assessment and intervention.

Situation: Your patient is a 27-year-old man who fell into a bonfire while drinking with his friends. He sustained a 55% total body surface area burn. He was fluid resuscitated using Parkland formula guidelines. It is 1 day after the injury, and he is intubated and sedated. Sedation has not been effective, and his pulse oximeter reading is dropping as his agitation increases. The physician prescribes vecuronium (Norcuron). After you gave the vecuronium, the physician prescribes an antianxiety agent. What is the purpose of adding the antianxiety agent? A) It improves the patient's ability to rest and recuperate. B) It decreases anxiety because the vecuronium only causes muscular blockade. C) It improves oxygenation while the patient is paralyzed. D) It improves relaxation and circulatory system functioning.

(B) B) It decreases anxiety because the vecuronium only causes muscular blockade. Rationale: These drugs do not prevent the patient from seeing and hearing or from experiencing fear, pain, and loss of control. Any patient receiving neuromuscular blockade drugs must also receive drugs for sedation, analgesia, and antianxiety unless clinically contraindicated. p. 535

The RN is teamed with a nursing assistant to provide care to patients on the burn unit. Which of these tasks can be safely delegated to the nursing assistant? A) Educating a patient in the rehabilitation phase of burn injury about how to apply ointment to partial-thickness burns B) Changing a routine sterile dressing for a patient with a circumferential partial-thickness burn on the chest and back C) Measuring and documenting hourly urine outputs for a catheterized patient who was admitted yesterday with burns over 35% of TBSA D) Assessing the pain level using a 0-to-10 scale for a burn patient who is using a fentanyl (Duramorph) patch for pain control

(C) C) Measuring and documenting hourly urine outputs for a catheterized patient who was admitted yesterday with burns over 35% of TBSA Rationale: Measurement and documentation of urine output are included in nursing assistant education and scope of practice. Assessing, patient teaching, and sterile dressing changes should be done by licensed nursing personnel.

Which assessment information about a 60-kg patient who was admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area will be of most concern to the nurse? A) The bowel sounds are absent. B) The pulse oximetry level is 91%. C) The serum potassium level is 8.1 mEq/L. D) The urine output since admission is 370 mL

(C) C) The serum potassium level is 8.1 mEq/L. Rationale: An elevated serum potassium level can cause cardiac arrest. The other findings are normal for the patient during the emergent phase of burn injury

When delegating care for patients on the burn unit, which patient should the charge nurse assign to an RN who has floated to the burn unit from the pediatric unit? A) A patient who is being discharged after 6 weeks on the burn unit and who needs teaching about wound care B) A patient who has just been admitted after a high-voltage electrical burn C) A patient who has a 25% total body surface area (TBSA) burn injury and who has daily wound débridement prescribed D) A patient who is receiving IV lactated Ringer's solution at 100 mL/hr

(D) D) A patient who is receiving IV lactated Ringer's solution at 100 mL/hr Rationale: An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath. The other patients will require more specialized knowledge about assessment and interventions in burn injuries and should be assigned to RNs who have experience caring for patients with burn injuries. Click to flip

Ultraviolet light (UVL) therapy is prescribed in the treatment plan for a client with psoriasis. The nurse reinforces instructions to the client regarding safety measures related to the therapy. Which statement made by the client indicates a need for further instructions? 1. "Each treatment will last 30 minutes." 2. "I will expose only the area requiring treatment." 3. "I should wear eye goggles during the treatment." 4. "I will cover my face with a loosely applied covering."

1. "Each treatment will last 30 minutes." Rationale: Safety precautions are required during UVL therapy. Most UVL treatments require the person to stand in a light treatment chamber for up to 15 minutes. It is best to expose only those areas requiring treatment to the UVL. Placing protective wrap-around goggles prevents exposure of the eyes to the UVL. The face should shielded with a loosely applied cloth if it is unaffected. Direct contact with the light bulbs of the treatment unit should be avoided to prevent burning of the skin.

nurse arrives to work on the day shift and is assigned to care for a client with terminal cancer. The nurse notes that the client has been receiving a narcotic analgesic every 3 hours for pain. When entering the client's room, the client states, "I am so glad you are here. The medicine never works when the nurse who cared for me last night gives it to me." The nurse has previously observed the same occurrence with this client and other clients and suspects that the night nurse is substance impaired. Which of the following actions should the nurse take?

1. Report the information to the police 2. Report the information to a supervisor 3. Call the impaired nurse organization and report the nurse 4. Call the night nurse who gave the medication and discuss the event with the nurse.2. Report the information to a supervisor Rationale: The Nurse Practice Act requires reporting the suspicion of impaired nurses. The Board of Nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. The suspicion should be reported to the nursing supervisor who will then report to the Board of Nursing. Option 4 is incorrect and may cause a conflict. Option 1 and 3 are premature actions. Click to flip

A nurse is planning to reinforce instructions to a client with chronic vertigo about safety measures to prevent worsening of symptoms or injury. Which safety instruction should the nurse provide to the client? 1. Turn the head slowly when spoken to 2. Remove throw rugs and clutter in the home 3. Drive at times when the client does not feel dizzy 4. Go to the bedroom and lie down when vertigo is experienced

2. Remove throw rugs and clutter in the home Rationale: The client with chronic vertigo should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack. To further prevent vertigo attacks, the client should change position slowly and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should immediately sit down or grasp the nearest piece of stable furniture. The client should maintain a clutter-free home with throw rugs removed because the effort of regaining balance after slipping could trigger vertigo.

The patient who has had surgery this morning for cataracts is now going home. Discharge instructions include that the patient should (select all that apply): 1. sleep on the operated side. 2. use stool softeners. 3. avoid bending over. 4. not lift anything heavier than 5 pounds. 5. not wear an eye shield at night.

2. use stool softeners. 3. avoid bending over. 4. not lift anything heavier than 5 pounds