QT 7
The nurse visits the young adult at home with a diagnosis of hepatitis A. Which statement, if made by the client to the nurse, indicates that further teaching is needed? Select all that apply: 1. "I have been very careful to wash my hands after I go to the bathroom."2. "I have had to take acetaminophen several times this week for this sinus infection I have." 3. "I have been very careful not to handle my child's toys or eating utensils."4. "My husband has been preparing all of the meals since I've been sick."5. "My spouse had the Hep B vaccine so they are safe." 6. "I have to sleep in a separate room from my spouse."
Strategy: "Further teaching is needed" indicates you are looking for an incorrect response. (1) because hepatitis A is spread by the oral-rectal route, it is important to protect others by practicing good hand-washing techniques and avoiding contact with items that will be placed in others' mouths (2) correct—client should be cautioned about taking any drugs not approved by the health care provider; may become dangerous because of the liver's inability to detoxify and excrete them (3) because hepatitis A is spread by the oral-rectal route, it is important to protect others by practicing good hand-washing techniques and avoiding contact with items that will be placed in others' mouths (4) because hepatitis A is spread by the oral-rectal route, it is important to protect others by practicing good hand-washing techniques and avoiding contact with items that will be placed in others' mouths (5) correct—The Hep B vaccine is not helpful to a Hep A exposure. (6) correct—This is not a requirement for Hep A.
The nurse plans care for the client with Graves' disease. The nurse intervenes if the client drinks which fluid? Select all that apply. 1. Iced coffee.2. Diet cola.3. Orange juice.4. Hot tea.5. Apple juice.6. Milk.
Strategy: "Intervenes" indicates a wrong action. 1) CORRECT — stimulant that would increase metabolic rate 2) CORRECT — stimulant that would increase metabolic rate 3) not limited for Graves' disease 4) CORRECT — stimulant that would increase metabolic rate 5) not limited for Graves' disease 6) not limited for Graves' disease
The nurse in the pediatrician's office instructs the parents of the toddler about a scheduled magnetic resonance imaging (MRI). The nurse tells the parents the child should be sedated using chloral hydrate prior to the MRI. The parents ask if they can administer the medication at home so that the toddler will be asleep when they arrive at the hospital. Which response by the nurse is most appropriate? 1. "I will ask the health care provider if it is permissible."2. "The medication should be administered at the hospital."3. "The child should be awake when arriving at the hospital."4. "Are you sure you can handle your sedated toddler?"
Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) chloral hydrate causes paradoxical excitation in children; administer at facility where MRI is scheduled (2) correct—chloral hydrate, a sedative, can have the opposite effect on a toddler, causing excitability; child should be continuously monitored after medication is administered (3) safety of toddler is most important (4) medication should not be given at home prior to coming to facility
The nurse performs an ice massage for the client in chronic pain. The nurse is most concerned if which finding is observed? 1. Redness or inflammation of the tissue.2. Mottling or graying of the tissue.3. The client states that they feel a burning and tingling sensation in the area.4. The client states that they feel a numbness and a cold sensation in the area.
Strategy: "MOST concerned" indicates a complication. (1) indicates inflammation (2) correct—site should be observed every five minutes for signs of tissue intolerance, including blanching, mottling, or graying (3) usually indicates ischemia or sensorineural impairment (4) expected outcome of numbness, which would lead to decreased pain perception
The client diagnosed with a tumor of the pituitary gland has a transphenoidal hypophysectomy. The nurse plans care for the client two days after surgery. It is most important for the nurse to monitor which finding? 1. Complete blood count (CBC).2. Temperature. 3. Urine specific gravity.4. Intracranial pressure.
Strategy: "MOST important" indicates this is a priority question. Determine what each assessment measures and how it relates to the situation. 1) not affected by surgery 2) controlled by the hypothalamus, not the pituitary 3) CORRECT—lack of ADH from pituitary will cause diabetes insipidus and diuresis with very low specific gravity 4) surgery performed through nose; does not affect cerebral pressure
A woman is in active labor with her first child when her membranes rupture. She voices concern to the nurse that she is afraid of having a "dry labor." Which response by the nurse is mostappropriate? 1. "The amniotic fluid provides only minimal lubrication for the labor process."2. "The amniotic sac may impede the progress of labor and is often ruptured artificially." 3. "Labor is only slightly more difficult with early rupture of the amniotic sac."4. "Because there is limited amniotic fluid, additional fluids will be supplied."
Strategy: "MOST" indicates there may be more than one attractive answer. (1) amniotic fluid cushions fetus, allows freedom of movement for musculoskeletal development, facilitates symmetrical growth, maintains constant body temperature, is a source of oral fluids, and collects wastes (2) correct—sometimes done to assist or induce labor (3) does not make labor more difficult (4) no additional fluids will be supplied
The nurse believes a co-worker is diverting narcotics for personal consumption. The nurse approaches the nurse manager to report the suspicions. Which statement by the nurse is BEST? 1. "After my co-worker has been on duty, the clients often need repeated doses of pain medication. I have seen them sleeping on duty three times."2. "I saw my co-worker downtown after work. They were acting really strange, like they didn't even recognize me."3. "I think my co-worker is stealing narcotics because they are always acting euphoric and seem high."4. "My co-worker is hanging around with drug dealers, and I think I saw tracks on their arms."
Strategy: All answers are assessment. Determine how each relates to the situation. (1) correct—report objective information that can be verified; clues to possible substance abuse by staff include memory lapses, frequent absences from the floor, increased number of clients reporting unrelieved pain or insomnia (2) subjective observation (3) subjective observation (4) "hanging around with drug dealers" is subjective
The nurse plans care for the older client with left-sided weakness due to a stroke. The client has a history of hypertension and osteoporosis. It is most important for the nurse to encourage the client to increase which implementation? 1. Calcium in the daily diet.2. Vitamin D in the daily diet.3. Time of exposure to sunlight.4. Activities that involve weight bearing.
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? 1) diet should have adequate calcium; client should increase intake in middle age to protect against skeletal demineralization; not most important 2) adequate serum levels of vitamin D are needed for calcium to be absorbed from gastrointestinal tract, should increase intake in middle age to protect against skeletal demineralization; not most important 3) vitamin D is synthesized in the skin with exposure to sunshine; not most important for this client 4) CORRECT — weight bearing and exercise are primary ways to develop high-density bones; decrease bone resorption, and stimulate bone formation; would also help maintain mobility with left-sided weakness
The nurse provides care for a client with this cardiac rhythm strip. Which health care provider prescription does the nurse question? 1. Administer lidocaine 50 mg IV push for PVCs in excess of six per minute. 2. Administer atropine sulfate 0.5 mg IV for symptomatic bradycardia.3. Schedule the client for a temporary pacemaker if the pulse continues to decrease. 4. Mix 10 mL of 1:5000 solution of isoproterenol in 500 mL D5W for sustained bradycardia below 30 bpm.
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?" 1) CORRECT - In complete heart block, the AV node blocks all impulses from the SA node, so the atria and ventricles beat independently. Because lidocaine suppresses ventricular irritability, it may diminish the existing ventricular response; therefore, cardiac depressants are contraindicated in the presence of complete heart block. 2) This is an appropriate treatment; therefore, the nurse does not question this prescription. 3) This is an appropriate treatment; therefore, the nurse does not question this prescription. 4) This is an appropriate treatment; therefore, the nurse does not question this prescription.
The nurse performs hypertension screening at the local grocery store. It is most important for the nurse to complete which task? 1. Use a blood pressure cuff that overlaps the arm at least 4 inches.2. Support the client's arm above the level of the heart.3. Take two readings at least five minutes apart.4. Take the blood pressure after the client has exercised for 10 minutes.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary (2) arm should be supported at the level of the heart (3) correct—recognition of adult hypertension should be done after two readings taken at least five minutes apart (4) unnecessary
The client recieves chlorpromazine 400 mg/day for four weeks. The client experiences an oral temperature of 105°F (40.5°C), severe rigidity, oculogyric crisis, and severe hypertension. It is most important for the nurse to take which action? 1. Administer PRN benztropine mesylate immediately.2. Hold the chlorpromazine, and notify the health care provider stat.3. Place the client in isolation on bedrest in semi-Fowler's position.4. Administer acetaminophen 500 mg, and place the client on a cooling mattress.
Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) bromocriptine or dantrolene is used for CNS toxicity (2) correct—client is experiencing neuroleptic malignant syndrome; fatal in about 15-20% of cases; is toxic effect of antipsychotic medication (3) isolation is unnecessary (4) is not most important; cooling blanket is used for fever, IV fluids for hydration, airway if necessary, frequent monitoring of vital signs
The nurse is caring for a client in a manic phase of bipolar disorder. It is most important for the nurse to offer which meal? 1. Tuna salad sandwich and orange slices.2. Bologna sandwich and french fries.3. Milkshake and banana.4. Fried chicken and tossed salad.
Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) correct—clients with mania need nutritious finger foods; foods contain protein, carbohydrates, vitamin C, and fiber (2) finger foods but little nutritive value (3) finger foods but not as balanced (4) too difficult to eat in manic phase
The client has an order for hydrochlorothiazide 50 mg qd. The nurse knows that further teaching is needed if the client makes which statement? Select all that apply. 1. "I should not operate heavy machinery."2. "I should drink five glasses of liquid per day."3. "This medication will cause my urine to turn orange."4. "I should eat dried apricots each day."5. "I should take this medication on an empty stomach
Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) correct—medication does not cause drowsiness (2) correct—there are no specific restrictions on fluid at this time (3) correct—does not occur (4) continued use of this diuretic may cause a loss of potassium; dietary intake of foods such as bananas or dried apricots, which are high in potassium, should be encouraged (5) correct—This medication should be taken with food because it causes GI upset.
The client visits the rape-crisis clinic one week after being assaulted. The client is currently taking alprazolam 0.25 mg PO q 6 hours for anxiety. Which statement, if made by the client to the nurse, reflects a correct understanding of this medication? Select all that apply: 1. "I will make an appointment when I want to stop taking this."2. "I should not take this with anything but water."3. "I guess I need to stop drinking white wine."4. "This medication will help me forget and go on."5. "I can take it whenever I feel upset."
Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) correct—needs to be withdrawn slowly under supervision. (2) indicates a need for further medication teaching (3) correct—antianxiety, should not be taken with alcoholic beverages (4) indicates a need for further medication teaching (5) indicates a need for further medication teaching
The health care provider prescribes ciprofloxacin for the client. Which instruction should the nurse include about this medication? Select all that apply. 1. "Drink plenty of fluids."2. "You may take this medication with your multivitamin."3. "Eliminate dairy products from your diet."4. "Always take this medication with meals."5. "You should avoid exposure to the sun while on this medication"6. "Try to avoid caffeine while you take this medication."
Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) correct—prevents crystalluria and stone formation (2) do not take within 6 hours before ciprofloxacin (3) do not take with milk or yogurt alone, decreases the absorption of ciprofloxacin; can ingest dietary sources of calcium (4) may take with meals if gastric irritation occurs (5) correct—this medication makes skin exposure a risk. (6) correct—caffeine consumption increase caffeine effects while on this medication
Which nursing action is most appropriate after intubating a postoperative client who had a respiratory arrest? 1. Soak the intubation equipment in concentrated Betadine solution.2. Place the intubation blade in a bag, and arrange for gas sterilization.3. Soak the intubation blade in Cidex solution.4. Wash the equipment with soap and water and allow to air-dry.
Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate action (2) correct—sterilization of equipment after exposure to body fluids of a client is protocol (3) inappropriate action (4) inappropriate action
The nurse cares for the client with a long leg cast on the right leg. The nurse notes that the right foot is pale and cool to the touch, and the client continues to report pain even though an analgesic was administered 45 minutes ago. Which action should the nurse should take first? 1. Apply a heating pad to the client's right toes.2. Repeat the dose of the analgesic stat.3. Remove the cast immediately.4. Notify the health care provider immediately.
Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate response to the symptoms observed (2) although no time frame for administration is specified, it is not likely that the analgesic was ordered q 45 minutes; is only palliative (3) is the action that probably will be done by the health care provider (4) correct—symptoms of compartmental syndrome; document observations and secure health care provider's intervention immediately
The client had a thoracotomy three hours ago. For the past two hours, there has been 100 ml/hour of bloody chest drainage. Which action should the nurse take first? 1. Increase the IV fluid rate.2. Administer oxygen at 5 L/minute per oxygen mask.3. Elevate the head of the bed.4. Advise the health care provider (HCP) of the amount of drainage.
Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) may be appropriate after the HCP is notified (2) may be appropriate after the HCP is notified (3) may be appropriate after the HCP is notified (4) correct—chest drainage of 100 ml/hour is abnormal; HCP should be notified
The psychiatric client admitted involuntarily asks the nurse to mail a letter to the President. The client states that the letter will make the President regret his actions to prevent homosexuals from serving in the military. Which response by the nurse is best? 1. Accept the letter and place it in the client's medical record.2. Read the client's letter and decide if it is appropriate to mail.3. Call the client's health care provider and inform them of the letter.4. Discourage the client from sending the letter, but mail it if client insists.
Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) psychiatric clients do not forfeit their civil rights (2) client has the right to send and receive unopened mail (3) has the right to mail the letter (4) correct—retains the right to communicate with elected officials
The client diagnosed with end-stage metastatic cancer of the breast is admitted to the hospital. Which action is most important for the nurse to take? 1. Suction the client frequently.2. Provide an air mattress. 3. Turn the client every two hours.4. Give the client frequent baths.
Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? 1) decreases oxygen levels, is uncomfortable and unnecessary 2) equipment is not most important 3) CORRECT - prevents complications such as skin breakdown 4) will dry out the skin and cause chilling
The nurse administers oral medications to an elderly, confused client. The client states, "These pills look funny. They belong to the lady down the hall." Which response by the nurse is best? 1. "Your health care provider has ordered new medications for you. They will help you get well." 2. "Remember yesterday when I brought your medications? They look the same." 3. "I'll explain why you are receiving these medications."4. "I'll be back after I check your medications again."
Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? 1) unsafe action 2) unsafe action 3) unsafe action 4) CORRECT — even a confused client should have his/her medications rechecked when there is any possibility of an error; always observe the six rights of medication administration
The client is to receive regional anesthesia (spinal anesthesia) during surgery. Which finding is the most important nursing implication regarding this anesthesia? 1. Adequately hydrate the client. 2. NPO client for at least 12 hours. 3. Assess the client for any allergies to iodine preparations.4. Determine the specific gravity of the urine.
Strategy: Answers are a mix of assessments and implementations. Do the assessments make sense? No. (1) correct—implementation; important that the client be well hydrated to prevent hypotensive problems after the spinal anesthesia is initiated (2) implementation; unnecessary for client to be NPO for 12 hours (3) assessment; unnecessary, as iodine dyes are not used (4) assessment; irrelevant to the procedure
The nurse cares for clients in a rehabilitation facility. The nursing team reports a client recovering from a hip fracture has repeatedly "transferred herself to the floor." Which action, if taken by the nurse, is best? 1. Place the call light within the client's reach.2. Remove the footrests from the wheelchair.3. Observe the client rise from a sitting to a standing position.4. Place a Posey vest restraint on the client.
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) implementation; assumes that client can't reach the call light (2) implementation; assumes that client is tripping on the footrest (3) correct—assessment; nurse can determine if client is safe to perform this activity (4) implementation; must exhaust all other interventions before restraining client
The school-aged child informs the school nurse that the right knee "doesn't feel right." Which action should the nurse take first? 1. Instruct the child to extend the right leg.2. Put both of the child's legs through range of motion.3. Advise the child to soak the right knee in warm water.4. Compare the appearance of the right knee with the left knee.
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) will not help determine if the knee is edematous (2) inspection first step of physical assessment (3) implementation; need to assess to determine the problem (4) correct—should compare corresponding joints for symmetry and to determine normal parameters
The health care provider administers an epidural to the client in labor, which nursing action has the highestpriority? 1. Decrease IV fluids. 2. Assess the fetal heart monitor. 3. Place the client on the right side.4. Obtain the blood pressure.
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. 1) implementation; client must be well hydrated before and after the procedure 2) assessment; may be done as ongoing management but is not a priority 3) implementation; laboring client would be placed on left side to promote uterine perfusion 4) CORRECT — assessment; adverse effect of an epidural is hypotension from the vasodilation that occurs
The client comes to the clinic for a glycosylated hemoglobin assay (HbA1c). The result is 6%. The nurse should take which action? 1. Document the findings in the chart. 2. Call the health care provider about orders to adjust the insulin dosage. 3. Give the client 15 g of carbohydrates. 4. Ask the client to list the foods eaten in the last 24 hours.
Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each answer choice. (1) correct—results normal, indicates good control of diabetes (2) no adjustments need to be made (3) does not reflect hypoglycemia (4) no adjustment needs to be made in diet; result is not altered by intake day before test
One hour after receiving 7 units of regular insulin, the client presents with diaphoresis, pallor, and tachycardia. Which action should the nurse take first? 1. Notify the health care provider.2. Call the lab for a blood glucose level.3. Offer the client milk and crackers.4. Administer glucagon.
Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. (1) action should be taken prior to notifying the health care provider (2) does not require validation, implementation required (3) correct—onset of action for regular insulin is 30-60 minutes; assessment indicates a problem with hypoglycemia; foods such as milk and crackers should be given if blood sugar is around 40-60 mg/dL3 (2.2 - 3.3 mmol/L); if orange juice or simple sugar is given, it should be followed with a meal or with protein intake (4) unnecessary, unless client is unresponsive
The 11-month-old baby is having trouble gaining weight after discharge from the hospital. Which action by the nurse is best? 1. Observe the child at mealtime.2. Inquire about the child's eating patterns.3. Weigh the baby each month.4. Attempt to feed the baby for the mother.
Strategy: Answers are a mix of assessments and implementations. Is validation required? Yes. (1) correct—assessment; will provide the most information (2) assessment; may or may not secure an accurate picture (3) assessment; weight should be obtained more often or on each visit (4) implementation; need to assess before determining appropriate interventions
Which action should the nurse instruct the client to complete first to establish a normal urinary pattern? 1. Urinate every two hours.2. Record each time the client urinates.3. Keep a record of daily fluid intake.4. Stay near a bathroom.
Strategy: Answers are all implementations. Determine the outcome of each answer. Is it desired? (1) client should start voiding every two hours and gradually progress to three to four hours (2) second thing to do (3) correct— client needs to know how much and when fluid is ingested (4) appropriate but not the first thing to do
The parent of the 1-day-old infant works the evening shift (1500 to 2300) at another hospital. Which action is a priority to meet the needs of this parent? 1. Encourage the parent to call the spouse after work.2. Instruct the parent about visiting policy and suggest morning visits.3. Adjust visiting hours to meet the new parents' needs.4. Present a change of visiting hours to the appropriate hospital committee.
Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired? (1) inflexible (2) inflexible (3) correct—role of nurse is to be a family and client advocate; this provides individualized care (4) not a priority, although it may be an appropriate long-range goal
The nurse plans care for the client who had surgery for an ileal conduit 2 days ago. Which action is most important for the nurse to take? 1. Remove the appliance regularly, and clean the skin with antiseptic solution. 2. Apply a close-fitting drainage bag to the stoma.3. Massage the skin around the stoma with an emollient.4. Expose the area around the stoma to air twice a day.
Strategy: Answers are implementations. Determine the outcome of each answer. Is it desired? 1) nurse should use soap and water, not an antiseptic solution, to clean the skin 2) CORRECT— primary preventative measure to prevent urine from contacting the skin 3) would hinder the application of the bag for urine collection 4) unnecessary; would not help prevent skin breakdown
The nurse obtains a health history from the client in the medical clinic. The client states, "I think I have an ulcer." Which response by the nurse is best? 1. "Do you have a burning pain in the epigastric region?"2. "Do you have sharp pain in your lower abdomen?"3. "Do you have right shoulder pain with vomiting?"4. "Do you have heartburn when you lie down?"
Strategy: Determine how each answer relates to an ulcer. (1) correct—peptic ulcer pain is often referred to as a "boring pain in the back" or a "burning, gnawing" feeling in the midepigastric area (2) may indicate intestinal perforation (3) often associated with gallbladder disease or with irritation of the diaphragm, most often caused by free air in abdominal cavity (a postoperative complication) (4) describes indigestion or possible hiatal hernia
The nurse cares for the client receiving treatment for hypoparathyroidism. The nurse determines that treatment is successful if which finding is observed? 1. The client's output is 1,500 ml of clear, straw-colored urine.2. The client is unable to state his name.3. The client denies numbness and tingling.4. The client loses 3 lb in 1 week.
Strategy: Determine how each answer relates to hypoparathyroidism. (1) important to monitor but is not top priority (2) confusion and decreased memory are symptoms of hypercalcemia (3) correct—tetany is major sign of hypoparathyroidism (4) most frequently observed with hyperparathyroidism
The nurse cares for the neonate diagnosed with an infection. The nurse is most concerned if which finding is observed? 1. Heart rate of 150 bpm.2. Axillary temperature of 96°F (35.5°C).3. Weight increase of 4 oz.4. Respiratory rate of 65 at rest.
Strategy: Determine how each answer relates to neonatal infection. (1) is within the normal range (2) axillary temperature is less than tympanic membrane or rectal temperature in neonate (3) neonates normally experience a 5-10% loss of weight within the first few days of life (4) correct—normal respiratory rate of a neonate is 30-50; tachypnea is a sign of sepsis or hypoxia in a neonate
The nurse cares for the client receiving chemotherapy. The client has a WBC count of 1,200/mm3(1.2 x 109/L). Which action should the nurse take first? 1. Check temperature q4h.2. Monitor urine output.3. Assess for bleeding gums.4. Obtain an order for blood cultures.
Strategy: Determine how each assessment relates to a low white count. (1) correct—important to monitor for infection, which would be evidenced by an elevated temperature in a client with a low WBC (2) important because of problems of increased uric acid excretion from chemotherapeutic drugs but should not be done first (3) would be associated with a low platelet count (4) would be done if the temperature were elevated to determine the type of organism involved
The nurse cares for the client after dental surgery. The dentist prescribes ibuprofen 600 mg PO. The nurse is most concerned if the client makes which statement? 1. "I was treated for a peptic ulcer two years ago."2. "I had a transurethral resection of the prostate (TURP) last year."3. "I attend Weight Watchers."4. "I have been having problems with gout."
Strategy: Determine how each statement relates to ibuprofen. (1) correct—side effects include epigastric distress, nausea, occult blood loss, peptic ulceration; use cautiously with history of previous gastrointestinal disorders (2) medication not contraindicated (3) medication not contraindicated (4) medication not contraindicated
The infant of a mother diagnosed with diabetes has a blood glucose of 90 mg/dL (5 mmol/L) and a total serum calcium level of 7.0 mg/dL (1.8 mmol/L). The nurse should anticipate that which medication would be administered IV? 1. Insulin.2. Glucose.3. Phenobarbital.4. Calcium gluconate.
Strategy: Determine the action of each drug and how it relates to the lab values. (1) would be given for blood sugar problems (2) would be given for blood sugar problems (3) not appropriate for a neonate (4) correct—hypocalcemia causes tetany; calcium gluconate will replace the calcium
A client has a cataract removed from the left eye. Which actions are important for the nurse to take in the immediate postoperative period? Select all that apply. 1. Position the client on the right side with the head slightly elevated. 2. Place the client on the left side to protect the eye. 3. Perform sensory neurological checks every two hours. 4. Maintain complete bedrest for the first 48 hours. 5. Assess client's level of consciousness.6. Assess client knowledge of home care.
Strategy: Determine the outcome of each answer choice. Is it desired? 1) CORRECT — should be positioned on back or unaffected side to prevent trauma to surgical eye 2) should be positioned on unaffected side 3) unnecessary for cataract clients 4) unnecessary for cataract clients 5) CORRECT — assessing the level of anesthesia is necessary immediately postop 6) this is not necessary until the anesthesia is cleared, so not immediately
The nurse in the labor and delivery unit receives report about four clients in active labor. In which order does the nurse see the clients? Place the answers in order of priority. All options must be used. The multipara at term, cervical dilation of 8 cm, vertex, +2 station, strong contractions q 2 mins. The nullipara at term, cervical dilation of 10 cm, LOP, moderate-strong contractions q 2-3 mins. The multipara at 37 weeks, cervical dilation of 3 cm, transverse lie, 0 station, mild contractions. The nullipara at 38 weeks gestation, cervical dilation of 2 cm, frank breech, no contractions.
Strategy: Determine who is the least stable client. 1) The multipara at term, cervical dilation of 8 cm, vertex, +2 station, strong contractions q 2 mins. see first; end of transition phase of labor and delivery quick for many multiparas 2) The nullipara at term, cervical dilation of 10 cm, LOP, moderate-strong contractions q 2-3 mins. see second; second phase of labor nulliparas usually have a longer second stage than multiparas, approximately 2 hours 3) The multipara at 37 weeks, cervical dilation of 3 cm, transverse lie, 0 station, mild contractions. see third; cesarean delivery for transverse presentation; next highest priority for fetal risk 4) The nullipara at 38 weeks gestation, cervical dilation of 2 cm, frank breech, no contractions. see last; most stable, labor has not progressed very far
The nurse on postpartum prepares four clients for discharge. It is most important for the nurse to refer which client for home care? 1. A 15-year-old who vaginally delivered a 7-lb male 2 days ago.2. An 18-year-old multipara who delivered a 9-lb female by cesarean section 2 days ago.3. A 20-year-old multipara who delivered 1 day ago and reports cramping.4. A 22-year-old who delivered by cesarean section and reports burning on urination.
Strategy: Eliminate the most stable clients. (1) stable situation, no indication of problems with mother or baby (2) stable situation, no indication of problems with mother or baby (3) stable client, cramping due to uterine contractions (4) correct—unstable client, indicates urinary tract infection; requires follow-up
The nurse cares for the client who had a cholecystectomy. Which observation is most important for the nurse to report to the next shift? 1. Resting after receiving IM pain medication.2. No bowel sounds present.3. IV infusing at 100 ml/h.4. Breath sounds decreased in both lower lobes.
Strategy: Priority question. Remember Maslow and the ABCs. (1) psychosocial; not a priority (2) physical; expected finding after surgery due to decrease in peristalsis from anesthetic agents (3) physical; not a priority (4) correct—physical; incision for a cholecystectomy is high on the abdominal wall, which inhibits ventilatory movement; decreased breath sounds might indicate a complication of pneumonia
The 16-year-old is brought by her parents to the outpatient clinic for treatment of pelvic inflammatory disease (PID). While the nurse obtains a history, the client says bitterly, "My parents are mean and don't really care about me." Which response by the nurse is best? 1. "You feel your parents don't care about you?"2. "Your parents brought you to the clinic, didn't they?"3. "I am sure that your parents have your best interests at heart."4. "Did you have a disagreement with your parents?"
Strategy: Remember the principles of therapeutic communication. (1) correct—uses therapeutic technique of reflecting; validates feelings without placing value judgment or giving approval or disapproval (2) negates client's feelings, blocks communication (3) negates client's feelings, blocks communication (4) yes/no question
A husband and wife meet at the mental health clinic to make an appointment for family therapy. Suddenly, the wife begins to sob loudly. As the nurse approaches, the husband says, "I guess we just don't get along." Which response by the nurse is most appropriate? 1. "Your wife seems to be upset by the situation." 2. "Perhaps you should both go home now." 3. "Try to think about what precipitated her crying."4. "The situation is difficult for both of you."
Strategy: Remember therapeutic communication. (1) nontherapeutic; emphasis is placed on wife, not the situation (2) nontherapeutic; closes off communication (3) nontherapeutic; appears to blame the husband for precipitating the wife's behavior, would cause him to react defensively (4) correct—therapeutic; avoids blaming, focuses on feelings of both husband and wife
The client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The client's vital signs are B/P 162/100, pulse 78, respirations 30 and labored with wheezing. The nurse should question which order? Select all that apply: 1. Theophylline 0.7 mg/kg/h IV.2. Tetracycline hydrochloride 250 mg IM qd.3. Ipratropium bromide inhaler 2 inhalations qid.4. Propranolol hydrochloride 40 mg PO bid.5. IV of Normal Saline at 200mL per hour.
Strategy: Select the incorrect order. Think about the action of each implementation. (1) drug of choice for acute asthma (2) broad spectrum antibiotic, not contraindicated (3) blocks parasympathetic stimulation and decreases mucus; used with asthma (4) correct—beta-blocker that blocks beta adrenergic impulses to the bronchial tree that cause bronchodilation resulting in increased bronchoconstriction (5) correct—This rate of IV fluid will increase the risk of fluid volume overload.
The client is receiving parenteral nutrition. It is most important for the nurse to monitor which finding? 1. Vital signs and level of consciousness.2. Arterial blood gases and liver enzymes.3. Serum glucose and electrolytes. 4. Skin turgor and daily weights.
Strategy: The "most important" indicates a priority question. 1) The most common complications involve fluid and electrolytes. 2) Abnormalities in liver function may occur, but the most common complications involve fluid and electrolytes. 3) CORRECT - Hyperglycemia can cause diuresis and excessive fluid loss. A finger stick blood glucose should be checked every 6 hours. Check serum electrolytes (sodium, potassium, calcium, magnesium, and phosphates) several times a week. 4) The nurse should assess skin turgor to check for dehydration and weigh the client daily to help determine fluid levels. This is not the most important.
The LPN/LVN provides care for low-risk clients on a medical-surgical unit. The LPN/LVN contacts the employee health nurse stating, "I have crusted shingles lesions on my back." Which response by the nurse is best? 1. "You can't take care of any clients for two weeks."2. "You may come to work for your scheduled shift."3. "You can't care for clients until the lesions are fully healed."4. "Contact your health care provider before returning to work."
Strategy: The topic of the question is unstated. Read answer choices for clues. 1) Staff with localized, crusted lesions can care for non-high-risk clients if the lesions are covered. 2) CORRECT - The LPN/LVN is able to care for non-high-risk clients. The crusted lesions must be covered. The LPN/LVN should not care for pregnant women, premature neonates, or immunocompromised clients. 3) The LPN/LVN is able to care for low risk clients if crusted lesions are covered. It is not necessary to wait until the lesions are fully healed. 4) It is not necessary to contact the health care provider because the nurse knows if the lesions are all crusted over and covered; the LPN/LVN can return to work.
Which finding indicates that a client is beginning to develop a trusting relationship with the nurse? 1. The client describes delusions to the nurse.2. The client can describe his/her feelings to the nurse.3. The nurse feels more comfortable with the client.4. The client reports feeling less anxious.
Strategy: Think about each answer. Does the behavior indicate trust? (1) delusional system is indication of anxiety, delusions will increase with greater anxiety; trust of nurse is not related to an explanation of client's delusions (2) correct—client who is suspicious and delusional begins to demonstrate trusting behaviors when she/he shares feelings with the nurse (3) nurse's response can be an indication of transference/countertransference issues; is not indicative of client beginning to enter a trusting relationship (4) is beneficial that the client's anxiety level is becoming less intense; will facilitate development of a trusting relationship
The nurse performs diet teaching for a client with a spinal cord injury at S3. Which meal, if chosen by the client, indicates to the nurse that teaching is effective? 1. Cheeseburger with tomato and onion.2. Spaghetti with meat sauce and green beans. 3. Tuna fish sandwich with orange juice. 4. Grilled cheese sandwich and chocolate pudding.
Strategy: Type of diet needed by the client is unstated. Determine what type of diet is required and select the appropriate menu. (1) should have high-fiber, low-fat diet; this diet is high in fat (2) correct—high-fiber diet is an important part of bowel program; fiber helps prevent the complication of constipation; includes whole-grain foods, bran, fresh and dried fruits; increased fiber will facilitate defecation, especially with reduction in fat intake (3) should increase intake of fiber foods and decrease intake of fat (4) should have high-fiber, low-fat diet; this is a high-fat diet
The nurse in the newborn nursery receives report from the previous shift. In which order should the nurse see the infants? Place the answers in order of priority. All options must be used. The 12-hour-old infant held by the mother, respirations 65 and deep. The 2-day-old infant, lying quietly alert, heart rate of 185 bpm. The 1-day-old infant, sleeping, and the anterior fontanel is bulging. The 5-hour-old infant, sleeping, hands and feet are blue bilaterally.
Strategy: Using unstable through stable. (1) The 12-hour-old infant held by the mother, respirations 65 and deep. See first: Unstable, Unexpected, Respiratory. Newborn respiratory rates while quiet are 30-50 bpm and abdominal. Requires immediate assessment. (2) The 2-day-old infant, lying quietly alert, heart rate of 185 bpm. See second; Unstable, Unexpected, Cardiac. infant has tachycardia; normal resting rate is 120-160 bpm; requires further investigation (3) The 1-day-old infant, sleeping, and the anterior fontanel is bulging. See third; Unstable, Unexpected, Neurological. the anterior fontanel should be flat when the infant is at rest. May indicate increased fluid in the cranium. The fontanel may bulge with crying as a normal finding. (4) The 5-hour-old infant, sleeping, hands and feet are blue bilaterally. See last; Stable; acrocyanosis is normal for two to six hours post delivery.
The nurse screens the 8-month-old girl in a well-baby clinic. The nurse knows the parent understands growth and development if the parent makes which statement? Select all that apply: 1. "My daughter has almost doubled her birth weight."2. "When I walk in the room, my child smiles at me."3. "When she is around her grandpa, my child cries."4. "My daughter can't quite say "mama" yet."5. "My child should be able to do a large piece puzzle by now."6. "I will use a pillow to support her all the time."
Strategy: understands indicates you are looking for something correct. (1) weight should double by 5 months of age (2) correct—begins to recognize parents at 6 months of age (3) correct—begins to fear strangers at 6 months, increases until 9 months of age (4) correct—begins to say "dada" and "mama" with meaning at 10 months of age (5) outside the range of an 8 month old. (6) inappropriate for an 8 month old.
