Test 2
The client comes to the emergency department status post fall. The client is squinting both eyes and reports sudden blurry vision. The nurse is aware that this deficit reflects injury to which area of the brain? Frontal lobe Temporal lobe Parietal lobe Occipital lobe Cerebellum Brainstem
Answer: The occipital lobe of the brain registered visual images. Injury to the occipital lobe could result in a deficit with vision. The nurse should notify the health care provider immediately and document the finding.
A registered nurse (RN), a licensed practical nurse (LPN), and unlicensed assistive personnel are caring for a client who is 1-day postoperative gastric bypass surgery. Which pain management-related tasks should the RN delegate to the LPN? SELECT ALL THAT APPLY 1. Administering oral pain medication 2. Assessing characteristics of pain 3. Measuring vital signs before and after analgesic administration 4. Monitoring pain level using a numeric scale 5. Providing discharge teaching about pain management
Answer: (Option 1 & 4) Educational objective: The registered nurse is responsible for assessing pain characteristics, developing the care plan, and providing initial and discharge teaching. A licensed practical nurse may monitor pain level and administer pain medication. The nurse should consider the 5 rights of delegation and effective use of resources when delegating tasks.
A laboring client at 35 weeks gestation comes to the labor and delivery unit with preterm rupture of membranes "about 18 Horus ago". The client's group B Streptococcus status is unknown. What intervention is PRIORITY for this client? 1. Administration of prophylactic antibiotics 2. Assessment of uterine contraction frequency 3. collection of a clean-catch urine specimen 4. Vaginal examination to assess cervical dilation
Answer: (Option 1) Group B Streptococcus (CBS) may be present as part of normal vaginal flora in up to 30% of pregnant clients. Although colonization with GBS rarely poses harm to the client, it can be transmitted to the newborn during labor and birth, resulting in serious complications (eg, neonatal GBS sepsis, pneumonia). Pregnant clients are tested for GBS colonization at 35-37 weeks gestation and receive prophylactic antibiotics during labor if results are positive. If FBS status is unknown, antibiotics are typically indicated when membranes have been ruptures for >18 hours, maternal temperature is >100.4 F (38 C), or gestation is <37 weeks. (Option 2) Part of the client's assessment includes evaluation of the uterine contraction pattern. However, the client and newborn are at risk for infection due to prolonged rupture of membranes and unknown GBS status, so antibiotic administration is the priority. (Option 3) A urine specimen is often collected to evaluate for proteinuria in clients with elevated blood pressure or to assess for urinary tract infection in symptomatic clients. Urine specimen collection is not the priority for this client. (Option 4) Vaginal examinations should be limited in the presence of ruptured membranes. Multiple Vaginal examinations in such a client correlate with an increased risk for infection (eg, chorioamnionitis).
The unit implemented a quality improvement program to address client pain relief. Which set of criteria is the BEST determinant that the goal has been met? 1. Char audits found clients self-reported pain scores improved by 10% 2. Number of narcotics used on the unit increased by 20% 3. Positive comments on returned client satisfaction surveys increased by 30% 4. Surgery found that 90% of the nurses believed clients had better pain control
Answer: (Option 1) Measurements should be objective, rather than subjective. Evidence-based criteria should be used if applicable. Theses survey results are objective, retrospective measurements of a positive change (Option 2) This increase in use could be attributed to many other factors, including difference in the number or type of clients on the unit and theft of the narcotics. In addition, clients may obtain pain relief by alternate means. (Option 3) These are subjective criteria. It is possible to consider satisfaction as an outcome, but there is no indication in the option that the percentage of returned surveys is a satisfactory amount. There is no indication whether the positive comments are about pain relief of other aspects of care. There is no indication if theses clients had pain relief as part of their nursing needs.
The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which Client statement is MOST concerning and would warrant health care provider notification? 1. "I am going for repeat testing to confirm glaucoma." 2. "I am not able to exercise as much as I used to." 3. "I started taking esomeprazole for heartburn." 4. "My bowel movements are not regular."
Answer: (Option 1) Parkinson disease (PD) is a progressive neurological disorder characterized by bradykinesia (loss of autonomic movements), rigidity, and tremors. Clients with PD have an imbalance between dopamine and acetylcholine in which dopamine is not produced in high enough quantities to inhibit acetylcholine. Anticholinergic medications (eg, benztropine, trihexyphenidyl) are commonly used to treat tremor in these clients. However, in clients with benign prostatic hyperplasia or glaucoma, caution must be taken as anticholinergic drugs can precipitate urinary retention and an acute glaucoma episode. As a result, such medications are contraindicated in these clients. (Option 2) Decreased ability to exercise is common in clients with PD due to tremors and bradykinesia, and they require physical and occupational therapy consultations. However, acute glaucoma can be sight threatening and is the priority. (Option 3) Esomeprazole is safe to take with benztropine and will not cause an advert reaction. (Option 4) Constipation is a common side effect of benztropine. Due to the characteristic degreased mobility, PD can also cause constipation. The client should be instructed to increase dietary fiber intake and drink plenty of water. However, this is not the most concerning issue.
A client who is 24 hours postoperative bowel resection is receiving IV opioids PRN for severe pain. The nurse reviews the health care provider's prescription to discontinue the continuous IV normal saline. What is the nurse's MOST appropriate action? 1. Convert to a saline lock 2. Remove the IV catheter 3. Request a prescription for a saline lock 4. Slow the IV fluids to a keep-vein-open rate
Answer: (Option 1) The nurse should discontinue the IV infusion of normal saline and apply a saline lock to maintain IV access while preventing clotting. The prescription of the health care provider (HCP) to lock the IV catheter is implied, as the client is currently receiving PRN IV opioids. A saline lock is sufficient to maintain the line patency and allows greater mobility than continuous infusion. (Option 2) The client is only 24 hours postoperative abdominal surgery, so IV access is necessary to administer medications (eg, antibiotics, analgesics, antiemetics) (Option 2) The client is only 24 hours postoperative abdominal surgery, so IV access is necessary to administer medications (eg, antibiotics, analgesics, antiemetics) (Option 3 & 4) The HCP's prescription specifies discontinuing IV fluids but not removing the IV catheter or slowing the infusion to a keep-vein-open (KVO) rate. Also, the nurse would need to clarify a KVO prescription with the HCP for a precise rate.
The postpartum nurse receives report on 4 mother-baby couplets. Which tasks can be elevated to unlicensed assistive personnel? SELECT ALL THAT APPLY 1. Assisting the mother with morning hygiene 2. Demonstrating neonate bathing technique 3. Documenting intake and output on the mother 4. Evaluating caregiver interaction with the neonate 5. Obtaining an axillary temperature on the neonate 6. Swaddling the neonate after diaper changes
Answer: (Option 1, 3, 5 & 6) (Option 2) The RN assumes responsibility for initial client teaching and demonstration of home care. Once teaching and demonstration are complete, the UAP can assist the mother with bathing the neonate (Option 4) The RN should assess caregiver interaction with the newborn to identify any attachment issues. Elements of the nursing process (assessment, planning, and evaluation) and tasks requiring nursing judgment cannot be delegated Educational objective: The registered nurse is responsible for any care requiring clinical judgement. Unlicensed assistive personnel can assist with activities of daily living, documenting intake and output, positioning, and taking the vital signs of stable clients
The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies would the nurse include? SELECT ALL THAT APPLY 1. Choose foods that are low in fat 2. Do not consume any foods containing dairy 3. Eat three large meals a day and minimize snacking 4. Limit or eliminate the use of alcohol and tobacco 5. Try to avoid caffeine, chocolate, and peppermint
Answer: (Option 1, 4 & 5) Gastroesophageal reflux disease (GERD) occurs when chronic reflux of stomach contents causes inflammation of the esophageal mucosa. The lower esophageal sphincter (LES) normally prevents stomach contents from entering the esophagus. Any factor that decreases the tone of the LES (eg, caffeine, alcohol), delays gastric emptying (eg, fatty foods), or increases gastric pressure (eg, large meals) can precipitate GERD. Lifestyle and dietary measures that may prevent GERD and associated symptoms include: • Weight loss, as excessive abdominal fat may increase gastric pressure Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages *** • Chewing gum to promote salivation, which may help neutralize and clear acid from the esophagus • sleeping with the head of the bed elevated • Refraining from eating at bedtime and or lying down immediately after eating (Option 2) Clients with GERD generally do not need to minimize or eliminate dairy products from the diet; however, they should choose low-fat or nonfat products (Option 3) Small, frequent meals with sips of water or fluids to help facilitate the passage of stomach contents into the small intestine and prevent reflux from becoming overly full during meals
The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the 1following incidents does the nurse recognize as a violation of client confidentiality? SELECT ALL THAT APPLY 1. A visitor talking in the waiting room states that the client has alcoholism 2. The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home 3. The nursing assistant tells a client that the hospital roommate went for a gallbladder test 4. The registered nurse tells a visitor to wear a mask because the client is on isolation precautions 5. Two LPNs are discussing a possible cure for AIDS on a crowded elevator
Answer: (Option 2 & 3 ) The nurse is ethically and legally obligated to protect client's privacy and maintain confidentiality of their medical information. Clients' health information should be shared only with other health care team members directly involved in those client's care. Report sheets used by nursing staff often include clients's private health information and must be shredded at the end of the shift. Without the client' permission, information about the diagnosis or diagnostic tests cannot be shared with a hospital roommate. (Option 1) Health care staff are not required to censor visitor conversation in waiting rooms. (Option 4) Nurses are obligated to help protect visitors and others by instructing visitors to wear appropriate personal protective equipment. However, the nurse should not violate the client's privacy by sharing the client's diagnosis. (Option 5) Although discussion about specific client information is not permissible, general discussion about health care topics (eg, a potential cure for AIDS) is not a violation of clients' privacy.
The registered nurse is leading a support group for partners of military veterans suffering from post traumatic stress disorder (PTSD). A participant asks the nurse how to identify the typical symptoms of PTSD. The nurse responds that most individuals with PTSD report which symptoms? 1. Auditory hallucinations, feelings of paranoia, isolation from others 2. Increased anxiety, reliving the event, feeling detached from others 3. Rapidly changing emotions, delusions, lethargy 4. Recurring nightmares, uncontrollable anger, daytime sleepiness
Answer: (Option 2) Posttraumatic stress disorder (PTSD) is a reaction to a traumatic or catastrophic event that is typically life-threatening to oneself or others. There are 3 categories of PTSD symptoms: • Reexperiencing the traumatic event. Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (rapid, pounding heart; gastrointestinal distress; diaphoresis) • Avoiding reminders of the trauma. Examples include avoidance of activities, places, thoughts or other triggers that could be trauma reminders, feeling detached and emotionally numb, loss of interest in life, lack of future goals, and amnesia related to important details of the event. • Increased anxiety and emotional arousal. Examples include insomnia, irritability, outbursts of anger and/or rage, difficulty concentrating, hypervigilance, and feeling jumpy. (Option 1) Auditory hallucinations and feelings of paranoia are not characteristic symptoms of PTS. These are characteristic of schizophrenia. (Option 3) Rapidly changing emotions, delusions, and lethargy are not characteristics symptoms of PTSD. (Option 4) Daytime sleepiness is not characteristic of PTSD.
The registered nurse is caring for multiple clients on a medical-surgical unit and has finished the morning assessment. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel? 1. Apply a collagenase dressing to a client's pressure ulcer for wound debridement 2. Assist a client 1 day postoperative hip fracture repair to the bathroom 3. Feed a client through a gastrostomy tube after elevating the head of the bed 4. Offer orange juice to a client if the blood glucose level is <70 mg/dL (<3.9 mol/L)
Answer: (Option 2) The unlicensed assistive personnel (UAP) can assist clients out of bed or to the bathroom, assist which activities of daily living, and position clients. (Option 1) Debridement of a wound involves removing debris or dead tissue to convert contaminated wounds into clean wounds so that normal healing can take place. Dressing (eg, collagenase) changes for debridement require sterile technique; UAP can change dressings only for chronic wound using clean technique (Option 3) The UAP can elevate the head of the bed when a client receives enteral nutrition to prevent aspiration. However, feeding through a gastrostomy tube cannot be delegated to the UAP as it requires assessment of tube placement and aspiration of gastric residual volume (Option 4) Offering orange juice is an intervention for treating hypoglycemia that is outside the UAP's scope of practice. the UAP should report the blood glucose level to the RN so that the RN can first reassess the client for accompanying symptoms of hypoglycemia; these would require RN assessment and interpretation before intervention.
The nurse receives new prescriptions for a client with right lower quadrant pain and suspected acute appendicitis. Which prescription should the nurse implement FIRST? 1. Administer 0.25 mg hydromorphone IV push for pain 2. Draw blood for complete blood count and electrolyte levels 3. Initiate IV access and infuse normal saline 100 mL/hr 4. Obtain urine specimen for urinalysis
Answer: (Option 3) Appendicitis is inflammation of the appendix and often results from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation. As appendices intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendices perforation, a medical emergency, which may lead to peritonitis and sepsis. When prioritizing care of the client with appendicitis, the nurse should utilize the ABCs (ie, airway, breathing, circulation). Fluid resuscitation with IV crystalloids (eg, normal saline, lactated Ringer solution) is an important intervention aimed at preventing circulatory collapse resulting from fluid losses (eg, vomiting, diarrhea) and NPO status. (Option 1) Pain medications may be administered to promote comfort, but should be administered via IV route to maintain NPO status in case of emergency surgery. However, circulation takes priority over pain medication. (Option 2 & 4) Blood and urine samples often are prescribed to assist with treatment and care decisions. However, the nurse should prioritize circulatory status over obtaining laboratory specimens.
The nurse is caring for a client with sepsis and acute respiratory failure who was intubated and prescribed mechanical ventilation 3 days ago. The nurse assesses for which adverse effect associated with the administration of positive pressure ventilation (PPV)? 1. Dehydration 2. Hypokalemia 3. Hypotension 4. Increased cardiac output
Answer: (Option 3) Positive pressure ventilation (PPV) delivers positive pressure to the lungs using a mechanical ventilator (MV), either invasively through a tracheostomy or endotracheal tube or noninvasively through a nasal mask/facemask, nasal prongs, or a mouthpiece. The most common type used in the acute care setting for clients with acute respiratory failure is the volume cycled positive pressure MV, which delivers a preset volume and concentration of oxygen (eg, 21%-100%) with varying pressure. Positive pressure applied to the lungs compresses the thoracic vessels and increased intrathoracic pressure during inspiration. This leads to reduced venous return, ventricular preload, and cardiac output, which results in hypotension. The hypotensive effect of PPV is even greater in the presence of hypovolemia (eg, hemorrhage, hypovolemic shock) and decreased venous tone (eg, septic shock, neurogenic shock). (Option 1) Fluid and/or sodium retention usually occurs about 48-72 hours after initiation of PPV due to: • increased intrathroacic pressure and decreased cardiac output that stimulate the kidneys to release renin • physiologic stress that leads to the release of antidiuretic hormone and cortisol • breathing through the ventilator's closed circuitry, which decreases insensible loss associated with respiration (Option 2) Hypokalemia is not associated with PPV (Option 4) PPV increased intrathroacic pressure and reduces venous return to the right side of the heart, reducing preload and cardiac output as well.
The nurse is reinforcing teaching to the parent of a child diagnosed with ringworm. Which statement by the parent indicates a need for further teaching? 1. "Antifungal cream must be applied to all affected areas to eradicate ringworm from the body." 2. "Hand washing is very important as ringworm can be spread among humans and pets." 3. "My child has been infected by a worm and must be treated to rid it from the body." 4. "My child will be uncomfortable due to itching, but this is not a dangerous condition."
Answer: (Option 3) Ringworm, or tinea corporis, is a fungal infection on the superficial keratin layers of the skin, hair, nails. Ringworm is a misleading name as the condition is not caused by a worm infestation. However, it is highly contagious and spreads via contact with infected skin, shared surfaces, and personal items (eg, hair brushes). Management includes teaching appropriate hygiene (eg, washing hands after touching infected areas), limited contact with personal items (eg, hair brush), and treatment with the prescribed shampoos as well as topical and/or oral medications (eg, terbinafine [Lamisil], miconazole). (Option 1) Antifungal cream (terbinafine [Lamisil]) is the preferred treatment and is applied to infected areas twice a day. It may take 1-4 weeks to complete treatment depending on infection severity. (Option 2) Ringworm is spread via contact with shared surfaces (eg, bathroom floors, gymnasium mats, car seats), personal items, or pets. Important preventive measures include cleaning surfaces frequently, not sharing personal items, and practicing hand hygiene. (Option 4) This is not a dangerous condition; however, the client will be uncomfortable sure to itching. Efforts should be made to discourage scratching as this facilitates spread of infection.
The nurse provides discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder (ADHD). The nurse advises the parent that the child might experience which side effects? 1. Decreased blood pressure and growth delays 2. Heart palpitations and weight gain 3. Loss of appetite and restlessness 4. Trouble sleeping and a dry cough
Answer: (Option 3) Stimulant medications are commonly used to treat ADHD in children and adults. Methylphenidate (Ritalin) and amphetamines (eg, dextroamphetamine, lisdexmfetamine) are the most commonly used stimulants. The major problems with stimulant medications include: • Decreased appetite and weight loss - can lead to growth delays • Cardiovascular effects - hypertension and tachycardia (particularly in adults) • Appearance of new or exacerbation of vocal/motor tics • Excess brain stimulation - restlessness, insomnia • Abuse potential - misses, diversion, addiction (Option 1) Growth delays are a common side effect. The medications may cause hypertension, not hypotension (Option 2) Heart palpitations are a common side effect; weight loss, not weight gain, can be a problem (Option 4) Trouble sleeping is a common side effect, but the medications do not cause a dry cough
The nurse is preparing a symptoms management teaching plan for a client diagnosed with carpal tunnel syndrome. Which instruction is appropriate to include in the teaching plan? 1. Apply elastic compression hose to wrists 2. Avoid use of caffeinated or tobacco products 3. Perform repetitive hand exercises daily 4. Wear a wrist immobilization splint
Answer: (Option 4) Carpal tunnel syndrome (CTS) is pain and paresthesia of the hand caused by median nerve compression within the carpal tunnel at the wrist. Nerve compression can occur due to inflammation of the tendons; narrowing or compression of the carpal tunnel; or wrist flexion or extension. Symptoms of CTS are often exacerbated during sleep due to prolonged and unintentional wrest flexion. (Option 4) Most clients with CTS can conservatively manage symptoms with wrist immobilization splits. Splinting and immobilization of wrist (particularly during sleep) reduces pain by preventing flexion or extension and subsequent nerve compression. Clients with CTS may require surgery to permanently relieve symptoms. (Option 1 & 3) Instructing clients to perform receptive hand exercises or wear elastic compression hose could worsen symptoms of CTS by increasing median nerve compression (Option 2) Although educating clients to avoid tobacco and caffeinated products is appropriate to improve general health, avoidance of such substances does not impact symptoms of CTS
A nurse in the emergency department cares for 4 clients with orthopedic injuries. Which client should the nurse assess FIRST? 1. Client who sustained a closed, incomplete ulnar fracture while playing sports 2. Client with bilateral metacarpal fractures after falling out of bed 3. Client with multiple myeloma who has a vertebral fracture and aching back pain 4. Client with pain and obvious shoulder deformity reporting a "pins-and-needles" sensation
Answer: (Option 4) Joint dislocations may become orthopedic emergencies because articular bone may compress surrounding vasculature, causing limb-threatening distal ischemia. When a joint is dislocated, the articular tissues, blood vessels, and nerves are often traumatized by stretching. Prolonged disruption of the vasculature and nerves may cause permanent injury and even loss of the distal extremity. Signs of joint dislocation include pain, deformity, decreased range of motion, and extremity paresthesia. The nurse should frequently assess neurovascular status and provide analgesics until the dislocation can be reduced and immobilized. (Option 1) In incomplete greenstick fractures, the bone bends and cracks but remains in one piece. These fractures are most common in children, as their bones are soft and flexible. The nurse should provide analgesics and offer reassurance; however, the client with neurovascular impairment should be assessed first. (Option 2) Fractures of the bones of the hand (ie, metacarpals) are common in fall injuries, when the brunt of the fall is borne against the hands and fingers, resulting in hyper flexion or hyperextension. The nurse should provide analgesics; however, the client with neurovascular impairment should be assessed first. (Option 3) Pathologic vertebral compression fractures and pain are expected in clients with multiple myeloma. These clients commonly experience fractures of the vertebral column and spinal processes as the cancer weakens and decalcifies the vertebrae. This client should be evaluated next to rule out spinal cord involvement.
The nurse is teaching a class of expectant parents about infant safety. Which statement by a class participant indicates a need for further instruction? 1. "I will allow my baby to sleep with a pacifier." 2. "I will dress my baby in a sleep sack to prevent my baby from getting cold." 3. "I will make sure there is a firm mattress in the crib." 4. "I will tie bumper pads to the sides of the crib to protect my baby's head."
Answer: (Option 4) Sudden infant death syndrome (SIDS) is the leading cause of death among infant age 1 month to 1 year. Nurses should inform caregivers about childcare practices that reduce the rusk of SIDS, including: • Place infant on the back to sleep on a firm surface every time. Infants should not share a bed with anyone. • Avoid soft objects (eg, stuffed animals, pillows) in the infant's bed. Nothin in the ed with the infant is safest. • Avoid bumper pads for the crib. Newer cribs do not require bumper pads because improved side rails prevent the infant's head from getting stuck between slates *** • Maintain a smoke-free environment. • Avoid overheating. Infants do not require more than one extra layer than adults require to be comfortable. • Breastfeed and ensure immunization are updated. (Option 1) Using a pacifier during sleep is appropriate and has been associated with a reduced incidence of SIDS. Pacifiers should be delayed until after breastfeeding is well established. (Option 2) A sleeper "onesie" or a sleeping sack and a comfortable room temperature reduce the need for a blanket, which could obstruct the infant's mouth and/or nose. (Option 3) Infants should sleep on a firm surface or mattress that fits the crib and is covered with a fitted sheet.
