416 exam practice questions

Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early?

Laryngeal edema Laryngeal edema with severe acute upper airway obstruction may be life threatening in anaphylactic shock and requires rapid intervention. The reaction may also involve symptoms of irritability, cutaneous signs of urticaria, tachycardia, and increasing restlessness, but these are not as life threatening as laryngeal edema. Ensuring an open airway is priority.

The nurse is assessing the client admitted with diabetic ketoacidosis. Which statement made by the client indicates a need for further education on sick day management?

"I need to stop taking my insulin when I am ill because I am not eating." The diabetic client's metabolic needs will require the same amount of insulin and sometimes more when in a stressed state, including illness. The client checking the urine for ketones when blood sugar is over 250, drinking water and Gatorade, and continuing insulin indicate that the client has an understanding of the basic sick day rules.

The nurse is administering lactulose to a client with a history of cirrhosis of the liver. The client asks the nurse why this medication is needed because the client is not constipated. How will the nurse respond?

"This medication helps you lower the high ammonia level caused by your liver disease." Lactulose is a hyperosmotic laxative and ammonia detoxicant. It decreases serum ammonia concentration by preventing reabsorption of ammonia. Lactulose has been used to lower blood ammonia content in clients with portal hypertension and hepatic encephalopathy secondary to chronic liver disease. Lactulose has no effect on the craving for alcohol or anxiety and is not prescribed to reduce abdominal distension.

A client with type 1 diabetes receives regular insulin every morning at 8:00 AM. During what period of time does the nurse recognize the risk of hypoglycemia is greatest?

10:00 AM to 1:00 PM Regular insulin peaks in 2 to 5 hours; therefore the greatest risk is between 10:00 AM and 1:00 PM. Although the onset of action occurs earlier, during the period from 8:30 to 9:30 AM, the level is not yet at its highest, so the risk of hypoglycemia is not at its greatest. NPH insulin's peak action is 4 to 12 hours; if hypoglycemia occurs, it will happen most likely between midnight and 8 PM.

The nurse uses the rule of nines to estimate the percentage of the burn surface area on a client who has burns covering the entire surface of both arms, the posterior trunk, the genitals, and the entire left leg. What is the percentage of burn injury for this client? Record your answer as a whole number. ________%

55% The rule of nines is used to determine the body surface area (BSA) of a burn injury. The head accounts for 9%; each arm accounts for 9%; and the anterior torso, posterior torso, and each leg are 18% each. The genitals account for 1%. 9 + 9 + 18 + 1 + 18 = 55%.

A client is in cardiogenic shock. Which explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition?

A failure of the circulatory pump In cardiogenic shock, the failure of peripheral circulation is caused by the ineffective pumping action of the heart. Shock may have different etiologies (e.g., hypovolemic, cardiogenic, septic, anaphylactic) but always involves a drop in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Shock can be reversed by the administration of fluids, plasma expanders, and vasoconstrictors. It may be a reaction to tissue injury, but there are many different etiologies (e.g., hypovolemia, sepsis, anaphylaxis); it is not fleeting. Hypovolemia will lead to hypovolemic shock; cardiogenic refers to the heart capabilities.

Which assessment should the nurse obtain before administering digoxin to a client?

Apical heart rate Because digoxin slows the heart rate, the apical pulse should be counted for 1 minute before administration. If the apical rate is below a preset parameter (usually 60 beats/min), digoxin should be withheld because its administration may further decrease the heart rate. Some protocols permit waiting for one hour and retaking the apical rate; the result determines if it is administered or if the healthcare provider is notified. Obtaining the radial pulse on the left side is not as accurate as an apical pulse; the client also may have an atrial dysrhythmia, which cannot be detected through a radial rate alone. Obtaining the radial pulse in both right and left arms is not as accurate as an apical pulse; the client also may have an atrial dysrhythmia, which cannot be detected through a radial rate alone. Obtaining the difference between apical and radial pulses is a pulse deficit, not a pulse rate.Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options . Example: If the item relates to and identifies stroke rehabilitation as its focus and only one of the options contains the word stroke in relation to rehabilitation, you are safe in identifying this choice as the correct response.

Which action should be the nurse's first priority for a client with major burns?

Assessing airway patency The first action of the nurse for a client with major burns should be assessing airway patency because airway obstruction will lead to the death of the client. Other subsequently important actions of the nurse for the client should be assessment of the client from head to toe. The client should be administered oxygen according to need. The extremities should be elevated if there are no fractures.

During the discharge conference with a client who has had a hysterectomy the nurse includes instructions for avoiding the thromboembolic phenomena that may occur as a complication. What should these instructions include?

Avoid sitting for long periods of time. Sitting for long periods leads to pooling of blood in the pelvic area, predisposing the client to thrombus formation. Fluids should be increased to 3000 mL daily to decrease blood viscosity, which can lead to thrombus formation. Blood coagulation tests are not done routinely, because clotting elements are not usually disturbed by a hysterectomy. Hormone replacement therapy is not considered unless the client is premenopausal and an oophorectomy has been performed.

A nurse is caring for a 7-year-old child with severe burns who has extensive eschar formation on the arms. What is the priority nursing intervention?

Checking radial pulses The radial pulses are a reflection of how the child is adapting to the eschar formation. Eschar is rigid and may restrict circulation, leading to loss of perfusion to the limbs. Blisters are a protective adaptation and should not be disturbed. There is no information to indicate that the child has a respiratory infection. Although range-of-motion exercises are important, adequate arterial perfusion is the priority.

On the second day after sustaining extensive severe burns a 6-year-old child exhibits edema and decreased urine output. For which additional adverse response should the nurse assess the child in this early stage of burn injury?

Disorientation Disorientation may be an initial indication of dehydration or an early sign of hypoxia resulting from respiratory complications. Tachycardia, not bradycardia, is usually associated with the early phases of burn injury. A fever, not a subnormal temperature, is associated with burns because of the increased basal metabolic rate. The systolic blood pressure range for a 6-year-old child is 95 to 110 mm Hg.

What instructions should a nurse give a client for whom nitroglycerin tablets are prescribed?

Ensure that the medication is stored in its original dark container. Nitroglycerin is sensitive to light and moisture, so it must be stored in a dark, airtight container. Limit the number of tablets to four per day, taken as needed. If more than three tablets are necessary in a 15-minute period, emergency medical attention should be received. A headache may be an expected side effect, and the medication should not be discontinued. Dizziness indicates the dosage may need to be decreased by the healthcare provider.

The nurse is caring for a client with type 1 diabetes. Which signs or symptoms will indicate to the nurse that the client is experiencing hypoglycemia? Select all that apply.

Headache Diaphoresis Hypoglycemia affects the central nervous system, causing headache. Hypoglycemia affects the sympathetic nervous system, causing diaphoresis. Lethargy is associated with hyperglycemia because glucose is not being used for cellular metabolism. Excessive thirst is associated with hyperglycemia because fluid shifts, along with the excess glucose being excreted by the kidneys, result in polyuria. Deep respirations (Kussmaul respirations) are associated with hyperglycemia because the body is attempting to blow off carbon dioxide to compensate for the metabolic acidosis.

The nurse is caring for a client with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia (autonomic dysreflexia)?

Hypertension and bradycardia Hypertension and bradycardia occur as a result of exaggerated autonomic responses. If autonomic hyperreflexia is identified, immediate intervention is necessary to prevent serious complications. Paralysis is related to transection, not autonomic hyperreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs above the level of injury. Bradycardia occurs.

A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingling and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the cardiac monitor. What should the nurse conclude is causing these clinical findings?

Hypokalemia These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose. Clinical manifestations of hyponatremia include nausea, malaise, and changes in mental status. Clinical manifestations of hyperglycemia include weakness, dry skin, flushing, polyuria, and thirst. Clinical manifestations of hypercalcemia include lethargy, nausea, vomiting, paresthesias, and personality changes.

Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care?

Increased intracranial pressure Increased intracranial pressure is manifested by a sluggish pupillary reaction and elevation of the systolic blood pressure. Spinal shock is manifested by a decreased systolic blood pressure with no pupillary changes. Brain herniation is manifested by dilated pupils and severe posturing. Hypovolemic shock is indicated by a decrease in systolic pressure and tachycardia, with no changes in pupillary reaction.

The nurse is explaining insulin needs to a client with gestational diabetes who is in her second trimester of pregnancy. Which information should the nurse give to this client?

Insulin needs will increase during the second trimester The second trimester of pregnancy exerts a diabetogenic effect on the maternal metabolic status. Major hormonal changes result in decreased tolerance of glucose, increased insulin resistance, decreased hepatic glycogen stores, and increased hepatic production of glucose. Increasing levels of human chorionic somatomammotropin, estrogen, progesterone, prolactin, cortisol, and insulinase increase insulin resistance through their actions as insulin antagonists. Insulin resistance is a glucose-sparing mechanism that ensures an abundant supply of glucose for the fetus. Maternal insulin requirements gradually increase from about 18 to 24 weeks of gestation to about 36 weeks' gestation. The use of oral antidiabetes agents is currently not recommended by the American Diabetes Association for use during pregnancy.

A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop?

Metabolic acidosis Decreased oxygen increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Hyperkalemia will occur because of renal shutdown; hypokalemia can occur in early shock. Respiratory alkalosis can occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The Pco 2 level will increase in profound shock.

A client has a tonic-clonic seizure. Which is the priority nursing intervention during the tonic-clonic stage of the seizure?

Protect the client from injury Protecting the client from injury, together with observation and documentation of the seizure activity, is the primary nursing care for a client with a tonic-clonic seizure. The client should not be left unattended. Establishing a patent airway is done after the seizure; the mouth should not be pried open to insert an airway during a seizure because injury may occur. Turning the client on the side will assist with establishing an airway after the seizure, but it is an unsafe action during a seizure.

The nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which finding in the client is consistent with the diagnosis?

Retention of water SIADH is manifested in the form of retention of free water. This is because of excessive secretion of vasopressin causing reabsorption of water in renal tubules. There is hyponatremia and dilution of serum sodium in SIADH. Decreased vasopressin is seen in diabetes insipidus. Generally pedal (dependent) edema is not seen in SIADH despite the water retention.

A healthcare provider in the emergency department identifies that a client is in cardiogenic shock. Which type of drug does the nurse anticipate will be prescribed?

Sympathomimetic Sympathomimetics are vasopressors that induce arterial constriction, which increases venous return and cardiac output. Diuretics promote excretion of fluid, which is not indicated. Cardiac glycosides slow and strengthen the heartbeat; they do not increase the blood pressure and may decrease it. Alpha-adrenergic blockers decrease peripheral resistance, resulting in a decreased blood pressure.

A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock?

Thirst, cool skin, and orthostatic hypotension With hypovolemic shock, extravascular fluid depletion leads to thirst, peripheral vasoconstriction produces cool skin, and inadequate venous return leads to orthostatic hypotension. Although irritability may occur with hypovolemic shock, decreased blood flow to the kidney leads to oliguria; the temperature usually decreases with hypovolemic shock. Restlessness, not lethargy, occurs with hypovolemic shock; hypotension and cool skin are signs of hypovolemic shock. Although restlessness may occur with hypovolemic shock, the pulse is thready, not bounding; subtle changes in sensorium will not result in slurred speech.

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client's spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection in which direction?

To the client from outside sources Protective environment isolation implies that the activities and actions of the nurse will protect the client from infectious agents because the client's own immune defense ability is compromised (neutropenia). Protective environment isolation is also referred to as reverse isolation. "From the client to others," "From the client by using special techniques to destroy infectious fluids and secretions," and "To the client by using special sterilization techniques for linens and personal items" are incorrect concepts related to protective environment isolation.

A nurse is monitoring a 6-year-old child for toxicity precipitated by digoxin. For what sign of digoxin toxicity will the nurse assess the child?

Vomiting Vomiting is a sign of digoxin toxicity in children. Oliguria is associated with renal failure, not toxicity. Tachypnea is associated with heart failure, not toxicity. Splenomegaly is associated with heart failure, specifically right ventricular failure.

The nurse is caring for a client with diabetes mellitus who is scheduled to receive an intravenous (IV) administration of 25 units of insulin in 250 mL normal saline. What does the nurse recognize as the only type of insulin that is compatible with intravenous solutions?

regular insulin Regular insulin acts rapidly, is approved for IV administration, and is compatible with intravenous solutions. Insulin lispro is not compatible with intravenous solutions; it is a rapid-acting insulin. Insulin glargine is not compatible with intravenous solutions; it is a long-acting insulin. NPH insulin is not compatible with intravenous solutions; it is an intermediate-acting insulin.