BoardVital cluster #5
A nurse is providing nutritional teaching to the guardian of an infant who has heart failure. Which of the following guardian statements indicates an understanding of the teaching?
"I will add corn oil to my baby's bottles" -The guardian should add corn oil produced just for consumption by infants to fortify the formula by increasing the number of calories per ounce. This addition allows the infant to consume more calories in a smaller amount of formula.
A nurse is teaching a group of clients about stomatitis related to chemotherapy. Which of the following statements by a client indicates an understanding of the teaching?
"I will eat scrambled eggs and bananas for breakfast." -Foods such as scrambled eggs and bananas are nonirritating and soft; therefore, might be easily tolerated by a client who has stomatitis -Nutritional recommendations to manage stomatitis include eating cold foods, consuming soft or nonirritating foods, and adding gravies or sauces to increase fluid content.
A nurse is teaching a client who was admitted with preterm labor about terbutaline. Which of the following client statements indicates an understanding of the teaching?
"This medication is used to stop my contractions.?" -Terbutaline, a beta2-adrenergic agonist, is indicated in the suppression of preterm labor. -Adverse reactions: Nervousness, restlessness, headache, Pulmonary edema , Angina , hypertension, Hyperglycemia, Hypokalemia. -Nursing implications: Monitor maternal pulse and blood pressure, frequency and duration of contractions, fetal heart rate, symptoms of pulmonary edema, symptoms of hyperglycemia.
A nurse is providing teaching at a health fair about nutritional guidelines for the prevention of cancer. Which of the following instructions should the nurse include? (Select all that apply)
*"Eat foods that are high in vitamin A." *"Add nonstarchy vegetables to your diet." -Aside from nutritional guidelines, other lifestyle choices to reduce the risk of cancer include maintaining a healthy weight, smoking cessation, and avoiding sun exposure.
A nurse is reinforcing discharge teaching with a parent of a child who has HIV. Which of the following information should the nurse include? (Select all that apply.)
*"Ensure the child obtains a yearly influenza vaccination." *"Have your child avoid individuals who have colds." *"Provide nutritional supplements for your child." *"Administer acetaminophen if your child has pain." -There is no cure for HIV, only measures to lessen the severity of symptoms. Some common initial manifestations: fever, chills, muscle aches, swollen lymph nodes, weight loss, decreased appetite, oral candidiasis, failure to thrive, and diarrhea. Interventions for HIV: the administration of antiretroviral therapy, childhood immunizations, nutritional supplements, avoiding individuals who are sick, promptly calling the provider for acute illness, and administering a non-aspirin analgesic for pain relief.
A nurse is teaching a class in a wellness clinic about low-sodium diets and how they are used in the treatment of hypertension. Which of the following statements by an attendee indicates an understanding of the teaching? (Select all that apply).
*"I need to read food labels when grocery shopping." *"I know that deli meats are usually high in sodium." *"I can season food with herbs, lemon, or spices." -Following a low-sodium diet can decrease the client's risk for heart attack and stroke. The pt should consume no more than 1,500 mg of sodium per day, reducing sodium intake, such as reading food labels, consuming fresh or frozen fruits and vegetables, and using salt-free condiments.
A nurse is caring for a client who suspects that she is pregnant and has presumptive signs of pregnancy. Which of the following findings should the nurse expect the client to report? (Select all that apply.)
*Amenorrhea *Nausea and vomiting *Quickening -Quickening is a presumptive sign of pregnancy. Quickening is the sensation of fluttering movements or motions the client can feel.
A 24-year-old client comes to the emergency department with epistaxis. The nurse identifies which of the following interventions to help control the bleeding? (Select all that apply).
*Applying pressure for 10 minutes *Silver nitrate application *Electrocuterization -The first intervention for epistaxis is to hold pressure to the area for at least 10 minutes to control the bleeding. Additional interventions include an application of silver nitrate, Gelfoam packing, electrocautery, or vasoconstrictors. -Silver nitrate creates a mild chemical burn which seals the blood vessels and promotes scar tissue formation. -Electrocaterization uses electricity to heat the tissue to seal off the blood vessels.
Which of the following nursing behaviors promote interdisciplinary collaboration? (SELECT ALL THAT APPLY):
*Assertiveness *Good communication skills *Conflict negotiation skills *Decision making and critical thinking -Direct and actionable nursing behaviors are most successful in promoting interdisciplinary collaboration.
Assessment, problem identification, goal setting, implementation, and evaluation are the five core tenants of client care planning. Which of the following sequences illustrate these principles correctly, respectively. (Select all that apply):
*Data acquisition, compare data against norms, apply Maslow's hierarchy of needs, supportive measures to assist with client activities, and compare client's health status with goals and objectives *Direct observation of the client, seek client's point of view, communicate reasons for priorities, reinforce adaptive coping mechanisms, and implement continuous evaluation *Subjective data acquisition, identify cause of problem, institute objective goals, implement therapeutic measures, and question interventions based on goal outcomes *Objective evaluation, physical examination, construct measurable goals, coordinate care between healthcare team, and respond to continual monitoring of outcome achievement -these are the best answers to navigating the sequence of assessment, problem identification, goal setting, implementation, and evaluation successfully.
The nurse is learning about the Americans with Disabilities Act (ADA) passed in 1990. The nurse understands this is a civil rights legislation for disabled individuals that does which of the following? (Select all that apply).
*Grants individuals with disabilities fair access to job opportunities *Prohibits discrimination on the basis of disability in employment
A client has asked you to explain the MCH (mean cell hemoglobin) test to her. While you council her to ask the attending physician for details, which of the following is an appropriate answer? (SELECT ALL THAT APPLY):
*It measures % volume of hemoglobin per red blood cell and a value lower than the normal range suggests microcytic anemia *It measures the average mass of hemoglobin per red blood cell and an decreased score indicates hypochromic blood cell characteristics *It means the total mass of hemoglobin in a volume of blood divided by the number of red blood cells The MCH (mean cell hemoglobin) is the average mass of hemoglobin per red blood cell in a sample of blood. -MCH is a useful tool in the diagnosis of anemia, particularly iron-deficiency anemia.
myocardial infarction (MI)
*Occurs in the morning without any activity or apparent cause. *Pain lasts longer than 30 min and requires opioid analgesics for relief. -Other manifestations: Nausea, vomiting, diaphoresis, dysrhythmias, palpitations, anxiety, fatigue
Xui has been assigned as case manager in a large county hospital. Which of the following is in line with her duties and responsibilities? (SELECT ALL THAT APPLY):
*Oversee a caseload of clients with similar disorders or treatment regimens *Focus on managed care of the client through collaboration of the health care team in both inpatient and post-acute settings *Coordinate care provided by an interdisciplinary team -The case manager works to oversee client care, they focus on managed care and coordinate care by an interdisciplinary team.
A nurse is caring for a client who is pregnant and experiencing backaches. Which of the following measures should the nurse tell the client to take to help relieve backaches? (Select all that apply).
*Perform the pelvic rock exercise every day. *Position the knees higher than the hips when sitting.
A 66-year-old client with phagocytic cell disorder is admitted for enhanced care. The nurse caring knows that clients with this disorder are susceptible to which of the following conditions? (Select all that apply).
*Recurrent abscesses *Chronic eczema *Pneumonia -Phagocytic cell disorder is an inherited defect of the immune system. These clients often have recurrent bacterial infections that can involve the skin, respiratory tract, and lymph nodes. Clients with phagocytic cell disorders experience recurrent cutaneous abscesses, chronic eczema, bronchitis, pneumonia, chronic otitis media, and sinusitis.
A 73-year-old client has just been diagnosed with Parkinson's disease. Which of the following risks related to the Gl system should be included in the education for the patient and their family? (Select all that apply).
*Risk of aspiration *Risk of constipation *Risk of dysphagia *Risk of drooling -Common symptoms associated with Parkinson's disease include aspiration, choking, constipation, drooling, nausea, bloating, tremors, limb rigidity, gait and balance problems, sexual dysfunction, and dysphagia.
A 42-year-old female client was newly diagnosed with hypothyroidism and started on thyroid replacement therapy. What findings would indicate that the client is getting too much thyroid replacement, requiring a dose reduction? (Select all that apply).
*Tachycardia *Insomnia *Tremors -During the adjustment period, while the optimal dose is being determined, clients may experience symptoms of hyperthyroidism if they are getting too much thyroid replacement. Signs of this are increased metabolism, stimulation of the cardiovascular system resulting in tachycardia, hypertension, insomnia, and tremors.
The nurse can expect which of the following in a 23-year-old client who is diagnosed with food poisoning? (Select all that apply).
*Tachycardia *Lethargy *Delirium -In Food poisoning assess for signs and symptoms of fluid and electrolyte imbalances, including lethargy, tachycardia, fever, oliguria, anuria, hypotension, and delirium. -Tachycardia= if they are dehydrated due to diarrhea and vomiting. -Lethargy= due to the release of cytokines as the body tries to fight off the infection. -Delirium= confusion, and changes in mental status can be expected in severe cases of food poisoning.
Which of the following are elements of tier 1 of infection control? (Select all that apply.)
*Wearing gloves when coming in contact with blood or body fluids *Performing hand hygiene between client care encounters *Bagging contaminated laundry before removing it from the room -Precautions to prevent the spread of infection are classified into two tiers. -Tier 1 consists of standard precautions that should be used to prevent disease transmission during any client care encounter. Elements of standard precautions include wearing gloves when contacting potentially infectious blood or body fluids, bagging contaminated linen, and performing hand hygiene between clients. -Tier 2 consists of specific precautions against certain types of transmission, such as airborne or droplet precaution
A 62-year-old client is being discharged on warfarin (Coumadin) to prevent clotting from their underlying atrial fibrillation. What teaching topics should be offered for this client? (Select all that apply).
*When bruising is a concern *What to do if they see blood in urine or stool *The need for regular laboratory follow-up *Managing missed doses -Warfarin (Coumadin) is a potent orally administered anticoagulant often prescribed for clients with atrial fibrillation to prevent strokes. It works by blocking the production of active vitamin K, prolonging clotting time, and reducing clot formation. Clients should be sufficiently educated before being discharged on warfarin.
A client is admitted with rheumatoid arthritis. Which of the following signs should the nurse monitor in the client? (SELECT ALL THAT APPLY)
-Early morning pain and stiffness at joints -Elevated rheumatoid factor and erythrocyte sedimentation rate -Swelling at the joints
What are the immediate priority goals for a 24-year-old client admitted with a drug overdose? (Select all that apply).
-Stabilize respiratory function -Keep the client safe -Stabilize cardiac function -Help the client clear the toxic agent from the system -The immediate priority goals for a client with a drug overdose are to stabilize respiratory and cardiovascular function, help the client clear the toxic agent from the system, and ensure the client's safety. Education and counseling can be done after the client has been medically stabilized.
A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle?
1 1/2 1 1/2 inch is correct. A 1 1/2 inch needle is used for IM injections in adults. This length of needle is appropriate to use when administering an IM injection in the ventrogluteal muscle, which is a site commonly used for IM injections, in adults who have a BMI of 30.
The nurse is caring for a client who is 8 hours status-post forceps-assisted vaginal delivery with a 3rd-degree laceration and repair. The client reports pushing for 2 hours. The client has been unable to void since delivery and requires straight catheterization. The nurse is using a size ___ urinary catheter.
22 Fr -The size of the urinary catheter, the amount of fluid the catheter balloon can hold, and the size of the outer diameter in millimeters are found on the drainage port or channel. -Catheterization is used to empty the bladder when a client cannot void independently.
A 56-year-old client is receiving vancomycin (Vancocin). The provider has an order for a vancomycin trough level to be drawn. When should the nurse collect the blood sample?
30 minutes before the infusion -A vancomycin trough level should be drawn 30 minutes before the third or fourth dose of vancomycin.
A nurse is leading a group discussion about the risk factors of family and community violence. This nurse should include that which of the following clients has a risk factor for experiencing violence?
A 25-year-old female who is pregnant with her first child -The nurse should include pregnancy as a risk factor for partner violence. The patient's partner might resent the added responsibility of having a baby or be jealous of the relationship the mother has with the child.
A nurse is assigned to care for four clients. Which client should the nurse assess first?
A client on ventilator -The client on a ventilator is the highest actuity due to potential airway complications.
A nurse in a psychiatric clinic assesses four clients who have been taking lithium. Which of the following clients is most likely to need an adjustment in dosage?
A client who is training for a marathon. -A client who is training for a marathon most likely will require an adjustment in lithium dosage, because excessive sweating can increase the serum lithium level, possibly leading to toxicity. -The client should maintain stable, normal fluid and salt intake during therapy. Lithium is generally not recommended for clients with significant renal or cardiovascular disease, dehydration, or sodium depletion, due to risk of lithium toxicity.
A community health nurse is performing stroke risk screenings at a nearby health fair. Identification of high-risk individuals is the goal of these screenings. Which of the following individuals is at the highest risk for a stroke?
A male, age 60, with a history of uncontrolled hypertension -Uncontrolled hypertension is the primary cause of a stroke. A 60-year-old male with a history of uncontrolled hypertension is at the highest risk of stroke. The main risk factors for stroke are African American race, male sex, and over 55.
Which of the following is true concerning the procedure for venipuncture?
A tourniquet should be applied before choosing a vein. -Secure a tourniquet above the area where you plan to inject, and then select a vein. Cleanse the skin thoroughly per institutional protocol and insert the needle into the vein. After you observe return of blood into the catheter, syringe, or tubing, remove tourniquet and begin injection. If you are using a catheter, continue injecting until all contrast medium is injected, then disconnect the syringe and observe the area for swelling.
Which of the following body fluids is not considered potentially infectious? A. synovial fluid B. Blood C.Sputum D.A and C E. All of the above are considered potentially infectious.
All of the above are considered potentially infectious. -All body fluids are potentially infectious, including synovial fluid, blood, sputum, cerebrospinal fluid, vaginal secretions, tears, saliva and sputum, urine, feces, wound drainage, amniotic fluid, pleural fluid, peritoneal fluid, and pericardial fluid.
Which of the following decreases the risk of sleep-related deaths, including SIDS, in infants? A. Breastfeeding B. Age-appropriate immunization C. Discouraging the use of bumper pads in cribs D. Placing infants on their backs to sleep E. All of these
All of these -All of these actions have been shown to reduce the risk of sleep-related deaths in infants, including SIDS. Other actions to reduce risk include using a firm sleep surface, discouraging the use of pillows and the practice of co-sleeping, and avoiding exposure to tobacco smoke.
The nurse is collecting vital signs on an 18-month-old for a well-child physical. Where will the nurse obtain a pulse rate?
Apical pulse -For infants and children less than 2 years of age, obtaining an apical pulse is the more reliable method.
A nurse is reinforcing discharge teaching with a client who has cellulitis of the leg. Which of the following information should the nurse include in the teaching?
Apply warm compresses to the affected area. -The client should apply warm compresses to the affected area to promote comfort.
_________is defined as the threat of touching in an injurious way.
Assault -If a person feels threatened and is made to believe that he or she may be harmed, an assault charge can be justified.
A nurse in a clinic is caring for a client who has suspected uterine cancer. For which of the following procedures should the nurse prepare the client?
Bimanual pelvic examination -Due to the location of uterine cancer, the provider should perform a bimanual pelvic examination to assess for uterine size, shape, and contour, which can be altered by a mass. -Risk factors for uterine cancer: family history of uterine cancer, obesity, hypertension, diabetes mellitus, no pregnancies, late menopause, uterine polyps, and smoking.
A post-operative client has an NG tube following bowel surgery and has a temperature of 101.4. The physician has left orders that read "Acetaminophen 650 PRN for fever above 101." What is the most appropriate action for the nurse to take?
Call the physician and question the order -The order is incomplete. It does not specify the route of administration, the dosage units (mg) are not specified and the frequency of administration is not specified. The order must be clarified before the medication can be administered.
What is the most common cause of death in the United States?
Cardiovascular illnesses -Cardiovascular disease is the most common cause of death in the United States, but up to 80% of these deaths are preventable. Risk factors for cardiovascular disease that can be modified include consumption of a diet high in fat, lack of physical activity and smoking.
A 71-year-old client has a stage Ill pressure wound. What would be the best meal to choose for this client?
Chicken, baked potato, spinach -This choice has the right balance of protein, carbohydrates, and vitamins, which is needed for healing and recovery.
A 9 month old child weighs 20 Ibs. and has sustained a fracture of the right femur. The client is admitted and placed in Bryant's traction. The nurse knows that this type of traction is:
Continuous, skin -Bryant's traction is skin traction applied to both legs to minimize potential trauma to the affected leg while maintaining appropriate position of bone fragments.
The nurse encourages a client with a wound to take a diet rich in vitamin C. The nurse should know that this it is to:
Enhance collagen formation -Vitamin C is essential for collagen formation which is needed in wound healing.
A 46-year-old client at the clinic is reporting joint stiffness and occasional pain. Which of the following laboratory values would be the best diagnostic test for rheumatoid arthritis?
Erythrocyte sedimentation rate (ESR) -Erythrocyte sedimentation rate (ESR) is a nonspecific test for inflammation in the body. If elevated, it can indicate the presence of an inflammatory disease such as rheumatoid arthritis. It can also indicate the presence of an infection, a tumor, lupus, or other autoimmune diseases.
A 67-year-old client was treated for cellulitis of the lower extremities, and the nurse is now planning for his discharge to a rehabilitation facility. The nurse documents that the client is pain-free, without redness or edema. Which step of the nursing process does this reflect?
Evaluation -Evaluation, the final step of the nursing process, allows the nurse to determine the client's response to the nursing interventions and the extent to which the objectives have been achieved. As the nurse plans for the client's discharge, they are documenting the client's status after all interventions have been performed, which is part of the evaluation phase.
The primary risk for oral cancer is:
Excessive alcohol -Abuse of alcohol and tobacco are the leading causes of oral cancer.
A pregnant client with known HIV infection is admitted to the hospital in active labor. Which method for assessing the fetus is most appropriate for the nurse to perform at this time?
External fetal monitoring -External fetal monitoring minimizes the risk of exposing the fetus to the mother's HIV infected blood. External monitoring is the only non-invasive option listed.
The parents of a 3 month old child should include which of the following foods in the child's diet:
Formula or breast milk only -A 3-month-old infant should not receive whole milk. They should receive breast milk or formula only. Whole milk is very hard for an infant to digest. A pediatrician will usually allow cereal fortified with nutrients at the age of 4-6 months.
A 56-year-old client with a peptic ulcer has asked the nurse for help in selecting their dinner menu. Which beverage would be most appropriate for this client?
Grape juice -Orange juice is very acidic and can stimulate gastric acid secretion. Grape juice is the least likely to cause irritation in a client with a peptic ulcer out of all the options.
A client is on Coumadin therapy. Which of the following is the primary concern for the client?
Hemorrhage -Bleeding is the primary concern for the client taking anticoagulants. -Those who take Coumadin are at risk for bleeding.
A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first?
Inspection Inspection is correct. Inspection should be performed first while conducting an abdominal assessment on a client. Inspection allows the nurse to note the contour and symmetry of the abdomen.
The nurse is working in a clinic when a client is brought in with an acute asthma attack. The nurse knows that immediate treatment is needed when the client has:
Intercostal retractions -Intercostal retractions are an ominous sign in asthma and should be investigated and treated immediately.
A school nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test?
Intradermal injection -The Mantoux test (the purified protein derivative [PPD] or tuberculin skin test [TST]), is a screening tool for tuberculosis. It is injected into the intradermal layer of the ventral surface of the forearm. The injection site should be observed for induration 48-72 hours after administration.
Which of the following routes of administration is used for contrast agents when demonstration of the spinal canal is desired?
Intrathecal -it is the most appropriate modality of administration for contrast agents when demonstration of the spinal canal is indicated. -Intradermal refers to placement of the needle between layers of the skin.
The attending physician has requested a PT (prothrombin time) and has asked you to counsel the patient's spouse on the procedure. The client's PT findings are >80 seconds. How do vou explain the test?
It is a measure of clotting ability and the client's clotting time is abnormally extended -Under normal circumstances, blood clotting should occur in less than 15 seconds. The clotting time of 80 seconds is abnormal and reflects a defect in clotting factors or platelet deficiency in the count.
Anthralin is prescribed for a client with psoriasis. Which of the following information given by the nurse is incorrect? A. It can cause localirritation B. It should be applied at bed time C. It can stain clothing D. It is a vitamin A derivative
It is a vitamin A derivative -Anthralin is not a vitamin A derivative.
A student nurse develops hives and redness the first time she uses latex gloves on her initial clinical rotation. Which of the following precautions should be taken?
Latex items used by the student nurse should be replaced with latex-free items. -Type I latex allergies cause a range of symptoms, from redness, urticaria, and wheezing to anaphylactic shock. Symptoms of Type I latex allergies usually appear within minutes of exposure, although they can occur hours later. Individuals with symptoms of latex allergy should avoid all contact with latex products.
A client on assisted ventilation develops a right tension pneumothorax. Which of the following is associated with a right sided tension pneumothorax?
Left sided tracheal deviation -A pneumothorax results in tracheal deviation toward the unaffected side. -As pressure builds inside the right chest as a result of the tension pneumothorax the chest anatomy will be pushed to the left side.
A 43-year-old client is being treated for gout in the outpatient clinic. The client has been advised to follow a low purine diet. However, the nurse knows the client needs further teaching if he chose which of the following foods to eat regularly?
Liver -Liver and organ meats are high in purines and should be avoided for clients with gout. -Uric acid forms as a waste product when purine is broken down. Gout is an inflammatory disorder that affects the joints when there is too much uric acid in the body, and therefore foods high in purines should be avoided. Foods high in purines include organ meats (e.g., liver, kidneys), some kinds of seafood, and alcohol.
A nurse is caring for a client who has leukemia and thrombocytopenia. Which of the following actions is the nurse's priority?
Monitor the client's platelet counts -Platelets are essential for blood clotting. Thrombocytopenia is a decrease in the amount of platelets circulating in the bloodstream. The greatest risk to a client who has thrombocytopenia is injury due to bleeding. The priority action for the nurse to take is to initiate bleeding precautions, such as monitoring platelet count. -The expected reference range for platelets is 150,000 to 450,000/mm3. Clients are at an increased risk for bleeding once platelets drop below 100,000/mm3.
Drugs which dilate the pupil are called:
Mydriatics -Mydriactics are sometimes used to dilate the pupil so the contents of the interior eye can be examined. -Miotics contract the pupil
A nurse is preparing to administer a unit of blood to a client. While checking the vital signs, the nurse identifies elevated body temperature. What should be the nurse's initial action?
Notify the physician -If the client's temperature is elevated, notify the physician before beginning the transfusion; a fever may be cause for delaying the transfusion in addition to masking a possible symptom of a transfusion reaction.
The nurse is assessing a new client in the clinic. The 32-year-old female weighs 175 pounds and is 5 feet 3 inches tall. Her body mass index (BMI) is 31. How should this patient's BMI be categorized based on this data?
Obese -A BMI of 31 is considered obese.
A nurse is working in a large factory that makes wholesale furniture products. The nurse manages clients who have work-related injuries or illnesses. What is the role of this nurse?
Occupational health nurse -Occupational health nurses provide direct care to clients in their workplace who are ill or injured while at work; they also conduct programs and screenings for the safety of the staff.
What is negligence?
Omission of reasonable care -The omission of reasonable care or caution is considered negligence. This is under the "doctrine of the reasonable prudent person" where a person must perform as any reasonable person under similar circumstances.
The 1 year old child looks for objects that have been hidden from her. The nurse knows that this action demonstrates the concept of:
Permanence -By 12 months of age, a 1-year-old has developed the concept of object permanence and will look for objects that are suddenly hidden from her. Development of grasp, curiosity and transferring objects from one hand to the other are not related to the concept of object permanence.
A nurse is caring for a 37-year-old client who was admitted for a seizure. The client is confused after having the seizure. In which stage of a seizure is this client?
Postictal stage -The postictal stage of a seizure is the recovery period following a seizure until the client has returned to baseline. This stage can last anywhere from a few minutes to a few days for some clients. This phase includes a period of confusion, drowsiness, and memory loss. -The prodromal stage of a seizure is before the seizure, which can be a few hours or even days before the seizure starts. -The aura stage is considered the early part of the seizure. -The ictal stage or the middle stage is the active stage of the seizure, from the first symptom onset to the end of the seizure activity.
Which of the following best describes a nurse who collaborates with a client directly to create and implement the plan of care?
Primary Nurse -A primary nurse oversees the client's care, including client assessment, implementation of the care plan, and evaluation of the client's progress in light of the care given. The primary nurse role is based upon responsibility, accountability and authority.
A nurse is contributing to the plan of care for a client who has hepatitis B with jaundice. Which of the following interventions should the nurse recommend?
Provide a high-calorie, high-protein diet. -Pt's with hepatitis are at increased risk for inadequate nutrition due to nausea, vomiting, anorexia, and fatigue. During periods of nausea and vomiting, IV fluids might be required to ensure adequate fluid balance is maintained. When the client is able to tolerate an oral diet, small, frequent meals that are high in calories and protein are recommended to maintain muscle mass. Between meal supplements and multiple vitamins might be needed to ensure adequate nutrition is achieved.
A "Swan Ganz catheter" refers to which of the following?
Pulmonary Artery catheter -A Swan Ganz catheter is a pulmonary artery catheter that is used to introduce medications and IV fluids, to obtain pressure readings, and to measure the ability of the heart to pump blood. When checking for correct placement of a Swan-Ganz catheter, a chest X-ray may be overexposed to show the tip of the Swan-Ganz catheter overlying the cardiac silhouette.
Two nurses are discussing a client's plan of care during hand-off report at the change of shift. They are following the SBAR technique to ensure accuracy of communication and to avoid missing pertinent data. The R in SBAR stands for:
Recommendations S= situation B= background A= assessment R= recommendations. During this type of report, after giving essential information about the client's background and the work done during the shift, the nurse should then provide recommendations for further client care during the next shift.
A friend shares with a nurse about being engaged to be married. The nurse knows that the friend's fiance has tested positive for HIV. What is the nurse's legal obligation?
Safeguard information in the fiancé's history of health -The nurse has an ethical and legal responsibility to protect the confidentiality of the person who tested positive for HIV.
The practical nurse is working in a gynecologist's office. The nurse knows that a Pap smear:
Should be done beginning at age 21 unless otherwise indicated. -The National Cancer Institute recommends that Pap smears be performed beginning at age 21 unless symptoms occur sooner. After the age of 21, a Pap smear should be done as medically indicated.
A mother asks the nurse what toy might be appropriate for her 4 month old child. The nurse knows that the most appropriate toy would be:
Soft, washable toys -If an infant can lift an object, it will go into his mouth. Therefore, it is important that his toys are soft and washable.
A nurse is teaching a client about a new prescription for nitroglycerin sublingual tablets. Part of the nurse's teaching will include which of the following instructions?
Store the medication in a dark container -Nitroglycerin is sensitive to moisture and to light and should be kept in a dark, airtight container. -Nitroglycerin spray and sublingual tablets are prescribed PRN and used to stop an episode of angina or to prevent angina when taken before exertion.
A 33-year-old client comes to the obstetric clinic suspected of being pregnant after one missed period. She states she currently has twin boys that were delivered normally at 39 weeks. She has not had any abortions or stillbirths. According to the TPAL method, which of the following correctly shows the client's obstetric history?
T-1, P-0, A-O, L-2. -This client has had one term pregnancy (with twins), so the would be 1. -The L represents the number of living children, so for this client, it would be 2
A 55-year old client is currently being treated with albuterol for an acute asthma episode. You notice the client's breathing and pulse rate have increased dramatically. Which of the following adverse effects is most likely occurring? A. Tinnitus B. Tachycardia C. Dyspnea D. Dysphasia
Tachycardia -Tachycardia is a common side effect of albuterol.
Manifestations of Heart Failure:
Tachycardia Restlessness Dyspnea Nasal flaring Wheezing Grunting Weight gain Distended neck veins Cool, pale extremities Periorbital edema Decreased urine output
A client underwent transurethral resection of prostate and has a triple lumen indwelling catheter and is on continuous bladder irrigation. The nurse notes that 1000 mL of fluid was instilled and 600mL returned. The nurse should understand that:
The catheter is occluded -The output is less than the instilled amount of fluid, which indicates occlusion of the catheter.
The wound care nurse is caring for a 37-year-old client on the third postoperative day following a colostomy (see image). While changing the dressing, the wound care nurse notes that the stoma is dusky in color. What does the nurse suspect is the reason for this finding?
The circulation to the stoma has been compromised -A dusky-colored stoma indicates the circulation to the stoma has been compromised. A healthy stoma should be pink to beefy red and should look moist. -Ischemia or necrosis that is deeper, the stoma may even become black, and urgent surgical intervention may be needed.
A 42-year-old client came to a clinic to get a general allergy and sensitivity test. Under which circumstances would the nurse have to cancel the test?
The client is currently taking corticosteroids -The nurse should reschedule the test if the client is taking corticosteroids because this could result in false-negative results; corticosteroids suppress the immune system response and affect the allergy sensitivity and reactivity results.
A nurse prepared morning medications for his clients and then was called off the unit for an emergency before he was able to administer them. Who may administer the medications to the clients now?
The nurse who prepared the medications -The guidelines for safe administration of medications state that medications prepared by one nurse can be administered only by that nurse.
A nurse is reviewing the laboratory values of a client who has severe hyperemesis gravidarum. Which of the following laboratory findings should the nurse identify as a manifestation of this condition?
Urine ketones present -Clients who have hyperemesis gravidarum are unable to digest nutritious foods and the body will start using fat stores as a fuel. This results in ketosis, causing the client's urine to have high levels of ketones present. -Manifestations of hyperemesis gravidarum include weight loss, dehydration, nausea, vomiting, dry mucous membranes, and decrease skin turgor. -Nursing measures are focused on restoring fluid balance: observing for signs of metabolic acidosis due to hypovolemia or metabolic alkalosis due to loss of gastric secretions
A nurse is caring for a client with COPD who has a prescription for a precise oxygen concentration. Which of the following is the best oxygen delivery system for this client?
Venturi mask -is the best method for a client with chronic airflow limitations. It is a high-flow delivery device that delivers a precise concentration of oxygen despite client variations in respiratory rate, depth, or tidal volume. The Venturi mask can deliver up to 50% Fi02 (concentration of oxygen), depending on the device.
A nurse is assessing a newly admitted client who reports numbness in the distal extremities and ataxia for the past 3 weeks. Which nutritional deficiency could be the cause of the client's symptoms?
Vitamin B12 -Numbness and tingling of the hands and feet are neurologic manifestations associated with vitamin B12 deficiency.
A nurse is reviewing the charts of multiple clients at a community mental health facility. Which of the following events is an example of client experiencing an adventitious crisis?
Workplace violence -Workplace violence is an example of an adventitious crisis. It is not a part of everyday life.
What is stomatitis?
inflammation of the oral mucosa, which presents with ulcers that can cause pain and difficulty drinking and eating
Hypercapnia:
is usually the stimulus for increased respiration. -Clients with COPD have chronic hypercapnia and reduced sensitivity to this stimulus. In these clients, hypoxia is the stimulus for respiratory drive. Excess supplemental oxygen should be avoided in clients with COPD, since it depresses their respiratory drive, which further increases CO2 levels. A Venturi mask is the appropriate non-invasive device for delivery of supplemental oxygen to clients with COPD.
Where are Herberden's nodes seen in. osteoarthritis or rheumatoid arthritis?
osteoarthritis -Heberden's nodes are seen in osteoarthritis not rheumatoid arthritis. Heberden's nodes are located in the joint nearest the tip of the finger.
