Exam #2 Test Review

A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L (5.8 mmol/l). What should be the nurse's first response? a) Make a note on the front of the chart. b) Notify the anesthesiologist. c) Call the surgeon. d) Send the client to surgery.

The nurse should notify the anesthesiologist because a serum potassium level of 5.8 mEq/L (5.8 mmol/L) places the client at risk for arrhythmias when under general anesthesia.

Which of the following adverse effects occur when there is too rapid an infusion of TPN solution? a) Hypoglycemia. b) Negative nitrogen balance. c) Hypokalemia. d) Circulatory overload.

d) Circulatory overload

The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the following should be the nurse's first step in planning the dietary instructions? a) Explaining the importance of complying with the diet. b) Asking the client to name foods that are high in fat, cholesterol, and salt. c) Assessing the client's and family's typical food preferences. d) Determining the client's knowledge level about cholesterol.

c)

A child undergoes rehydration therapy after having diarrhea and dehydration. A nurse is teaching the child's parents about dietary management. The nurse understands that the teaching plan has been successful when the parents tell the nurse that they will follow which type of diet? a) Soft. b) Regular. c) Full liquid. d) Clear liquid.

b)

When teaching a mother about measures to prevent lead poisoning in her children, which of the following preventive measures should the nurse include as the most effective? a) Educating the public on the importance of good nutrition. b) Educating the public on common sources of lead. c) Keeping pregnant women out of old homes that are being remodeled. d) Condemning of old housing developments

b)

A nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by the mother indicates understanding? a) "My son can safely eat frozen and packaged foods." b) "My son can't eat wheat, rye, oats, or barley." c) "My son must avoid potatoes, rice, and cornstarch." d) "My son needs a gluten-rich diet."

b) A child with celiac disease must follow a gluten-free diet. If the child eats foods containing gluten, changes in the intestinal mucosa will prevent the absorption of fats and other foods. Therefore, all foods containing wheat, rye, oats, and barley must be eliminated from the diet. Such foods as potatoes, rice, and cornstarch may be included in a gluten-free diet. Frozen and packaged foods, which may contain gluten fillers, should be avoided

To help minimize calcium loss from a hospitalized client's bones, the nurse should: a) provide the client dairy products at frequent intervals. b) encourage the client to walk in the hall. c) provide supplemental feedings between meals. d) reposition the client every 2 hours.

b) Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity, such as by walking in the hall, helps minimize calcium loss.Providing dairy products and supplemental feedings wouldn't lessen calcium loss — even if the dairy products and feedings contained extra calcium — because the additional calcium doesn't increase bone stimulation or osteoblast activity.

Which of the following interventions would be the most appropriate for preventing the development of a paralytic ileus in a client who has undergone renal surgery? a) Encourage the client to ambulate every 2 to 4 hours. b) Encourage use of a stool softener. c) Offer 3 to 4 oz (90 to 120 mL) of a carbonated beverage periodically. d) Continue I.V. fluid therapy.

a) Ambulation stimulates peristalsis. A client with paralytic ileus is kept on nothing-by-mouth status until peristalsis returns. Carbonated beverages will increase gas and distention but will not stimulate peristalsis. A stool softener will not stimulate peristalsis. I.V. fluid infusion is a routine postoperative order that does not have any effect on preventing paralytic ileus.

A nurse assists in writing a community plan for responding to a bioterrorism threat or attack. When reviewing the plan, the director of emergency operations should have the nurse correct which intervention? a) All personnel should wear protective clothing, including a gown, gloves, and respiratory protection. b) Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper. c) Clients should be instructed to wash thoroughly with soap and water. d) Access to the area should be restricted.

a) Read the question.

Which activity would be appropriate to delegate to unlicensed personnel for a client diagnosed with a myocardial infarction who is stable? a) Help the client identify risk factors for CAD. b) Evaluate the lung sounds. c) Record the intake and output. d) Provide teaching on a 2 gram sodium diet.

c) Read the question

A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad? a) Client's risk for falls b) Client's nutritional status c) Client's vital signs and breath sounds d) Client's level of consciousness

d)

Which client is at increased risk for developing a wound infection? a) A client that does not ambulate on first post-op day. b) A client with a body mass index (BMI) of 27. c) A client with a hemoglobin of 11.4. d) A client with an albumin level of 2.4.

d) A client not ambulating post-op day one is at greater risk of deep vein thrombosis and pneumonia. Albumin less than 3 is bad.

Which of the following indicate that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful? a) Prevention of bone demineralization. b) Increase in muscle tone. c) Preservation of muscle mass. d) Maintenance of joint mobility.

d) Maintenance of joint mobility.

A physician orders a bland, full-liquid diet for a client. Which response, if made by the client, would indicate to the nurse that the client has understood the nurse's dietary teaching? a) "For breakfast I will choose pineapple juice, a bran muffin, and milk." b) "I can have oatmeal, custard, and tea." c) "I will have orange juice, farina, and coffee." d) "Today I can have apple juice, chicken broth, and vanilla ice cream."

d) Tea is an irritant.

A client has been taking furosemide (Lasix) for 2 days. The nurse should assess the client for: a) An elevated potassium level. b) An elevated blood urea nitrogen (BUN) level. c) An elevated sodium level. d) A decreased potassium level.

d)

A nurse implements a teaching plan for a client who's scheduled for discharge. Which client behavior best demonstrates effective teaching? a) Verbally repeating the instruction b) Making statements indicating understanding c) Exhibiting nonverbal signs such as nodding the head to indicate "yes" d) Exhibiting a positive change in behavior

d)

The unconscious client is to be placed in a right side-lying position. The nurse should intervene when observing a client in which of the following positions? a) The head is placed on a small pillow. b) The left leg is supported on a pillow with the knee flexed. c) The left arm is rested on the mattress with the elbow flexed. d) The right leg is extended without pillow support.

b) Read the questions. The client is not in proper body alignment if, when in the right side-lying position, the client's left arm rests on the mattress with the elbow flexed. This positioning of the arm pulls the left shoulder out of good alignment, restricting respiratory movements. The arm should be supported on a pillow. The client's head also should be placed on a small pillow to keep it in alignment with the body. The right leg should be extended on the mattress without a pillow to avoid hyperrotation of the hip. A pillow should be placed between the left and right legs with the left knee flexed so that on no parts of the legs is skin touching skin.

When preparing to administer a tap water enema, in which position should the nurse place the client? a) Right lateral. b) Left Sims. c) Semi-Fowler's. d) Supine.

b) When administering an enema, the nurse should position the client in a left Sims position. Placing the client in this position facilitates the flow of fluid into the rectum and colon. It also allows the client to flex the right leg forward, adequately exposing the rectal area.

A nurse is preparing to help a client with weakness in his right leg move from his bed to a chair. Where should the nurse place the chair? a) Parallel to the bed on the left side b) Perpendicular to the bed on the right side c) Parallel to the bed on the right side d) Parallel to the bed on either side

c)

A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which action should the nurse take? a) Start cardiopulmonary resuscitation. b) Stop the feeding and remove the NG tube as specified in the client's living will. c) Make the client comfortable as specified in the client's living will. d) Clear the client's airway.

d)

The managers of the physical and occupational therapy neurologic departments tell a nurse-manager of an adult neurologic rehabilitation unit that they're concerned that clients have been arriving late for therapy. In response, the nursing staff of the rehabilitation unit complains that therapy schedules don't allow sufficient time for performing nursing interventions. Which action by the nurse-manager is the best solution to this problem? a) Meet with physical and occupational therapy managers to identify scheduling solutions. b) Meet with the managers of physical and occupational therapy and determine how to reschedule clients; then inform the nursing staff. c) Ask several staff nurses to work with the therapy staff to help solve the scheduling problem and offer herself as a resource. d) Tell the nursing staff that nurses need to determine how to transport clients to therapy according to the schedules developed by the therapists.

c)

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a significant small and large bowel resection and is currently not taking anything by mouth. The nurse should: a) Designate a peripheral intravenous (IV) site for TPN administration. b) Administer TPN through a nasogastric or gastrostomy tube. c) Auscultate for bowel sounds prior to administering TPN. d) Handle TPN using strict aseptic technique.

d) TPN is hypertonic, high-calorie, high-protein, intravenous (IV) fluid that should be provided to clients without functional gastrointestinal tract motility, to better meet their metabolic needs and to support optimal nutrition and healing. TPN is ordered once daily, based on the client's current electrolyte and fluid balance, and must be handled with strict aseptic technique (because of its high glucose content, it is a perfect medium for bacterial growth). Also, because of the high tonicity, TPN must be administered through a central venous access, not a peripheral IV line. There is no specific need to auscultate for bowel sounds to determine whether TPN can safely be administered.

A nurse caring for a client with a fecal impaction should watch for: a) liquid or semiliquid stools. b) increased appetite. c) loss of urge to defecate. d) hard, brown, formed stools.

a)

The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate? a) Clean the eyelid with a washcloth every shift. b) Lightly tape the eyelid shut. c) Have the client wear eyeglasses at all times. d) Instill artificial tears once every shift.

b)

A client admitted to the mental health unit has exhibited physical behaviors that put him and others at risk. The nurse applies four-point restraints on the client without obtaining a physician's order or the client's consent. The nurse is at risk of being accused of which of the following? a) False imprisonment b) Malpractice c) Negligence d) Battery

d)

As the nurse assists the postoperative client out of bed, the client reports having gas pains in the abdomen. Which of the following is the most effective nursing intervention to relieve this discomfort? a) Encourage the client to ambulate. b) Insert a nasogastric (NG) tube. c) Insert a rectal tube. d) Encourage the client to drink carbonated liquids.

a)

When assessing a female adolescent for scoliosis, what should the nurse ask the client to do? a) Bend forward at the waist with arms hanging freely. b) Sit in a chair while lifting her feet and legs to a right angle with the trunk. c) Lie flat on the floor and extend her legs straight from the trunk. d) Stand against a wall while pressing the length of her back against the wall.

a)

Which nursing intervention is appropriate for a client with an arm restraint? a) Monitoring circulatory status every 2 hours b) Tying the restraint to the side rail c) Positioning the restrained arm in full extension d) Applying the restraint loosely to prevent pressure on the skin

a)

Which of the following should the nurse include in the plan of care to ensure adequate nutrition for a very active, talkative, and easily distractible client who is unable to sit through meals? a) Offer the client nutritious finger foods. b) Ask the client's family to bring his favorite foods from home. c) Ask the client about food preferences. d) Direct the client to the room to eat.

a)

Prior to going to surgery, the client tells the nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response? a) Tell the client that she will bring the hearing aid to the postanesthesia care unit so that she can have it as soon as she wakes up. b) Call the surgery unit to explain the client's concern and ask if she can wear her hearing aid to surgery. c) Explain to the client that she will have a premedication that will make her sleepy before she goes to surgery and she won't need to hear. d) Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken.

b)

Sodium polystyrene sulfonate (Kayexalate) is prescribed for a client following crush injury. The drug is effective if: a) The ECG is showing tall peaked T waves. b) The pulse is weak and irregular. c) There is muscle weakness on physical examination. d) The serum potassium is 4.0 meq/liter (4/0 mmol/l).

b)

The nurse should instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? a) Green leafy vegetables. b) Meats and dairy products. c) Broccoli and brussels sprouts. d) Whole grains.

b) Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green, leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Broccoli and brussels sprouts are good sources of ascorbic acid (vitamin C).

A nurse is teaching a client with left leg weakness to walk with a cane. The nurse should instruct the client to proceed in which manner? a) Hold the cane on the left side 4 inches to 6 inches from the base of the little toe. b) Hold the cane in the right hand. c) Hold the cane away from the body. d) Move the cane and the right leg simultaneously.

b) To ambulate safely, a client with a leg weakness should hold the cane in the hand opposite the weak leg 4 inches to 6 inches from the base of the little toe. Therefore, this client should hold the cane in his right hand. The client should hold the cane close to his body to prevent leaning and he should move the cane and the involved leg (left, in this case) simultaneously, and then move the uninvolved leg.

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? a) Imbalanced nutrition: Less than body requirements b) Deficient fluid volume c) Impaired urinary elimination d) Excess fluid volume

b) Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema.

Which of the following instructions should be given to the client prior to placement of an epidural/intrathecal catheter? Select all that apply. a) Report nausea, vomiting, itching, numbness, or weakness in legs. b) Call for assistance with turning or re-positioning while in bed. c) Take shallow breaths to prevent dislodging the catheter. d) Take only a shower, not a tub bath, while the catheter is in place, unless instructed otherwise by the physician. e) There must be a physician's order for out-of-bed activity and ambulating.

a) b) e)

An adult was admitted to the hospital with a hemoglobin of 6.5 g/dL (65 g/L) and is experiencing signs and symptoms of cerebral tissue hypoxia. The nurse should: a) Assist the client in ambulating to the bathroom. b) Refer the client to occupational therapy for energy conservation interventions. c) Check the temperature of the water before the client showers. d) Plan frequent rest periods throughout the day.

a) Cerebral hypoxia is commonly associated with dizziness. The greatest risk of injury to a client with dizziness is a fall. Frequent rests and energy conservation measures should be included in the client's plan of care, but safety from falls is the greatest need. Checking the shower water temperature is not critical for this client, who will not be showering because of her fall risk.

The nurse is assessing a client who is restless and agitated, has dry mucous membranes, and has intense thirst. The nurse should assess the client further for which of the following electrolyte imbalances? a) Hypernatremia. b) Hypomagnesemia. c) Hypercalcemia. d) Hypokalemia.

a) Restlessness, agitation, dry mucous membranes, and thirst are indicative of fluid loss and hypernatremia. Hypokalemia causes such symptoms as fatigue, muscle weakness, and cardiac irregularities. Clinical manifestations of hypercalcemia include lethargy, weakness, depressed reflexes, constipation, polyuria, and bone pain. Hypomagnesemia is manifested by confusion, tremors, hyperactive reflexes, and seizures

A nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include? a) Encourage a high-calorie, high-protein diet. b) Limit salt intake to 2 g per day. c) Encourage foods high in vitamin B. d) Restrict fluids to 1,500 ml per day.

a) The child should be encouraged to eat a high-calorie, high-protein diet. In cystic fibrosis, the pancreatic enzymes (lipase, trypsin, and amylase) become so thick that they plug the ducts. In the absence of these enzymes, the duodenum can't digest fat, protein, and some sugars; therefore, the child can become malnourished. A child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising, to help maintain hydration and adequate sodium levels. Water-soluble forms of the fat-soluble vitamins (A, D, E, and K) are essential.

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin: a) enhances protein synthesis. b) reduces edema. c) restores the inflammatory response. d) enhances oxygen transport to tissues.

a) The client should be encouraged to consume foods high in vitamin C because vitamin C is essential for protein synthesis, an important part of wound healing. Hemostasis (stopping the flow of blood) is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport.

The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate? a) Placing a pillow in the axilla so the arm is away from the body. b) Positioning a hand cone in the hand so the fingers are barely flexed. c) Immobilizing the extremity in a sling. d) Keeping the arm at the side using a pillow. e) Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow.

a) b) e)

A nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy? a) Monitor the appearance, size, and number of stools. b) Measure blood urea nitrogen and serum creatinine levels. c) Monitor vital signs every 4 hours. d) Measure intake and output.

a) A gluten-free diet should eliminate fat, bulky, foul-smelling stools in a child with celiac disease. This finding indicates that the disease is controlled and the child is using nutrients effectively. Taking vital signs, measuring blood urea nitrogen and serum creatinine levels, and measuring intake and output don't indicate the effectiveness of nutritional therapy.

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe? a) Red, swollen skin with inflammation spreading to surrounding tissues b) Cold, red skin c) Small, localized blackened area of skin d) Painful skin that is swollen and pale in color

a) Cellulitis, an inflammation.

Clients who are receiving total parenteral nutrition (TPN) are at risk for development of which of the following complications? a) Fluid imbalances. b) Pulmonary hypertension. c) Orthostatic hypotension. d) Hypostatic pneumonia.

a) Clients receiving TPN are at risk for a number of complications, including fluid imbalances such as fluid overload and hyperosmolar diuresis. Other common complications include hyperglycemia, sepsis, pneumothorax, and air embolism. Hypostatic pneumonia, pulmonary hypertension, and orthostatic hypotension are not complications of TPN

When bandaging a client's ankle, the nurse should use which technique? a) Figure-eight b) Circular c) Spiral reverse d) Recurrent

a) Figure-eight The nurse uses a figure-eight technique to bandage a joint, such as an ankle, elbow, wrist, or knee. The nurse uses the circular bandaging technique to anchor a bandage; the recurrent technique to bandage a stump, hand, or scalp; and the spiral reverse bandaging technique to accommodate the increasing circumference of a body part such as when in a cast.

A child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child? a) Hypernatremia b) Hypokalemia c) Hyperphosphatemia d) Hypercalcemia

b) Hypokalemia occurs when insulin administration causes glucose and potassium to move into the cells. Insulin administration doesn't directly affect calcium levels. Hypophosphatemia — not hyperphosphatemia — may occur with insulin administration because phosphorus enters the cells with insulin and potassium. Insulin administration doesn't directly affect sodium levels