Exam 3

470. Sulfisoxazole, 1 g orally twice daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads "500-mg tablets." The nurse has determined that the dosage prescribed is safe. The nurse administers how many tablets per dose to the adolescent? 1. 1⁄2 tablet 2. 1 tablet 3. 2 tablets 4. 3 tablets

3 CHANGE 1G TO MG

179. The nurse receives a telephone call from the post- anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway. 2. Check tubes or drains for patency. 3. Check the dressing to assess for bleeding. 4. Assess the vital signs to compare with preoperative measurements.

1 The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.

150. The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? 1. Prepare the triage rooms. 2. Activate the emergency response plan. 3. Obtain additional supplies from the central supply department. 4. Obtain additional nursing staff to assist in treating the casualties.

2 In an external disaster (a disaster that occurs outside of the institution or agency), many victims may be brought to the ED for treatment. The initial nursing action must be to activate the emergency response plan. Once the emergency response plan is activated, the actions in the other options will occur.

135. A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? 1. A defect in the cochlea 2. A defect in cranial nerve VIII 3. A physical obstruction to the transmission of sound waves 4. A defect in the sensory fibers that lead to the cerebral cortex

3 A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. Asensorineural hearing loss occurs as a result of a pathological pro- cess in the inner ear, a defect in cranial nerve VIII, or a defect of the sensory fibers that lead to the cerebral cortex.

469. A pediatric client with ventricular septal defect repair is placed on a maintenance dosage of digoxin. The dosage is 8 mcg/kg/day, and the client's weight is 7.2 kg. The health care provider (HCP) prescribes the digoxin to be given twice daily. The nurse pre- pares how many mcg of digoxin to administer to the client at each dose? 1. 12.6 mcg 2. 21.4mcg 3. 28.8mcg 4. 32.2mcg

3 CALCULATE DAILY DOSE BY WEIGHT FIRST

471. Penicillin G procaine, 1,000,000 units IM (intra- muscularly), is prescribed for a child with an infection. The medication label reads "1,200,000 units per 2mL." The nurse has determined that the dose prescribed is safe. The nurse administers how many milliliters per dose to the child? 1. 0.8mL 2. 1.2mL 3. 1.4mL 4. 1.7mL

4

146. The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan? 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a lead apron when providing direct care to the client 4. Placing the client in a semiprivate room at the end of the hallway

4 A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent accidental exposure of other clients to radiation. The remaining options identify accurate interventions for a client with an internal radiation implant and protect the nurse from exposure.

178. A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Hemoglobin, 8.0 g/dL (80 mmol/L) 2. Sodium, 145 mEq/L (145 mmol/L) 3. Serum creatinine, 0.8 mg/dL (70.6 μmol/L) 4. Platelets, 210,000 cells/mm3 (210 Â 103/μL/210Â109/L)

1 Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All of these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon. Test-Taking Strategy: Focus on the subject, an abnormal lab- oratory result that needs to be reported. Use knowledge of the normal reference intervals to assist in answering correctly. The hemoglobin value is the only abnormal laboratory finding.

134. The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? 1. Rhythmic respirations with periods of apnea 2. Regular rapid and deep, sustained respirations 3. Totally irregular respiration in rhythm and depth 4. Irregular respirations with pauses at the end of inspiration and expiration

1 Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

151. The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client? 1. Private room or cohort client 2. Personal respiratory protection device 3. Private room with negative airflow pressure 4. Mask worn by staff when the client needs to leave the room

1 Meningitis is transmitted by droplet infection. Pre- cautions for this disease include a private room or cohort client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis. When appropriate, a mask must be worn by the client and not the staff when the client leaves the room.

138. The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? 1. After a shower or bath 2. While standing to void 3. After having a bowel movement 4. While lying in bed before arising

1 The nurse needs to teach the client how to perform a TSE. The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. Palpation is easier and the client will be better able to identify an y ab normalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing a TSE.

177. A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply. 1. Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken. 5. Place a sterile saline dressing and ice packs over the wound. 6. Place the client in a supine position without a pillow under the head.

1, 2, 3, 4 Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

142. The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride and plans to use an IV infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? 1. Initiate the IV line without the use of a pump. 2. Contact the electrical maintenance department for assistance. 3. Plug in the pump cord in the available plug above the room sink. 4. Use an extension cord from the nurses' lounge for the pump plug.

2 Electrical equipment must be maintained in good working order and should be grounded; otherwise, it presents a physical hazard. An IVline that contains a dose of potassium chloride should be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard.

137. The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? 1. Test the corneal reflexes. 2. Test the 6 cardinal positions of gaze. 3. Test visual acuity, using a Snellen eye chart. 4. Test sensory function by asking the client to close the eyes and then lightly touching the fore- head, cheeks, and chin.

2 Testing the 6 cardinal positions of gaze is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the 2 eyes. A Snellen eye chart assesses visual acuity and cranial nerve II (optic). Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V (trigeminal).

143. The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP? 1. Placing a safety knot in the safety device straps 2. Safely securing the safety device straps to the side rails 3. Applying safety device straps that do not tighten when force is applied against them 4. Securing so that 2 fingers can slide easily between the safety device and the client's skin

2 The safety device straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released. A half-bow or safety knot or device with a quick release buckle should be used to apply a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device should be secure, and 1 or 2 fingers should slide easily between the safety device and the client's skin.

144. The community health nurse is providing a teach- ing session about anthrax to members of the com- munity and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply. 1. Bites from ticks or deer flies 2. Inhalation of bacterial spores 3. Through a cut or abrasion in the skin 4. Direct contact with an infected individual 5. Sexual contact with an infected individual 6. Ingestion of contaminated undercooked meat

2, 3, 6 Anthrax is caused by Bacillus anthracis and can be contracted through the digestive system or abrasions in the skin, or inhaled through the lungs. It cannot be spread from person to person, and it is not contracted via bites from ticks or deer flies.

172. A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

3 Explanations should begin with the information that the client knows. By providing the client with individual- ized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preopera- tive experience. Clients who are calm and emotionally pre- pared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option 4 avoids the client's anxiety and is focused on postoperative care.

183. The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1. Out-of-bed activities as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a dependent position

3 For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. A flat or dependent position of the leg would not achieve this goal. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking.

152. The nurse working in the emergency department (ED) is assessing a client who recently returned from Liberia and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next? 1. Check the client's temperature. 2. Contact the health care provider. 3. Isolate the client in a private room. 4. Check a complete set of vital signs.

3 The nurse should suspect the potential for Ebola virus disease (EVD) because of the client's recent travel to Liberia. The nurse needs to consider the symptoms that the client is reporting, and clients who meet the exposure criteria should be isolated in a private room before other treatment measures are taken. Exposure criteria include a fever reported at home or in the ED of 38.0 °C (100.4 °F) or headache, fatigue, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or signs of bleeding. This client is reporting a fever and is showing other signs of EVD, and therefore should be isolated. After isolating the client, it would be acceptable to then collect further data and notify the health care provider and other state and local authorities of the client's signs and symptoms.

170. The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash. 2. Verify that the client has not eaten for the last 24 hours. 3. Have the client void immediately before going into surgery. 4. Report immediately any slight increase in blood pressure or pulse.

3 The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours (or longer as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.

136. While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? 1. Lub-dub sounds 2. Scratchy, leathery heart noise 3. A blowing or swooshing noise 4. Abrupt, high-pitched snapping noise

3 Aheart murmur is an abnormal heart sound and is described as a faint or loud blowing, swooshing sound with a high, medium, or low pitch. Lub-dub sounds are normal and represent the S1 (first) heart sound and S2 (second) heart sound, respectively. A pericardial friction rub is described as a scratchy, leathery heart sound. A click is described as an abrupt, high-pitched snapping sound.

140. A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? 1. Stridor 2. Crackles 3. Wheezes 4. Diminished

3 Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.

139. The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4. The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

3 Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest) and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.

133. The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation? 1. An involuntary rhythmic, rapid, twitching of the eyeballs 2. A dorsiflexion of the ankle and great toe with fanning of the other toes 3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed 4. Alack of normal sense of position when the client is unable to return extended fingers to a point of reference

3 In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the ankle and great toe with fanning of the other toes; if this occurs in anyone older than 2 years it indicates the presence of central nervous system disease.

467. The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction? 1. "I should cuddle my child after giving the medication." 2."I can give my child a frozen juice bar after he swallows the medication." 3."I should mix the medication in the baby food and give it when I feed my child." 4."If my child does not like the taste of the medicine, I should encourage him to pinch his nose and drink the medication through a straw."

3 The nurse would teach the parent to avoid putting medications in foods because it may give an unpleasant taste to the food, and the child may refuse to accept the same food in the future. In addition, the child may not consume the entire serving and would not receive the required medication dosage. The mother should provide comfort measures immediately after medication administration, such as touching, holding, cuddling, and providing a favorite toy. The mother should offer juice, a soft drink, or a frozen juice bar to the child after the child swallows the medication. If the taste of the medication is unpleasant, the child should pinch the nose and drink the medication through a straw.

189. The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral vessel. The nurse checks the health care provider's (HCP's) prescription and plans to allow which client position or activity following the procedure? 1. Bed rest in high Fowler's position 2. Bed rest with bathroom privileges only 3. Bed rest with head elevation at 60 degrees 4. Bed rest with head elevation no greater than 30 degrees

4 After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4 to 6 hours. The client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depending on the HCP's preference and on whether a vascular closure device was used) and the client may turn from side to side. The head is elevated no more than 30 degrees (although some HCPs prefer a lower position or the flat position) until hemostasis is adequately achieved.

171. A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed con- sent immediately. 3. Send the client to surgery without the consent form being signed. 4. Obtain a telephone consent from a family member, following agency policy.

4 Every effort should be made to obtain permission from a responsible family member to perform surgery if the cli- ent is unable to sign the consent form. A telephone consent must be witnessed by 2 persons who hear the family member's oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to per- form surgery without consent, but the data in the question do not indicate an emergency. Options 1, 2, and 3 are not appro- priate in this situation. Also, agency policies regarding informed consent should always be followed.

468. A health care provider's prescription reads "ampicillin sodium 125 mg IV every 6 hours." The medication label reads "when reconstituted with 7.4 mL of bacteriostatic water, the final concentration is 1 g/7.4mL." The nurse prepares to draw up how many milliliters to administer 1 dose? 1. 1.1 mL 2. 0.54mL 3. 7.425mL 4. 0.925 mL

4 Convert 1 g to milligrams. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal point 3 places to the right

472. The nurse prepares to administer an intramuscular injection to a 4-month-old infant. The nurse selects which best site to administer the injection? 1. Ventrogluteal 2. Lateral deltoid 3. Rectus femoris 4. Vastus lateralis

4 Intramuscular injection sites are selected on the basis of the child's age and muscle development of the child. The vastus lateralis is the only safe muscle group to use for intramuscular injection in a 4-month-old infant. The sites identified in options 1, 2, and 3 are unsafe for a child of this age.

147. Contact precautions are initiated for a client with a health care associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? 1. Gloves and gown 2. Gloves and goggles 3. Gloves, gown, and shoe protectors 4. Gloves, gown, goggles, and a mask or face shield

4 Splashes of body secretions can occur when providing colostomy care. Goggles and a mask or face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.

145. The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 30 minutes

4 The nurse should instruct the UAP to check safety devices and skin integrity every 30 minutes. The neurovascular and circulatory status of the extremity should also be checked every 30 minutes. In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed.

162. A health care provider's prescription reads levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg/tablet. The nurse administers how many tablet(s) to the client? Fill in the blank. Answer: _______ tablet(s)

1.5 CONVERT 150MCG TO MILLIGRAMS

166. A health care provider's prescription reads morphine sulfate, 8 mg stat. The medication ampule reads morphine sulfate, 10 mg/mL. The nurse pre- pares how many milliliters to administer the correct dose? Fill in the blank. Answer: _______ m L

0.8

165. A health care provider prescribes 1 unit of packed red blood cells to infuse over 4 hours. The unit of blood contains 250 mL. The drop factor is 10 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. Answer: _______ drops per minute

10 USE IV FLOW RATE

160. A health care provider prescribes 3000 mL of D5W to be administered over a 24-hour period. The nurse determines that how many milliliters per hour will be administered to the client? Fill in the blank. Answer: _______ mL per hour

125 USE THE IV FORMULA

155. A health care provider's prescription reads potassium chloride 30 mEq to be added to 1000 mL normal saline (NS) and to be administered over a 10-hour period. The label on the medication bottle reads 40 mEq/20 mL. The nurse prepares how many milliliters of potassium chloride to administer the correct dose of medication? Fill in the blank. Answer: _______ mL

15 USE THE MEDICATION CALULATION FORMULA

157. A health care provider's prescription reads phenytoin 0.2 g orally twice daily. The medication label states that each capsule is 100 mg. The nurse pre- pares how many capsule(s) to administer 1 dose? Fill in the blank. Answer: _______ capsule(s)

2 CONVERT GRAMS TO MILIGRAMS THEN CALCULATE

158. A health care provider prescribes 1000 mL of normal saline 0.9% to infuse over 8 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. Answer: _______ drops per minute

31 USE THE IV FLOW RATE

161. Gentamicin sulfate, 80 mg in 100 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 10 drops (gtt)/1mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. Answer: _______ drops per minute

33 USE THE IV FLOW RATE FORMULA

187. A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? 1.Prone 2. Reverse Trendelenburg's 3. Supine, with the residual limb flat on the bed 4. Supine, with the residual limb supported with pillows

4 The residual limb is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the residual limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check health care provider prescrip- tions regarding positioning following amputation.

185. The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? 1. "I should sleep on my left side." 2. "I should sleep on my right side." 3. "I should sleep with my head flat." 4. "I should not wear my glasses at any time."

1 After cataract surgery, the client should not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client also should be placed in a semi-Fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.

186. The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? 1.LeftSims'position 2. Right Sims' position 3. On the left side of the body, with the head of the bed elevated 45 degrees 4. On the right side of the body, with the head of the bed elevated 45 degrees

1 For administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position.

176. The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. Apulseof86beats/minute 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all 4 quadrants

1 Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all 4 quadrants are a normal occurrence in the immediate postoperative period.

141. The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. 1. Auscultating lung sounds 2. Obtaining the client's temperature 3. Assessing the strength of peripheral pulses 4. Obtaining information about the client's respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or disease

1, 2, 4 A focused assessment focuses on a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete assessment includes a complete health history and physical examination and forms a baseline database. Assessing the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete assessment. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

154. A health care provider's prescription reads to administer an intravenous (IV) dose of 400,000 units of penicillin G benzathine. The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine, 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Fill in the blank. Record your answer using 1 decimal place. Answer: _______ mL

1.3 USE THE MEDICATION DOSE FORMULA

188. The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? 1. Maintain the client in a prone position. 2. Elevate and immobilize the grafted extremity. 3. Maintain the grafted extremity in a flat position. 4. Keep the grafted extremity covered with a blanket.

2 Autografts placed over joints or on lower extremi- ties are elevated and immobilized following surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extrem- ity with a blanket can disrupt the graft site.

181. A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? 1. Lying in bed on the affected side 2. Lying in bed on the unaffected side 3. Sims' position with the head of the bed flat 4. Prone with the head turned to the side and supported by a pillow

2 To facilitate removal of fluid from the chest, the cli- ent is positioned sitting at the edge of the bed leaning over the bedside table, with the feet supported on a stool; or lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. The prone and Sims' positions are inappropriate positions for this procedure.

174. The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? 1. "Aspirin can cause bleeding after surgery." 2. "Aspirin can cause my ability to clot blood to be abnormal." 3. "I need to continue to take the aspirin until the day of surgery." 4. "I need to check with my health care provider about the need to stop the aspirin before the scheduled surgery."

3 Antiplatelets alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has proper- ties that can alter platelet aggregation and should be discontin- ued at least 48 hours before surgery. However, the client should always check with his or her health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements.

190. The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1.Rightside 2. Low Fowler's 3. High Fowler's 4. Supine with the head flat

3 During insertion of a nasogastric tube, the client is placed in a sitting or high Fowler's position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the client should vomit. The right side, and low Fowler's and supine positions place the client at risk for aspiration; in addition, these positions do not facilitate insertion of the tube.

132. A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? 1. Have one of the client's family members interpret. 2. Have the Spanish-speaking triage receptionist interpret. 3. Page an interpreter from the hospital's interpreter services. 4. Obtain a Spanish-English dictionary and attempt to triage the client.

3 The best action is to have a professional hospital based interpreter translate for the client. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality as well as accurate information may be compromised when a family member or a non-health care provider acts as interpreter.

180. The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine 4. Conjugated estrogen

1 Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily and may be given parenterally rather than orally. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. These last 3 medications may be withheld before surgery without undue effects on the client.

169. The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? 1. "Use of an incentive spirometer will help pre- vent pneumonia." 2. "Close monitoring of your oxygen saturation will detect hypoxemia." 3. "Administration of intravenous fluids will prevent or treat fluid imbalance." 4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."

1 Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate con- centration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help to detect hypoxemia, monitoring is not directly related to coughing and deep- breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to 1 or more lobes of the lung; this is usually due to clot formation. Early ambulation and administration of blood thinners helps to prevent this complication; however, it is not related to coughing and deep-breathing techniques.

168. The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 mL/hour 2. Temperature of 37.6 °C (99.6 °F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing

1 Rationale: Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30 mL for 2 consecutive hours should be reported to the health care provider. A temperature higher than 37.7 °C (100 °F) or lower than 179.

184. The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? 1. Side-lying on the operative side 2. On the nonoperative side with the legs abducted 3. Side-lying with the affected leg internally rotated 4. Side-lying with the affected leg externally rotated

2 Positioning following a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the health care provider's (HCP's) preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or side-lying on the operative side (unless specifically prescribed by the HCP) is avoided to prevent displacement of the prosthesis.

159. A health care provider prescribes heparin sodium, 1300 units/hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin sodium 20,000 units/250 mLD5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 1300 units/hour? Fill in the blank. Record your answer to the nearest whole number. Answer: _______ mL per hour

16

175. The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1.Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin

2 Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic tech- nique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immuno- compromise may place the client at risk.

156. A health care provider's prescription reads clindamycin phosphate 0.3 g in 50 mL normal saline (NS) to be administered intravenously over 30 minutes. The medication label reads clindamycin phosphate 900 mg in 6 mL. The nurse prepares how many milliliters of the medication to administer the correct dose? Fill in the blank. Answer: _______ m L

2 CONVERT GRAMS TO MILIGRAMS THEN CALCULATE

153. A health care provider's prescription reads 1000 mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. Answer: _______ drops per minute

21 USE THE IV FLOW RATE FORMULA

163. Cefuroxime sodium, 1 g in 50 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 15 drops (gtt)/1mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Answer: _______ drops per minute

25 USE IV FLOW RATE FORMULA

149. A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action? 1. Induce vomiting. 2. Call an ambulance. 3. Call the Poison Control Center. 4. Bring the child to the emergency department.

3 If a poisoning occurs, the Poison Control Center should be contacted immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would not be the initial action because this would delay treatment. The Poison Control Center may advise the mother to bring the child to the emergency department; if this is the case, the mother should call an ambulance.

148. The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door.

3 The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing all doors and, finally, the fire is extinguished.

173. The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible. 2. Keep a loose seal between the lips and the mouthpiece. 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

4 For optimal lung expansion with the incentive spi- rometer, the client should assume the semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

164. A health care provider prescribes 1000 mLD5W to infuse at a rate of 125 mL/hour. The nurse determines that it will take how many hours for 1 L to infuse? Fill in the blank. Answer: _______ h o u r(s)

8 CONVERT LITER TO ML

167. A health care provider prescribes regular insulin, 8 units/hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 100 units of regular insulin in 100 mL normal saline (NS). An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 8 units/hour? Fill in the blank. Answer: _______ mL/hour

8 DETERMINE AMOUNT OF INSULIN IN 1ML, DETERMINE INFUSION RATE (ML PER HOUR)