HA Quiz 3

While caring for a client with a burn injury and in the resuscitation phase, the nurse notices that the client is hoarse and produces audible breath sound on exhalation. Which immediate action would be appropriate for the safe care of the client? Select all that apply. 1 Providing oxygen immediately 2 Notifying the rapid response team 3 Considering it a normal observation 4 Initiating an intravenous (IV) line and beginning fluid replacement 5 Obtaining an electrocardiogram (ECG) of the client

1 Providing oxygen immediately 2 Notifying the rapid response team Hoarseness of voice, difficulty in swallowing, or an audible breath sound on exhalation after a burn injury indicates an impaired airway. Therefore the client should be given oxygen immediately. The rapid response team should also be notified for further management. This occurrence should not be considered a normal observation. An IV line should be initiated for fluid replacement only once the client's airway is patent. An ECG is obtained when the client suffers from electrical burns.

The PSA is an indication of cancer of the prostate; the higher the level, the greater the tumor burden. Albumin is a protein that is an indicator of nutritional and fluid status. Increased creatinine or BUN levels may be caused by impaired renal function as a result of blockage by an enlarged prostate but do not indicate that metastasis has occurred.

B

Which glands help in lubricating the urinary meatus in female clients? 1 Skene glands 2 Prostate glands 3 Cowper glands 4 Bartholin glands

Skene glands Skene glands are located along the urinary meatus and therefore help in lubricating the urinary meatus. The prostate and Cowper gland are the sex glands of the male reproductive system. Bartholin gland lies at the vaginal orifice and contributes in lubricating the vagina during sexual intercourse.

A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man? 1 "Do you have chest pain?" 2 "Are you feeling anxious?" 3 "Do you have any palpitations?" 4 "Are you feeling short of breath?"

"Do you have chest pain?"

Which instructions given to a client with renal calculi would be most beneficial? Select all that apply. 1 "Drink plenty of water." 2 "Have spinach soup every day." 3 "Substitute lemon juice for tea." 4 "Include high amounts of protein in the diet." 5 "Consume foods rich in omega-3-fatty acids."

"Drink plenty of water." "Substitute lemon juice for tea." Renal calculi is the formation of kidney stones. Drinking plenty of water will keep the body hydrated and prevent further formation of stones. Tea contains caffeine, a diuretic, which causes dehydration. Therefore the client must be advised to replace tea with lemon juice. Spinach is rich in oxalates. Consuming spinach soup may aggravate the problem, due to the formation of oxalate crystals. Excessive consumption of proteins may precipitate uric acid stones. Therefore the use of proteins should not be encouraged. Foods rich in omega-3-fatty acids are beneficial in maintaining good health. However, the use of omega-3-fatty acids, specifically in the treatment, mitigation, or prevention of kidney stones, is not justified.

After a natural disaster, four clients are admitted to the emergency department. Which order should the nurse triage the clients based on the threat to organs? Client with cystitis Client with hip fracture Client with intubated trauma Client with chest pain resulting from ischemia Client with minor burns

1. Client with intubated trauma 2.Client with chest pain resulting from ischemia 3. Client with hip fracture 4. Client with cystitis 5. Client with minor burns

The nurse is providing education to a client with calculi in the calyces of the right kidney. The client is scheduled to have the calculi removed. Which information should the nurse include in the teaching? 1 The calculi are too large for transurethral removal. 2 During the surgery, the right ureter will be removed. 3 After surgery, a suprapubic catheter will be in place. 4 After surgery, there will be a small incision in the right flank area.

After surgery, there will be a small incision in the right flank area. If the calculi are in the renal pelvis, a percutaneous pyelolithotomy is performed. The calculi are removed via a small flank incision which will be evident in the right flank area. The calculi can be removed without damage to the ureter. Transurethral removal of large ureteral and renal calculi can be performed using ureteroscopic ultrasonic lithotripsy. Placement of a suprapubic catheter usually is unnecessary unless there is damage to the ureter during the procedure.

The nurse is categorizing victims of hypothermia as having mild, moderate, and severe hypothermia. Which assessment findings will help the nurse identify the clients with moderate hypothermia? Select all that apply. 1 Asystole 2 Lethargy 3 Hypovolemia 4 Respiratory acidosis 5 Fixed and dilated pupils

3 Hypovolemia 4 Respiratory acidosis Moderate hypothermia causes hypovolemia and metabolic and respiratory acidosis. Asystole may be present in severe hypothermia; in fact, metabolic rate, heart rate, and respirations are so slow in severe hypothermia that they may be difficult to detect. Lethargy is a characteristic of mild hypothermia. Reflexes are absent in severe hypothermia, and the pupils are fixed and dilated.

A nurse writes a goal of preventing renal calculi in a care plan for a client with paraplegia. Which information most likely caused the nurse to write this goal? 1 High fluid intake 2 Increased intake of calcium 3 Inadequate kidney function 4 Accelerated bone demineralization

Accelerated bone demineralization Calcium that has left the bones as a response to prolonged inactivity enters the blood and may precipitate in the kidneys, forming calculi. Increased fluid intake is helpful in preventing this condition by preventing urinary stasis. Calcium intake usually is limited to prevent the increased risk for calculi. Calculi may develop despite adequate kidney function; kidney function may be impaired by the presence of calculi and urinary tract infections associated with urinary stasis or repeated catheterizations.

A client is admitted to the hospital with severe flank pain, nausea, and hematuria caused by a ureteral calculus. What should be the nurse's initial intervention? 1 Strain all urine output. 2 Increase oral fluid intake. 3 Obtain a urine specimen for culture. 4 Administer the prescribed analgesic.

Administer the prescribed analgesic. Pain of renal colic may be excruciating; unless relief is obtained, the client will be unable to cooperate with other therapy. Urine can be saved and strained after the client's priority needs are met. Increasing fluid intake may or may not be helpful. If the stone is large the fluid can build up, leading to hydronephrosis; however, if the stone is small, fluids may help flush the stone. Although a culture generally is prescribed, this is not the priority when a client has severe pain.

A nurse is reviewing the clinical record of a client with a diagnosis of benign prostatic hyperplasia (BPH). Which test result will the nurse check to confirm the diagnosis? 1 Rectal examination 2 Serum phosphatase level 3 Biopsy of prostatic tissue 4 Massage of prostatic fluid

Biopsy of prostatic tissue

The nurse is caring for victims of a bomb blast in the emergency department who are receiving different pain medications. Which client must be placed on electrocardiogram equipment? A. Aspirin B. Methadone C. Butorphanol D. Naproxen

D. Naproxen Nonsteroidal antiinflammatory medications such as naproxen may result in cardiovascular events such as myocardial infarction, stroke, and heart failure, so the client who is on naproxen requires continuous assessment of the cardiovascular system. Therefore the nurse places client D on the electrocardiogram equipment. Aspirin does not result in myocardial infarction, stroke, or heart failure, so client A does not need to be on the electrocardiogram equipment. Methadone and butorphanol do not cause cardiovascular risks. Therefore clients B and C do not need to be on electrocardiogram equipment.

A nurse is caring for a client during the early postoperative period after a prostatectomy. Which action is the priority? 1 Have the client stand to void. 2 Discourage straining for a bowel movement. 3 Use a bulb syringe to aspirate urine from the retention catheter. 4 Notify the primary healthcare provider if the client does not void by bedtime.

Discourage straining for a bowel movement. Straining applies pressure to the operative site, which can precipitate bleeding and should be avoided. A retention catheter is routinely put into place, so standing to void and not voiding by bedtime are not applicable. To prevent trauma, negative pressure should not be exerted on the bladder by using a bulb syringe to aspirate.

A nurse on the high-risk unit assesses a client admitted with severe preeclampsia. The client has audible crackles in the lower left lobe, slight blurring of vision in the right eye, generalized facial edema, and epigastric discomfort. Which clinical manifestation indicates the potential for a seizure? 1 Audible crackles 2 Blurring of vision 3 Epigastric discomfort 4 Generalized facial edema

Epigastric discomfort Epigastric discomfort suggests liver edema; it is an ominous symptom that indicates an impending seizure. Audible crackles indicate pulmonary edema, but although they are a sign of severe preeclampsia they are not as definitive as epigastric pain. Blurred vision is a sign of retinal edema; although it is a sign of severe preeclampsia it is not as definitive as epigastric pain. Although generalized facial edema is an indication of severe preeclampsia, it is not as definitive as epigastric pain.

A nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? Select all that apply. 1 Polyuria 2 Lethargy 3 Hypotension 4 Muscle twitching 5 Respiratory acidosis

Lethargy Muscle twitching Lethargy results from anemia, buildup of urea, and vitamin deficiencies. Muscle twitching results from excess nitrogenous wastes. Extensive nephron damage causes oliguria, not polyuria. Hypotension does not occur; the blood pressure is within the expected range or elevated as a result of increased total body fluid. Metabolic, not respiratory, acidosis occurs because of the kidneys' inability to excrete hydrogen and regulate sodium and bicarbonate levels.

A client who was in a motor bike accident has a severe neck injury. Which priority nursing care is most needed? 1 Assessing for crepitus 2 Assessing for bleeding 3 Maintaining a patent airway 4 Performing neurologic assessment

Maintaining a patent airway

Which emergency medical service agency offers service such as a first aid stations and special-need shelters during a disaster or pandemic disease outbreak? 1 Medical Reserve Corps (MRC) 2 National Disaster Medical System (NDMS) 3 Disaster Medical Assistance Team (DMAT) 4 Federal Emergency Management Agency (FEMA)

Medical Reserve Corps (MRC) Medical Reserve Corps (MRC) may help staff hospitals or community health settings that face shortages and provide first aid stations or special-need shelters. The National Disaster Medical System (NDMS) manages mass fatalities, emergency animal care, and establishes fully functional field surgical facilities. A Disaster Medical Assistance Team (DMAT) is a medical relief team deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours. The Federal Emergency Management Agency (FEMA) provides Community Emergency Response Team (CERT) training so that people are better prepared for disasters and hazard situations in their own communities.

The nurse is caring for a client in labor whose medical report states posterior pituitary hormone deficiency. Which medication administration is required for the client considering the medical condition? 1 Oxytocin to promote uterine contractions 2 Prolactin to promote breast milk ejection 3 Luteinizing hormone to promote painless labor 4 Follicle-stimulating hormone to promote estrogen secretion

Oxytocin to promote uterine contractions Oxytocin is a posterior pituitary hormone that acts on the uterus to stimulate uterine contractions. Therefore the nurse should administer oxytocin to the client. Prolactin is an anterior pituitary hormone that promotes breast milk production, not milk ejection. Luteinizing hormone is an anterior pituitary hormone that stimulates progesterone secretion and ovulation and does not promote painless labor. Follicle-stimulating hormone is secreted by the anterior pituitary and is involved in estrogen secretion and follicle maturation.

A client with burns caused by flames is hospitalized. Which specific emergency burn management would be appropriate for this client? 1 Removing all metal objects 2 Helping the client bathe or shower 3 Initiating cardiopulmonary resuscitation 4 Administering tetanus toxoid for prophylaxis

Removing all metal objects When a client with flame burn injuries is hospitalized, the primary healthcare provider should first remove all smoldering clothing and metal objects. In case of radiation burns, the client is helped to bathe or shower. Cardiopulmonary resuscitation would be appropriate in the emergency management of an electrical burn injury. The administration of tetanus toxoid for prophylaxis would be considered as the general management for all types of burns.

A fetal monitor is applied to a client in labor. The nurse should take immediate action in response to which fetal heart rate? 1 Remains at 140 beats/min during contractions 2 Uniformly drops to 120 beats/min with each contraction 3 Fluctuates from 130 to 140 beats/min unrelated to contractions 4 Repeatedly drops abruptly to 90 beats/min unrelated to contractions

Repeatedly drops abruptly to 90 beats/min unrelated to contractions This fetal heart rate change is known as variable-type decelerations. This is indicative of umbilical cord compression that, if left uncorrected, may lead to fetal compromise; interventions are directed at improving umbilical circulation. A fetal heart rate that remains at 140 beats/min during contractions is not an unusual finding and therefore does not require nursing intervention. Uniform drops to 120 beats/min are recurrent early decelerations, a result of fetal head compression during a contraction. They are a benign reflex response requiring no immediate intervention. Fluctuation from 130 to 140 beats/min unrelated to contractions is an expected variation of the fetal heart rate reflecting a well-oxygenated fetal nervous system.

A nurse is monitoring a client who is having a computed tomography (CT) scan of the brain with contrast. Which response indicates that the client is having a reaction to the contrast medium? 1 Pelvic warmth 2 Feeling flushed 3 Shortness of breath 4 Salty taste in the mouth

Shortness of breath An untoward response to the iodinated dye used as a contrast is anaphylaxis, a life-threatening allergic response. Anaphylaxis is manifested by respiratory distress, hypotension, and shock; counteractive measures must be instituted. A feeling of warmth or flushing is an expected minor side effect. A salty taste is an expected minor side effect.

A nurse stops at the scene of an accident and finds a man with a deep laceration on his hand, a fractured arm and leg, and abdominal pain. The nurse wraps the man's hand in a soiled cloth and drives him to the nearest hospital. How will the nurse's behavior be interpreted? 1 The nurse is negligent and can be sued for malpractice. 2 The nurse is practicing under guidelines of the nurse practice act. 3 The nurse is protected for these actions, in most states (Canada: provinces/territories), by Good Samaritan legislation. 4 The nurse is treating a health problem that can and should be addressed by a primary healthcare provider

The nurse is negligent and can be sued for malpractice. The nurse at the scene of an accident should function in a responsible and prudent manner; the use of a soiled cloth on an open wound is not prudent, nor is the independent transfer of an accident victim from the scene. Although a nurse practice act defines nursing, it does not provide detailed standards for practice; the nurse's action was not prudent. The nurse's action was not what a reasonably prudent nurse would do, and therefore the nurse is not protected by Good Samaritan legislation. The nurse's intervention was not prudent and placed the client in jeopardy; the nurse was not practicing medicine but attempting to provide first aid.

The nurse is analyzing the client's rhythm when the nurse notes multiple premature ventricular contractions (PVCs). Each PVC occurs in no particular pattern and looks like all other PVCs. How will the nurse interpret this finding? 1 Multifocal 2 Unifocal 3 Bigeminal 4 Couplet

Unifocal A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical in shape and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal) and every third beat (trigeminal). Two consecutive PVCs are called a couplet.

Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). What action does the nurse take to reduce the possibility of retinopathy of prematurity? 1 Humidifying oxygen flow to prevent dehydration 2 Uncovering the entire body to increase exposure to the oxygen 3 Applying eye patches to both eyes to protect them from the oxygen 4 Verifying oxygen saturation frequently to adjust flow on the basis of need

Verifying oxygen saturation frequently to adjust flow on the basis of need Determining oxygen saturation identifies the need for oxygen supplementation; prolonged use of oxygen concentrations exceeding those required to maintain adequate oxygenation contributes to the occurrence of retinopathy of prematurity. Preventing dehydration by humidifying the oxygen will not prevent retinopathy of prematurity. The skin does not absorb oxygen; it must enter the lungs through inhalation. Retinopathy of prematurity is caused by a high blood concentration of oxygen, not by exposure of the eyes to oxygen.

The nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation? 1 Measure other vital signs. 2 Stop administering the medication. 3 Elevate the head of the client's bed. 4 Report to the primary healthcare provider.

Stop administering the medication.

A client with kidney dysfunction is about to undergo renal testing using a contrast medium. Which nursing interventions should be conducted before the procedure to ensure the client's safety? Select all that apply. 1 Assessing the client for a history of cirrhosis 2 Asking the client if he or she has a known shellfish allergy 3 Assessing the client for a history of lactic acidosis 4 Assessing the client's hydration status by checking blood pressure and respiratory rate 5 Asking the client to discontinue metformin 12 hours before the procedure

Assessing the client for a history of cirrhosis Asking the client if he or she has a known shellfish allergy Assessing the client's hydration status by checking blood pressure and respiratory rate While interviewing a client who is about to undergo kidney procedure using a contrast medium, the nurse should assess for a history of cirrhosis. Clients with cirrhosis have an increased chance of developing kidney failure after the procedure. The nurse should confirm any known shellfish allergies because contrast dye administered during the study may cause nephrotoxicity. It is not necessary to check the client for a history of lactic acidosis when ensuring the client's safety for renal testing. If the client had lactic acidosis currently, then this would be a significant factor when ensuring the client's safety for renal testing. The nurse should also assess the client's hydration status by checking blood pressure and respiratory rate. The nurse should ask the client to discontinue metformin 24 hours before the procedure to prevent lactic acidosis.

A client complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination. On physical examination, the nurse finds a smooth, firm, and enlarged prostate. The digital rectal examination report indicates enlargement of prostate tissue surrounding the urethra. Which condition does the nurse suspect in the client? 1 Prostatitis 2 Paraphimosis 3 Prostate cancer 4 Benign prostatic hyperplasia (BPH)

Benign prostatic hyperplasia (BPH) BPH is a benign enlargement of the prostate gland caused by excessive accumulation of dihydrotestosterone in the prostate cells, which can stimulate cell growth and overgrowth of prostate tissue surrounding the urethra. The clinical manifestations of BPH include nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination. Presence of fever, chills, back pain, and perineal pain, along with acute urinary symptoms such as dysuria, urinary frequency, urgency, and cloudy urine indicates prostatitis, which involves inflammation of the prostate gland. Tightness of the foreskin of the penis resulting in the inability to pull it forward from a retracted position and preventing normal return over the glans indicates paraphimosis. Symptoms of prostate cancer include dysuria, hesitancy, urinary urgency, and leaking or dribbling.

The nurse is providing care to a client with preeclampsia who is receiving magnesium sulfate 2 g/hr. The nurse receives a call from the laboratory technician indicating that the client has a magnesium level of 6.4 mEq/L (0.30 mmol/L). What is the next nursing action? 1 Stopping the infusion 2 Assessing the client's deep tendon reflexes 3 Assessing the client's level of consciousness 4 Documenting the level in the client's electronic medical record

Documenting the level in the client's electronic medical record Documentation of the magnesium level on the fetal monitoring strip can serve as a point of correlation between the blood level and a decrease in fetal activity or fetal heart rate reactivity, which is common in a client receiving magnesium sulfate. There is no indication that the infusion of magnesium sulfate needs to be stopped. The therapeutic range for magnesium for the preeclamptic client is 4 to 7 mEq/L (0.28 to 0.44 mmol/L). The nurse must constantly assess the client for a toxic level of magnesium, which can depress the central nervous system and slow the respiratory rate, alter the level of consciousness, and cause deep tendon reflexes to diminish or disappear.

A nurse is caring for a client who has a burn in the emergent stage. Which assessment is the highest priority? 1 Extent of burn 2 Cause of burn 3 Where it occurred 4 Type of first aid given

Extent of burn During the emergent stage of a burn, the nurse first assesses the extent and then the cause of the burn, then where it occurred, and then determines first aid measures that were used. For immediate treatment of the burn, the nurse should be concerned with the body location and extent of the burn.

A nurse is caring for a client with a diagnosis of cancer of the prostate. The nurse should teach the client that which serum level will be monitored throughout the course of the disease? 1 Albumin 2 Creatinine 3 Blood urea nitrogen (BUN) 4 Prostate-specific antigen (PSA)

Prostate-specific antigen (PSA) The PSA is an indication of cancer of the prostate; the higher the level, the greater the tumor burden. Albumin is a protein that is an indicator of nutritional and fluid status. Increased creatinine or BUN levels may be caused by impaired renal function as a result of blockage by an enlarged prostate but do not indicate that metastasis has occurred.