Module 4 evolve quiz
Which intervention is most important in preventing hospital-acquired catheter-associated urinary tract infections (CAUTIs)? A) Removing the catheter B) Keeping the drainage bag off the floor C) Washing hands before and after assessing the catheter D) Cleansing the urinary meatus with soap and water daily
Answer: A Rationale: Research demonstrates that decreasing the use of indwelling urinary catheters is the most important intervention to prevent CAUTIs. Keeping the drainage bag off the floor, washing hands before and after assessing the catheter, and cleansing the urinary meatus daily with soap and water will help reduce infections; however, these are not the most important interventions to prevent CAUTIs.
Peritonitis develops in a client who had surgery for a ruptured appendix. Which clinical findings related to peritonitis should the nurse expect the client to exhibit? select all that apply. One, some, or all responses may be correct A) Fever B) Hyperactivity C) Extreme hunger D) Urinary retention E) Abdominal muscle rigidity
Answer: A, E Rationale: A moderate fever is associated with inflammation of the peritoneal membrane. Muscle rigidity over the affected area is a classic sign of peritonitis. Malaise, rather than hyperactivity, is often associated with peritonitis. Nausea, not hunger, is a common occurrence with peritonitis. Even though the kidneys are making the urine, the bladder often retains the urine after surgery as a complication of anesthesia, not peritonitis.
Which nursing intervention would prevent septic shock in the hospitalized client? A) Maintain the client in a normothermic state B) Administer blood products to replace fluid losses C) Use aseptic technique during all invasive procedures D) Keep the critically ill client immobilized to reduce metabolic demands
Answer: C Rationale: Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock
The nurse is evaluating a client who has been receiving medical intervention for a diagnosis of Crohn disease. Which expected outcome is most important for this client? A) Performs skin care B) Tolerated oral fluids C) Experiences less abdominal cramping D) Gains a half pound (0.2 kilograms) per week
Answer: D Rationale: Weight loss usually is severe with Crohn disease; therefore, weight gain is a priority. This goal is specific, realistic, and measurable and has a time frame. Although skin care, tolerating oral fluids, and experiencing less abdominal cramping are important, they are not as high a priority as weight gain
After obtaining vital sign data of blood pressure 90/60 mm Hg, pulse 96 beats/minute, and respiratory rate 10 breaths/minute for a postoperative client receiving hydromorphone by a patient-controlled analgesia (PCA) pump, which priority action would the nurse take? A) Give naloxone intravenously per protocol B) Assess the client's pain level on a 10-point scale C) Document the vital signs in the client record D) Notify the hospital rapid response team
Answer: A Rationale: A respiratory rate of 10 breaths/minute is abnormal and indicates oversedation with hydromorphone, which should be treated immediately with naloxone administration. Pain level would be assessed, but it is not as high a priority as reversing the opiate-induced respiratory depression. Documentation of findings also needs to be done, but this can be done after naloxone administration. The rapid response team may also be activated, but the nurse would not wait for the rapid response team to give the naloxone.
Which explanation would the nurse provide to a client about transient ischemic attacks (TIAs)? A) Temporary episodes of neurological dysfunction B) Intermittent attacks caused by multiple small clots C) Ischemic attacks that result in progressive neurological deterioration D) Exacerbations of neurological dysfunction alternating with remissions
Answer: A Rationale: Narrowing of the arteries supplying the brain causes temporary neurological deficits that last for a short period. Between attacks, neurological functioning is normal. Emboli result in a brain attack (cerebrovascular accident (CVA)); with a CVA the damage is usually permanent, not intermittent. Ischemic attacks that result in progressive neurological deterioration occur with multiple small brain attacks; TIAs do not result in permanent damage. Exacerbations of neurological dysfunction alternating with remission are not the description of a TIA; remissions and exacerbations occur with progressive degenerative neurological disorders.
Which rationale will the nurse provide to a client with Crohn's disease who asks why the prescribed vitamins have to be given intravenously (IV) rather than by mouth? Select all that apply. One, some, or all responses may be correct A) "They provide more rapid action results" B) "The decrease colon irritability" C) "Oral vitamins are less effective" D) "Intestinal absorption may be inadequate" E) "Allergic responses are less likely to occur"
Answer: A, C, D Rationale: Absorption through the gastrointestinal (GI) tract is impaired, and parenteral administration goes directly into the intravascular compartment. Disease of the GI tract hampers absorption. Because the mucosa of the intestinal tract is damaged, its ability to absorb vitamins taken orally is greatly impaired. IV vitamins do not decrease colonic irritability. Route of administration does not affect allergic response.
Which component of the Glasgow Coma Scale (GCS) assessment tool would the nurse recall when performing a neurological assessment on a client? Select all that apply. One, some, or all responses may be correct. A) Best verbal response B) Best pupillary response C) Best motor response D) Best eye-opening response E) Best cognitive response
Answer: A, C, D Rationale: The GCS is a common way of determining and documenting level of consciousness that scores verbal response, motor response, and eye-opening response. The lowest score is 3, which indicates a totally unresponsive client; a normal GCS score is 15. Pupillary and cognitive responses are not part of the GCS assessment
The nurse caring for a client with a nasogastric tube after gastric surgery would anticipate performing which action? A) Monitor for signs of electrolyte imbalance B) Change the tube at least once every 48 hours C) Connect the nasogastric tube to high continuous suction D) Assess placement by injecting 10 mL of water into the tube
Answer: A Rationale: Gastric secretions, which are electrolyte rich, are lost through the nasogastric tube; the imbalances that result can be life threatening. Changing the nasogastric tube every 48 hours is unnecessary and can damage the suture line. High continuous suction can cause trauma to the suture line. Injecting 10 mL of water into the nasogastric tube to test for placement is unsafe; if respiratory intubation has occurred, aspiration will result.
A client has closed fractures of the right femur and tibia with multiple soft-tissue contusions. Which action would the nurse plan to take? A) Perform a neurovascular assessment of the extremity B) Reassure the client that these injuries are not that serious C) Gather equipment needed for the application of skeletal traction D) Prepare the client for a surgical reduction of the injured extremity
Answer: A Rationale: Identifying the status of the damage is the priority. Before a treatment protocol is determined, the presence of nerve or vascular damage and compartment syndrome must be identified. False reassurance is never appropriate. Skeletal traction is used rarely. Closed fractures in the absence of soft tissue damage generally are reduced by manipulation. Closed fractures with soft tissue damage may require an external fixation device to reduce the fracture, immobilize the bone, and allow for treatment of the soft tissue damage. Preparing the client for surgery is premature; more data are necessary before a treatment option is determined.
A pediatric client is prescribed an intravenous infusion of methylprednisolone. Which clinical manifestation requires immediate intervention during administration of the initial dose? A) Polyuria B) Tinnitus C) Drowsiness D) Hypotension
Answer: A Rationale: Intravenous administration of a steroid can cause a rapid increase in the blood glucose level. One early sign of hyperglycemia is increased urine output. Blood glucose should be checked frequently, and insulin administered as needed. Tinnitus is associated with some antibiotics and with aspirin, not steroids. Drowsiness is associated with sedatives, not steroids. Hypertension, not hypotension, is associated with steroid administration
A client is transferred to the postanesthesia care unit after abdominal surgery. The client begins vomiting. Which nursing action is most important when caring for this client? A) Turning the client onto the side B) Measuring the amount of vomitus C) Assessing the wound for dehiscence D) Administering the prescribed antiemetic to the client
Answer: A Rationale: The side-lying position promotes drainage of emesis and secretions from the mouth, reducing the risk of aspiration. Although accurate assessment of intake and output is important, prevention of aspiration is the priority. Dehiscence is not probable at this time; is is more common 5-7 days after surgery. Although the antiemetic may prevent additional vomiting, the nurse's priority is to prevent aspiration.
Which prescribed action would the nurse perform first when caring for a client with hemodynamically stable sepsis who complains of abdominal pain? A) Draw peripheral blood cultures from two different sites B) Administer levofloxacin 500 mg intravenously over 30 minutes C) Administer 1 L intravenous bolus of Ringer's lactate over 30 minutes D) Take the client to x-ray for an abdominal computed tomography (CT) scan
Answer: A Rationale: This question requires the learner to recall the priority treatments for clients with sepsis. Mortality in septic clients increases by 7.6% for every hour an antibiotic is delayed. Because this client is hemodynamically stable, the priority is to draw the blood cultures so that the antibiotic can be initiated as soon as possible. Administering the antibiotic before obtaining blood cultures could mask the infection, delaying appropriate treatment. Taking the client to x-ray before obtaining the blood cultures would delay antibiotic initiation
A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestation of a pulmonary embolus would the nurse assess for in this client? Select all that apply. One, some, or all responses may be correct. A) Sharp chest pain B) Acute onset dyspnea C) Pain in the residual limb D) Absence of the popliteal pulse E) Blanching of the affected extremity
Answer: A, B Rationale: Emboli can occur with crushing injuries of the extremities. Lodging of a thrombus in the pulmonary system results in a lack of oxygen to pulmonary tissues, causing localized sharp chest pain. Lodging of a thrombus in the pulmonary system will result in decreased breath sounds and dyspnea. Pain in the residual limb is related not to a pulmonary embolus but to severed nerve endings in the residual limb. A pulmonary embolus will not interfere with arterial circulation to a distal portion of an extremity. Blanching of the affected extremity is associated with interference with arterial circulation to an extremity.
Which assessment finding indicates that a client has had a stroke? Select all that apply. One, some, or all of the responses may be correct A) Lopsided smile B) Unilateral vision C) Incoherent speech D) Unable to raise right arm E) Symptoms started 2 hours ago
Answer: A, B, C, D, E Rationale: The signs of a stroke follow the acronym FAST. The F stands for facial drooping ( a lopsided smile); A for arm weakness (inability to raise the right arm); and S for speech difficulties (incoherent speech) the T stands for time, as the signs and symptoms need to be evaluated as soon as possible. Tissue plasminogen activator (TPA) can be administered to reestablish blood flow if treatment is initiated within 4 1/2 hours of stroke onset. Unilateral vision loss can also signify stroke.
Which nursing intervention would the nurse include in the plan of care for a client after a hip replacement? Select all that apply. One, some, or all responses may be correct A) Place a pillow between the client's legs B) Require the client to sit in an armless chair C) Cross the client's legs at the ankles and knees D) Require the client to use an elevated toilet seat E) Keep the client's hip in a neutral, straight position
Answer: A, D, E Rationale: A client who has undergone hip replacement needs help while standing; therefore, the nurse should not have the client sit in an armless chair because the client may experience discomfort and difficulty when standing. Crossing the client's legs at the ankles and knees after a hip replacement may cause pain and venous stasis, promoting thrombus formation. Using a pillow between the legs provides comfort and helps keep the joint abducted. Use of an elevated toilet seat allows for easy movement and prevents hip dislodgement. Keeping the client's hip in a neutral, straight position prevents pain and discomfort and hip dislocation
Which action would the nurse take in caring for a client after surgical placement of an external fixator on the client's leg? A) Cleanse the pin sites with alcohol several times a day B) Perform a neurovascular assessment of the lower extremities C) Ambulate the client with partial weight bearing on the affected leg D) Maintain placement of an abduction pillow between the client's legs
Answer: B Rationale: A neurovascular assessment identifies early signs and symptoms of compartment syndrome. Compartment syndrome is increased pressure within a closed fascial space caused by a fracture or soft-tissue damage that compresses circulatory vessels, nerves, and tissues, compromising viability of the limb. The nurse would monitor for the six Ps: unrelenting pain, pallor, paresthesia, pressure, pulselessness, and paralysis. In addition, the circumference of the extremity will increase, and the leg will feel hard and firm on palpation. Both legs are assessed for symmetry. There is no established standard of care associated with pin care; some primary health care providers believe that pin care is contraindicated because it disrupts the skin's natural barrier to infection. Initially the client should use a wheelchair or walk without bearing weight on the affected extremity. As healing occurs, the primary health care provider will prescribe progressive weight bearing exercises. Maintaining abduction of the leg is not necessary with an external fixation of the tibia.
Which finding for a client who has a diagnosis of paroxysmal atrial fibrillation is most important to report quickly to the health care provider? A) Irregular heartbeat B) Right arm weakness C) Client report of palpitations D) Client report of lightheadedness
Answer: B Rationale: Because stagnation of blood in the atria with atrial fibrillation may lead to atrial clot formation and then embolization and stroke, the nurse would immediately notify the health care provider about any stroke symptoms so that thrombolytic medications could be administered as quickly as possible. An irregular heartbeat is expected with atrial fibrillation, which is characterized by an irregularly irregular rhythm. Palpitations can occur with sudden onset of rapid atrial Fibrillation and would be expected in a client with this diagnosis. Lightheadedness may occur with rapid atrial rates, but would not require treatment as rapidly as stroke.
Which intervention is best when an adolescent has been admitted with a history of symptoms of fatigue, intermittent fever, weight loss, and arthralgia, and the diagnosis is systemic lupus erythematosus? A) Implementation of corticosteroids B) Education about diet, rest, and exercise C) Sun avoidance and calcium supplements D) Avoidance of destructive coping mechanisms
Answer: B Rationale: Client education about the integrative interventions of diet, rest, and exercise will be of the most help to the adolescent client with newly diagnosed lupus. These are interventions that the client has some control over, and this is important to the adolescent. Corticosteroids may not be used until other therapies are unsuccessful. Although sun avoidance and calcium supplements may be helpful, they are not most important. Avoidance of negative coping strategies may be helpful if they are noted, but control over diet, rest, and exercise is a positive coping strategy.
Which medication would the nurse question when reviewing the home medication list for a client admitted with peptic ulcer disease (PUD)? A) Iron B) Ibuprofen C) Famotidine D) Acetaminophen
Answer: B Rationale: Clients with PUD should refrain from taking aspirin or nonsteroidal anti-inflammatory drug (NSAID) products as this can cause gastrointestinal (GI) bleeding. This includes ibuprofen. Iron helps with the production of more red blood cells, and famotidine is an H2 blocker that decreases gastric acid secretion. Acetaminophen does not irritate the GI mucosa and is safe for clients with PUD.
Which rationale explains why the nurse squeezes the collection container and recaps the drain when reestablishing a Jackson-Pratt drain after emptying its contents? A) To drain bile B) To restore suction C) To prevent infection D) To enhance gravity drainage
Answer: B Rationale: Closed suction drains such as Hemovac and Jackson-Pratt produce suction by means of compression and reexpansion of the system. A T-tube drains bile. Compression does not prevent infection. A Penrose drain works by gravity.
Which sign of compartment syndrome would the nurse assess for in the client who has sustained blunt trauma to the forearm? A) Warm skin at the site of injury B) Escalating pain in the fingers C) Rapid capillary refill in affected hand D) Bounding radial pulse in the injured arm
Answer: B Rationale: Elevated tissue pressure restricts blood flow, causing increasing ischemia and increasing pain; it is the cardinal early symptom of compartment syndrome. The arm will feel cool, not warm, because of a decrease in circulation. Sluggish, not rapid, capillary refill is a sign of compartment syndrome. The pulse will be diminished, not bounding; increasing edema impairs circulation
Which change in the client's lab results indicates the client is experiencing septic shock? A) Blood glucose of 80 mg/dL B) An increased serum lactate level C) An increased neutrophil level D) A white blood count (WBC) of 5000 cells/uL
Answer: B Rationale: The hallmark of sepsis is an increasing serum lactate level, a normal or low total WBC count >12,000 cells/uL or <4,000 cells/uL, and a decreasing segmented neutrophil level with a rising band neutrophil level. Blood glucose levels with sepsis are between 110 mg/dL and >150 mg/dL. Blood glucose of 70 mg/dL to 100 mg/dL are considered normal.
Acute appendicitis develops in an older client with a history of chronic constipation. Before arrival at the hospital, the client attempted self-care at home. Which self-care measure could potentially lead to rupture of the appendix? A) Avoiding food and liquids because of nausea B) Applying an ice pack to the abdomen C) Self-administering a small-volume enema D) Taking acetaminophen for pain
Answer: C Rationale: Enemas can increase pressure in the intestines and cause rupture of an inflamed appendix. Fasting from food and liquids or applying an ice pack will not lead to rupture of the appendix. Masking the symptoms by taking acetaminophen may delay treatment but will not directly increase the risk of rupture of the appendix.
Which represents appropriate nursing management of a client's nasogastric (NG) tube in the immediate postoperative period after gastroduodenostomy? A) Advancing the tube to the original insertion depth if the tube becomes dislodged B) Obtaining a prescription to vigorously irrigate the nasogastric tube if clogging is noted C) Carefully monitoring the nasogastric tube to ensure that the tube is patent and the suction is working D) Reporting the presence of bright red gastric aspirant in the suction canister during the immediate postoperative period
Answer: C Rationale: Ensuring that the nasogastric tube is patent and that the suction is working properly are priorities for the postoperative client to prevent retention of gastric secretions that may lead to abdominal distention, nausea, vomiting, and further serious complications. Advancing the tube to the original insertion depth if the tube becomes dislodged is not recommended. Improper reinsertion may result in the aspiration of gastric contents. Vigorous irrigation of the nasogastric tube, even if clogged, is not recommended because this can cause damage to the gastric mucosa. Finally, the presence of bright red gastric aspirant in the suction canister for the first 24 hours after surgery is a normal finding in the postoperative period.
Which initial action would the nurse take when obtaining consent for surgery? A) Describe the risks involved in the surgery B) Explain that obtaining the signature is routine for any surgery C) Witness the client's signature, which the nurse's signature will document D) Determine whether the client's knowledge level is sufficient to give consent
Answer: D Rationale: Informed consent means that the client must comprehend the surgery, the alternatives, and the consequences. Describing the risks involved in the surgery is not within nursing's domain. Although obtaining a signature is routine, explaining that obtaining the signature is routine for surgery does not determine the client's ability to give informed consent. Although witnessing the client's signature will be done, the nurse first would assess the client's knowledge of the surgery.
Which statement reflects understanding of sepsis screening requirements by the nurse? A) Blood cultures are required to diagnosis sepsis and begin sepsis protocols B) An oral temperature of 96.4 F (35.8 C) is not an indicator of sepsis C) A primary health care provider's prescription is required to screen for sepsis D) Sepsis mortality is affected greatly by treatments performed in the first 6 hours
Answer: D Rationale: Studies have shown that if a bundle treatment is not performed in the first 6 hours, the likelihood of survival dramatically decreases. Only in about 30% to 40% of the cases are blood cultures positive in septic clients; this is because in many cases sepsis works faster than the laboratory can produce the result using the current technology. Hypothermia is as strong a sepsis indicator as hyperthermia; however, the health care team members often miss this symptom. The signs and symptoms of sepsis are not specific and may indicate many other diseases as well. If the health care team is not actively looking for sepsis, it will be missed. A sepsis screening is an assessment that the nurse can perform at any time. To perform the screening, the nurse analyzes the vital signs, client history, and laboratory reports; the nurse synthesizes the findings to evaluate if the sepsis screening is negative or positive and then notifies the primary health care provider of the findings.
Which assessment finding indicated a need to activate the rapid response team when the nurse is caring for a diabetic client with a bacterial infection of the foot? A) Hypertonic bowel sounds in all 4 quadrants B) Blood glucose level 145 mg/dL (8.1 mmol/L) C) Client report of level 9 pain of the foot (0-10 scale) D) Systolic blood pressure persistently 85-90 mm Hg
Answer: D Rationale: Systolic blood pressure less than 90 in a client who is at risk for sepsis (such as this client with a bacterial infection and diabetes) indicates possible sepsis and systemic inflammatory response syndrome (SIRS). The nurse would immediately activate the rapid response team and anticipate collaborative actions such as further diagnostic testing, massive fluid infusion, and administration of vasoconstrictive medications. Hypotonic bowel sounds may indicate sepsis or SIRS. Blood glucose levels higher than 140 mg/dL (7.7 mmol/L) might indicate sepsis or SIRS in a nondiabetic client, but would not be unusual in a client with diabetes. Level 9 out of 10 pain would require administration of analgesics, but is not as concerning as hypotension and does not require activation of the rapid response team.
Which health problem history would increase an older adult's risk for experiencing a cerebrovascular accident (CVA)? A) Glaucoma B) Hypothyroidism C) Continuous nervousness, stress D) Transient ischemic attacks (TIAs)
Answer: D Rationale: TIAs are temporary neurological deficits related to cerebral hypoxia; about one third of the people who have TIAs will have a cerebrovascular accident (CVA) within 2-5 years. Glaucoma, hypothyroidism, and continuous nervousness are not risk factors associated with a CVA.
A client diagnosed with Bell palsy has many questions about the course of the disorder. Which information would the nurse share with the client? A) Cool compresses decrease facial involvement B) Pain occurs with transient ischemic attacks (TIAs) C) Most clients recover from the effects in several weeks D) Body changes should be expected with residual effects
Answer: C Rationale: The client should be assured that the symptoms are not caused by a stroke; the majority of clients recover in a few weeks. Moist heat, not a cool compress, increases blood circulation to the nerve. Bell palsy is not caused by a TIA. Paresis or paralysis of cranial nerve VII occurs; pain is usually present. The majority of clients recover without residual effects; occasionally some clients are left with evidence of Bell palsy. Exercises may help maintain muscle tone; also, surgery may be necessary.