NSG 1400 Unit 2

Which of the following statements is essential when teaching a patient who has received an injection of iodine-131? A. "Do not share a toilet with anyone else for 3 days." B. "You need to save all your urine for the next 7 days." C. "No special precautions are needed, because this is a weak type of radiation." D. "You need to avoid contact with everyone except family members until the radiation device is removed."

A. "Do not share a toilet with anyone else for 3 days." The radiation source is an unsealed isotope that is eliminated from the body mainly through urine and feces. This material is radioactive for about 48 hours after instillation. The patient should not share a toilet with others for 3 days to ensure the isotope has been completely eliminated and is no longer radioactive. Saving the urine is not necessary. Contact should be avoided with anyone who may be ill or immunocompromised. Patients are instructed to avoid crowded areas but isolation is not necessary.

Upon entering the room, the nurse finds the patient, who has just had a mastectomy, crying. When the nurse asks about her crying, the patient states, "I know I shouldn't cry because this surgery may well save my life." What is the nurse's best response? A. "It is okay to cry; mourning the loss of your breast is important for getting past this." B. "I know this is hard, but chances of survival are greatly improved now." C. "Would you like to talk to someone who also has had a mastectomy?" D. "How have you coped with difficult situations in the past?"

A. "It is okay to cry; mourning the loss of your breast is important for getting past this." Cancer surgery can involve the loss of a body part or a decrease in function. Mourning or grieving for a body image alteration is a healthy response in adapting or adjusting to a new image. Discussion of survival, talking with someone else who has undergone a mastectomy, or asking about prior coping behaviors does not address the patient's feelings about loss of the breast.

Which priority intervention will the nurse initiate for the patient having Kussmaul's respirations due to diabetic ketoacidosis? A. Administration of oxygen by nasal cannula at 15 L/min B. Intravenous infusion of 10% glucose C. Implementation of seizure precautions D. Administration of intravenous insulin

A. Administration of intravenous insulin The Kussmaul's respirations pattern is the body's attempt to reduce the acids produced by utilization of fat for fuel. Administration of insulin will reduce this respiration pattern by assisting glucose transport back into cells to be used for fuel instead of fat. Nasal cannula oxygen is given at 1 to 6 L per minute; intravenous glucose administration will not have the desired effect of treatment; and although seizure precautions may be implemented, they will not have any effect on glucose transport into cells.

The nurse is planning care for a patient with hypercalcemia secondary to bone metastasis. Which of the following interventions will be included in the plan of care? Select all that apply. A. Increasing oral fluids B. Placement of an oral airway at the bedside C. Monitoring for Chvostek's sign D. Implementing seizure precautions E. Hyperactive reflex assessment F. Observation for muscle weakness

A. Increasing oral fluids F. Observation for muscle weakness Serious complications of hypercalcemia include severe muscle weakness, dehydration, loss of deep tendon reflexes, paralytic ileus, and electrocardiographic changes. Early manifestations of hypercalcemia include fatigue, loss of appetite, nausea, vomiting, constipation, and polyuria (increased urine output).

Based on the nurse's assessment of a diabetic patient, which finding indicates the need for avoidance of exercise at this time? A. Ketone bodies in the urine B. Blood glucose level of 155 mg/dL C. Pulse rate of 66 beats per minute D. Weight gain of 1 pound over the previous week's weight

A. Ketone bodies in the urine Exercise would lead to further elevations in blood glucose levels due to inadequate insulin to promote intracellular glucose transport and uptake. Assessing for ketones in the urine may indicate insulin deficiency.

A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for what manifestations of hypothermia? A. Stupor B. Erythema C. Increased anxiety D. Rapid Respirations

A. Stupor Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient would be unable to focus on anxiety-producing aspects of the situation. Respirations would be decreased.

What priority intervention will the nurse employ to prevent injury to the patient with bone cancer? A. Using a lift sheet when repositioning the patient B. Positioning the patient so the heels do not touch the mattress C. Providing small, frequent meals rich in calcium and phosphorus D. Applying pressure for a full 5 minutes after intramuscular injections

A. Using a lift sheet when repositioning the patient The resultant bone destruction from bone cancer can cause pathological fractures by grasping or pulling on a patient by the extremities or trunk of the body during re-positioning. Use of a lift sheet evenly distributes the patient's weight, lessening the chance of fractures occurring. While safety risks exist, the priority for bone cancer is reducing risk of fractures.

When interpreting a patient's data the nurse inferred that the patient cried during the assessment due to pain. How best can the nurse verify that this interpretation of patient data is accurate? a. Assess the patient's pain level on a standardized scale. b. Ask the physician to order x-rays to identify potential injuries. c. Refer the patient to a psychiatrist to explore unresolved issues. d. Watch the patient ambulate without assistance to determine mobility.

ANS: A The best way to verify that interpretation of data is accurate is to assess for the probable etiology or cause using a variety of assessment methods. In this case, if the nurse thought that the patient's crying was a result of pain the best way to determine the presence and level of pain is through pain assessment using a scale of 0-10. Ordering x-rays, watching ambulation, or referring a patient to a psychiatrist simply because the patient cried would not be the first or best way to interpret that data.

The nurse recommends the pen-injector insulin delivery system for the client with which clinical presentation? A. Confusion and reliance on another person for insulin injections B. Requirements for intensive therapy with small, frequent insulin doses C. Visual impairment affecting the ability to draw up insulin accurately D. Frequent episodes of hypoglycemia

B. Requirements for intensive therapy with small, frequent insulin doses The pen injector allows greater accuracy with small doses of less than 5 units. It is not recommended for those with cognitive or visual impairments or those who suffer frequent hypoglycemic episodes.

When planning care for a diabetic patient with microalbuminuria, it is important to include which goal to reduce the progression to renal failure? A. Decrease the total percentage of calories from carbohydrates B. Decrease the total percentage of calories from fruits C. Decrease the total percentage of calories from proteins D. Decrease the total percentage of daily caloric intake

C. Decrease the total percentage of calories from proteins Restriction of dietary protein to 0.8 g/kg body weight per day is recommended for clients with microalbuminuria to reduce the progression to renal failure. All other choices can increase blood glucose and total body weight but are not specific for progression to renal failure.

What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia? A. Dyspnea B. Precordial pain C. Increased pulse rate D. Elevated blood pressure

C. Increased pulse rate The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may increase but does not cause difficulty in breathing. Pain is not related to fever. Blood pressure is not necessarily elevated in fever.

The nurse should institute which precaution for the hypoglycemic patient receiving intramuscular glucagon due to an inability to swallow the oral form? A. Elevate the head of the bed. B. Have a padded tongue blade at the bedside. C. Position the client face down or in a side-lying position. D. Apply pressure and massage the injection site for 5 minutes.

C. Position the client face down or in a side-lying position. Intramuscular injection of glucagon often causes vomiting, increasing the patient's risk for aspiration. Elevating the head of the bed, instituting the use of a padded tongue blade, or applying pressure at or massaging injection site is not a safe nursing practice.

Which clinical patient scenario is associated with the most critical need for the nurse to obtain vital signs? a. Ambulating for the first time after surgery b. Complaining of pressure in the chest c. Completing ambulating 100 feet after a stroke d. Complaining of hunger while NPO (nothing by mouth)

b. Complaining of pressure in the chest

The nurse understands that which statement is correct regarding respiratory rates? a. Infants have a lower respiratory rate than adults. b. Healthy adults breathe between 12 and 20 times a minute. c. A compensatory response to a fever is to breathe at a slower rate. d. An increase in intracranial pressure results in an increased rate.

b. Healthy adults breathe between 12 and 20 times a minute.

The nurse is caring for a patient who has a blood pressure of 184/110. An hour after administering an antihypertensive medication, the nurse returns to rechecks the blood pressure, only to find the patient in the chair pale, sweaty, and feeling faint. Which is the expected explanation for the nurse's observations? a. The blood pressure is 184/110- the medication has not had an effect. b. The blood pressure is 118/76-the sudden drop has caused the signs. c. The blood pressure is 174/96- the medication has made the patient sick. d. The blood pressure is 130/82-the symptoms are from another cause.

b. The blood pressure is 118/76-the sudden drop has caused the signs.

The nurse places a patient with a high fever on a cooling blanket. How is heat loss achieved with this treatment? a. Radiation b. Convection c. Conduction d. Evaporation

c. Conduction

It is 6 A.M. and the unlicensed assistive personnel reports to the nurse that the patient has a temperature of 96.7º F (35.9 º C) tympanic. Which factor explains this reading? a. The patient's room is cold. b. The patient was drinking cold water. c. The patient is exhibiting a normal circadian rhythm. d. The patient just completed a warm shower.

c. The patient is exhibiting a normal circadian rhythm

It is most important for the nurse to include which risk factors in a teaching plan associated with the development of type 2 diabetes mellitus? Select all that apply. A. Hypertension B. History of pancreatic trauma C. Weight gain of 30 pounds during pregnancy D. Body mass index greater than 25 kg/m E. Triglyceride levels between 150 and 200 mg/dL F. Delivery of a 4.99-kg baby

A. Hypertension D. Body mass index greater than 25 kg/m F. Delivery of a 4.99-kg baby Risk factors for type 2 diabetes include habitual inactivity, hypertension, delivery of a baby weighing over 9 pounds, a history of vascular disease, a body mass index greater than 25 kg/m, and triglyceride levels over 200 mg/dL.

The nurse is completing a postoperative assessment on a patient in the postanesthesia recovery unit. Which VS requires further assessment by the nurse for possible hypovolemic (low blood volume) shock? a. An increase in heart rate b. An increased temperature reading c. A decrease in blood pressure d. A decrease in respiratory rate

ANS: A The initial response of shock occurs when baroreceptors detect a drop in mean arterial pressure, which initiates the compensatory mechanisms of increased heart rate and increased respiratory rate. Temperature will drop as shock progresses. A decrease in blood pressure is a later sign of shock than the increase in heart rate and increase in respiratory rate.

A patient with hypothermia is brought to the emergency department. The nurse should explain which most likely treatment to the family members? A. Core rewarming with warm fluids B. Ambulation to increase metabolism C. Frequent oral temperature assessment D. Gastric tube feedings to increase fluids

A. Core rewarming with warm fluids Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The patient would be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.

The nurse understands that which statements regarding blood pressure and blood pressure measurement are true? (Select all that apply). a. The highest pressure is the systolic pressure. The lowest pressure is the diastolic pressure. b. The patient should be in a comfortable lying or sitting position when taking the blood pressure. c. Maximum blood pressure is created in the arteries when the right ventricle pushes blood into the aorta. d. The difference between systolic pressure and diastolic pressure is known as pulse deficit. e. The point on the gauge where the first faint but clear sound appears is known as diastolic pressure.

ANS: A, B It is correct that systolic is the highest pressure within the artery and diastolic pressure is the lowest. Preferred positions for assessing blood pressure are either lying or sitting with the cuff at heart level. Maximum pressure is created when the left ventricle contracts and falls as the heart relaxes. Pulse deficit is the difference between the apical and radial pulse rates. Systolic pressure is recorded as the first faint but clear sound heard.

The nurse is caring for a patient who experienced a major trauma and has lost approximately 2 units of blood. Which initial compensatory mechanisms would the nurse expect the patient to exhibit? (Select all that apply.) a. Increased blood pressure b. Increased urinary output c. Increased pulse rate d. Decreased temperature e. Decreased respirations

ANS: A, C Initial compensation by the body would include increased respirations to increase oxygenation, and increased pulse and blood pressure to circulate the oxygen and to compensate for decreased fluid volumes. Without intervention or stabilization, compensatory mechanisms will fail and all VS measurements will drop. Renal function will decrease as the body shunts resources to protect vital organs. Temperature is not initially affected.

The nurse is caring for a patient with a temperature of 103º F, respirations of 30 per minute, pulse rate of 50 beats per minute, and blood pressure of 100/60. The patient is cold and clammy. What does the nurse conclude about these findings? a. The temperature is causing a lowered pulse rate. It will improve if the temperature decreases. b. The low pulse rate is causing a decreased cardiac output, which has caused a low blood pressure. c. The pulse rate and blood pressure are compensatory mechanisms to decrease the increased metabolic rate from the temperature. d. The cool, clammy skin will help to increase the blood pressure and pulse as the body tries to warm the skin.

ANS: B This patient has a low pulse rate with a corresponding low blood pressure—the heart is not maintaining an output high enough to maintain normal blood pressure. A raised temperature will increase the heart rate as the metabolic processes are increased. If the body tries to warm the skin, the temperature would only go higher.

Which actions by the nurse could result in a blood pressure measurement error? (Select all that apply.) a. Placing the diaphragm of the stethoscope over the brachial artery b. Using the same cuff for all patients c. Wrapping the bottom edge of the cuff over the antecubital space d. Releasing the valve quickly to prevent patient discomfort e. Taking a measurement after the patient rests quietly for 5 minutes

ANS: B, C, D Patients of different sizes and ages require different size cuffs. The bottom edge of the cuff should not extend over the antecubital space as this prevent proper placement of the stethoscope. Release of the valve too quickly risks missing the initial and final beats.

The nurse notes that the patient has an irregular pulse. What is the first action the nurse should take? a. Assess the pulse at the carotid artery. b. Assess the pulse with a Doppler ultrasound. c. Assess the pulse for a full minute. d. Assess the pulse at two different sites.

ANS: C Assessing the pulse for a full minute is needed for an accurate count—counting the pulse for a fraction of a minute and then multiplying the value to equal a minute count will give an inaccurate count if the pulse is irregular. The apical pulse, not the carotid, is the site where the pulse should be obtained when there is a question about the count. A stethoscope is sufficient to assess the pulse. The apical pulse would be the first site assessed if there is a question, although the apical and radial pulses are compared to assess for a pulse deficit.

The nurse is working in a rural community hospital that serves patients of all ages. Which decision by the nurse shows the best judgment? a. Taking an oral temperature in a 6-month-old infant b. Taking a rectal temperature in a confused 78-year-old patient c. Taking an axillary temperature in a newborn d. Taking an oral temperature in a 26-year-old patient with dental extractions

ANS: C It is appropriate to take an axillary temperature in a newborn. Young infants are not able to maintain proper positioning for an oral thermometer. Confused patients may not understand the need to remain still for a rectal temperature, increasing the risk for injury. Oral temperatures would not be taken on a patient who has had oral surgery.

The nurse is caring for a patient who was burned in a house fire. The right arm is heavily bandaged and there is an intravenous line that was placed in the left forearm after three attempts. Which action does the nurse take related to obtaining VS? a. A blood pressure is not needed because the patient is awake, alert, and talking to the nurse. b. A smaller cuff should be used to cover less of the upper arm. c. The blood pressure should be taken on the popliteal artery. d. The systolic pressure should be palpated from the radial artery.

ANS: C Neither arm should be used to measure blood pressure: the popliteal artery is the alternate site that should be used in this case. There can be fluid shifts and physiologic changes in the burn patient—it is important to continue monitoring the blood pressure. Using a smaller cuff will not only give an inaccurate reading, it will increase the risk of injury to the burned arm or the chance of losing the intravenous access. Palpating the pressure from a radial artery still involves using a cuff on an arm, increasing the risk of injury to the patient.

Which assessment findings would require the nurse to further assess the patient? a. A young adult male with a pulse rate of 136 after running 2 miles b. A 40-year-old female with a blood pressure of 110/70 when first awakened c. A 72-year-old female with a respiratory rate of 10 breaths per minute d. A 50-year-old male with a pulse rate of 88 beats per minute

ANS: C Normal respiratory rate is 12 to 20 breaths per minute: rates below this should be further investigated. An increase in pulse rate is expected after aerobic activity. The blood pressure may be lower than other times when first awakened, and the pressure of 110/70 is within normal limits. A pulse rate of 88 is within the normal rate of 60-100 beats per minute for an adult.

A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when observing the child's nurse perform which action? A. Places a hypothermia blanket at the bedside B. Adjusts the bed to the Trendelenburg position C. Obtains electronic equipment for monitoring the vital signs D. Secures a pump to administer the ordered intravenous fluids

B. Adjusts the bed to the Trendelenburg position It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow to the brain, thereby increasing intracranial pressure. Temperature elevations may occur after a craniotomy because of stimulation of the hypothalamus. A hypothermic blanket should be ready if the temperature becomes precipitously elevated. Monitoring vital signs is a critical component of postoperative care. Intravenous infusions must be regulated precisely to minimize the possibility of cerebral edema.

A patient with breast cancer asks the nurse why 6 weeks of daily radiation treatments is necessary. What is the nurse's best response? A. "Your cancer is widespread and requires more than the usual amount of radiation treatment." B. "The cost of larger doses of radiation for a shorter period of time is justified by the results." C. "Research has shown more cancer cells are killed if the radiation is given in smaller doses over a longer period of time." D. "It is less likely your hair will fall out or you will become anemic if radiation is given in smaller doses over a longer period of time."

C. "Research has shown more cancer cells are killed if the radiation is given in smaller doses over a longer period of time." Because of the varying responses of all the cancer cells within a given tumor, smaller doses of radiation given on a daily basis for a set period of time provides multiple opportunities for the destruction of cancer cells while minimizing damage to normal tissues.

Which of the following findings during a female breast examination should the nurse report as suspicious for breast cancer? A. Multiple nodules of round, lumpy, tender tissue in both breasts B. A single soft, mobile, lobular nodule that is nontender C. A poorly defined, firm lump that is nontender and nonmovable D. A single soft lump that is well-defined and tender

C. A poorly defined, firm lump that is nontender and nonmovable A poorly defined, firm lump that is nontender, nonmovable, and fixed to the skin is characteristic of breast cancer. All other choices are usually associated with benign processes. All patients should have a diagnosis of cancer based upon physical assessment and tissue pathology.

A diabetic patient has proliferative retinopathy, nephropathy, and peripheral neuropathy. What should the nurse teach this patient about exercise? A. "Jogging for 20 minutes 5 to 7 days a week would most efficiently help you to lose weight." B. "One hour of vigorous exercise daily is needed to prevent progression of disease." C. "Avoid all forms of exercise because of your diabetic complications." D. "Swimming or water aerobics 30 minutes each day would be the safest exercise routine for you."

D. "Swimming or water aerobics 30 minutes each day would be the safest exercise routine for you." Exercise is not contraindicated for this client, but modifications are necessary to prevent further injury. Swimming or water aerobics provides support for the joints and muscles while increasing the uptake of glucose and promoting cardiovascular health. Jogging, vigorous exercise, or no exercise would increase the pathologies of this patient.

The nurse teaches which action to the diabetic client who self-injects insulin to prevent local irritation at the injection site? A. Be sure to aspirate prior to injecting insulin. B. Massage the site after injecting insulin. C. Use a 1-inch needle for the injection. D. Allow the insulin to warm to room temperature before injecting it.

D. Allow the insulin to warm to room temperature before injecting it. Cold insulin from the refrigerator is the most common cause of irritation. Aspiration of insulin is not recommended; massaging the site can cause irritation; and a 1-inch needle is the improper size for insulin injections.

The nurse identifies which priority nursing invention for a patient with hyperthermia? A. Initiating seizure precautions B. Limiting oral intake C. Providing a blanket D. Removing excess clothing

D. Removing excess clothing The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a high body temperature, so decreasing heat absorption through clothing is the highest priority. Oral intake, especially of fluids, should not be limited for a patient with hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be removed.

A diabetic patient is receiving intravenous insulin. Which laboratory results should the nurse anticipate as a potential problem? A. Serum chloride level of 90 mmol/L B. Serum calcium level of 8 mg/dL C. Serum sodium level of 132 mmol/L D. Serum potassium level of 2.5 mmol/L

D. Serum potassium level of 2.5 mmol/L Insulin activates the sodium-potassium adenosine triphosphatase (ATPase) pump, which increases the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. The chloride, calcium, and sodium levels are in normal parameters.

Which clinical manifestation of decreased renal function in the diabetic clinic should the nurse anticipate as a potential problem? A. Elevated specific gravity B. Ketone bodies in the urine C. Glucose in the urine D. Sustained increase in blood pressure from 130/82 mm Hg to 150/110 mm Hg

D. Sustained increase in blood pressure from 130/82 mm Hg to 150/110 mm Hg Hypertension is both a cause and a result of renal dysfunction in the diabetic client. Although ketones and glucose in the urine are findings in diabetes mellitus, they are not specific for renal function. Specific gravity is elevated with dehydration.

Which clinical manifestation indicates to the nurse a patient's hyperosmolar nonketotic syndrome (HNKS) therapy needs to be adjusted? A. Ketone bodies in the urine have been absent for 3 hours. B. Blood osmolarity has decreased from 350 to 330 mOsm. C. Serum potassium level has increased from 2.8 to 3.2 mEq/L. D. The Glasgow Coma Scale is unchanged from 3 hours ago.

D. The Glasgow Coma Scale is unchanged from 3 hours ago. Slow but steady improvement in central nervous system functioning should be seen with effective therapy for HNKS. An unchanged level of consciousness may indicate inadequate rates of fluid replacement. Ketone bodies, blood osmolarity, and serum potassium levels are consistent with improvement.

The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates A. increased respirations. B. rapid pulse rate. C. red, sweaty skin. D. slow capillary refill.

D. slow capillary refill. With hypothermia, there is slow capillary refill. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. The skin is usually pale or cyanotic with hypothermia.

From the nurse's understanding, which statements regarding temperature and heat production in the body are accurate? (Select all that apply.) a. Heat generates energy for cellular functions. b. Hormones, such as the thyroid, decrease metabolism and heat production. c. Exercise decreases heat production through muscular activity. d. Body temperature is 1º to 2º higher in the morning than in late afternoon. e. Expected temperature readings vary by the route selected for measurement. f. Women tend to have more fluctuations in temperature than do men.

a. Heat generates energy for cellular functions. e. Expected temperature readings vary by the route selected for measurement. f. Women tend to have more fluctuations in temperature than do men.

The nurse is admitting a stable patient for a minor outpatient procedure. What site would the nurse most commonly use to assess pulse rate? a. Radial site b. Apical site c. Brachial site d. Carotid site

a. Radial site

The nurse is measuring blood pressures as part of a community health fair. Which blood pressure reading would cause the nurse to refer the patient for follow-up regarding potential hypertension? a. 118/78 b. 126/84 c. 136/90 d. 144/94

d 144/94

The unlicensed assistive personnel reports vital signs for a patient to the nurse: temperature of 99.2º F (37.3º C) oral, pulse of 88 beats/min and regular, respirations of 18 BPM and regular, blood pressure of 178/112, oxygen saturation of 96%, and pain score of 3 on a 0-to-10 scale for headache. Which vital sign should the nurse be most concerned about? a. Temperature b. Pulse c. Respirations d. Blood pressure

d. Blood pressure

The nurse is performing an initial assessment of a patient with a severe infection at hospital admission. Vital signs for the patient indicate hypotension and tachycardia. Which data would support this evaluation? a. Pulse 88, blood pressure 140/88 b. Pulse 96, blood pressure 120/76 c. Pulse 100, blood pressure 118/80 d. Pulse 114, blood pressure 98/60

d. Pulse 114, blood pressure 98/60