Qbank #2
The home health nurse provides care for a partially deaf older adult client and notices several home safety concerns. Which environmental adaptation is most important for the nurse to recommend to this client? 1. Add a flashing light to the phone 2. Change the batteries in all smoke detectors 3. Add lights at the bottom and top of stairwell 4. Regularly check food package expiration dates
ANSWER: 1 (since this client is partially deaf, a hearing adaptation such as adding a light to the phone is best to increase safety at home). Why 2 is wrong: this is a routine part of home safety for all clients. it does not specifically address the needs for a deaf client. Why 3 is wrong: This adaptation is best for a client in need of a visual adaptation. Why 4 is wrong: This is best for a client in need of a smell or tactile adaptation.
The nurse assesses a 2-hour old client. The nurse notes the client's hands and feet are bluish in color. To which reason does the nurse attribute this finding? 1. A lack of adjustment to environmental temperature. 2. Poor perfusion of blood to the periphery of the body. 3. A lowered oxygen tension 4. A low hemoglobin level
ANSWER: 2 (acrocyanosis is a bluish color of hands and feet of the newborn. This expected finding is caused by sluggish peripheral circulation).
The nurse provides care for a toddler diagnosed with pneumonia caused by Haemophilus influenzae type b. Which transmission-based precautions will the nurse implement? 1. Standard precautions 2. Airborne precautions 3. Droplet precautions 4. Contact precautions
ANSWER: 3
The nurse in the ambulatory care clinic prepares to perform a venipuncture on a client diagnosed with Chron Disease. The client suddenly becomes upset and asks, "what are you really going to be injecting into my veins?". Which response is best by the nurse? 1. Nothing, I'm just going to draw some blood. 2. What makes you think I'm going to inject you with anything? 3. It sounds like you had a bad experience with venipuncture before 4. You sound frightened. What are your specific concerns?
ANSWER: 4 (this response reflects feelings of the client, and it allows the client to verbalize feelings and concerns).
The nurse assists an older adult client with bathing. The client asks the nurse what causes age-related skin problems. Which response by the nurse is appropriate? 1. Bruising is caused by increased vascular fragility 2. Itching is caused by increase glandular secretions 3. Hair loss is caused by decrease melanin production 4. A reduced body temperature is caused by increased capillary blood flow.
ANSWER: 1 (ecchymosis is a common issue reported by older adults. Easy bruising and bleeding occur as capillaries become more friable due to the aging process). Why 2 is wrong: glandular secretions are reduced by the aging process Why 3 is wrong: melanin production is reduced because of the aging process. Without melanin, new hair that grows in had no pigment which makes it appear gray/white/silver, However, it is not responsible for hair loss. Why 4 is wrong: aging results in decreased blood flow.
The home care nurse visits a client with a long cast on the right leg due to a fracture of the tibia. The client reports feeling a hot spot under the cast. Which action does the nurse take first? 1. Assess the circulation in the right leg 2. Suggest that the client change position 3. Obtain the client's temperature 4. Apply ice over the area that is hot.
ANSWER: 1 (heat under a cast is a sign of pressure. The nurse should first perform a neurovascular assessment to evaluate circulation).
An adolescent client presents to the ED for an overdose of aspirin. Which action does the nurse preform first? 1. Determine the time of drug ingestion and the amount consumed. 2. Initiate an IV and administer protamine sulfate. 3. Start an IV and administer vitamin K 4. Obtain and ABG and request respiratory therapy support.
ANSWER: 1 (the nurse first determines when the client consumed the aspirin. Charcoal, if given within 2 hours, will absorb particles of aspirin). Why 2 is wrong: protamine sulfate is an antidote for heparin, not aspirin. Why 3 is wrong: vitamin K is used only when the clotting cascade is affected and bleeding is noted. It is an antidote for heparin. Why 4 is wrong: ABGs may be necessary later, but the current need is to determine when the aspirin was taken.
The nurse learns that a client received a dose of aminophylline 4 hours earlier than prescribed. Which action by the nurse is best? 1. Complete an incident report, and notify the HCP 2. Change the time for the next medication administration. 3. Assess for bradycardia and lethargy before notifying the HCP 4. Skip the next dose of the medication
ANSWER: 1 (the nurse must document the medication error on an incident report and notify the HCP. these are the most appropriate first actions the nurse takes after assessing the client). Why 2 is wrong: changing the time for the next dose is an unsafe practice. This should not be done. Why 3 is wrong: While it is appropriate to assess the client before notifying the HCP, bradycardia and lethargy are not effects of aminophylline. Why 4 is wrong: Skipping the next dose of the medication is unsafe and should not be done.
The nurse provides care for clients on the medical-surgical unit. Which situation requires immediate intervention by the nurse? 1. A client who had a liver biopsy is resting quietly on the back after the procedure. 2. A visitor is sitting without a mask just inside the doorway of a client on droplet precautions. 3. A client who had a cholecystectomy 2 days ago is draining purulent fluid through T tube. 4. A client scheduled for cardiac catheterization is expressing anxiety and reservations about undergoing the procedure.
ANSWER: 1 (this client should be lying on the right side for several hours after the procedure in order to promote hemostasis and thereby prevent hemorrhage and bile leakage).
The nurse provides care for a postpartum client 4 days after delivery. Which finding most concerns the nurse? 1. Uterine fundus has descended 2 cm. 2. The vaginal walls are edematous. 3. Lacerations are noted to the perineum 4. Brown-tinged discharge is noted on the peripad.
ANSWER: 1 (this is an abnormal finding. the uterine fundus descends by approximately 1cm or one finger breadth, per day. Sub-involution occurs when process of involution does not occur properly and can lead to postpartum hemorrhage. By 10th day, the fundus has normally descended into the pelvic cavity and cannot be palpated abdominally. The descent is documented in relation to the umbilicus.
The nurse assesses a client's reflexes. Which finding indicates to the nurse an expected response? 1. Extension of the leg when the patellar tendon is tapped. 2. Spreading of the toes when the lateral part of the sole of the foot is stroked. 3. Flexion of the hips and knees when the neck is quickly flexed. 4. Rapid alternating flexion and extension of the ankle after holding the foot in a flexed position.
ANSWER: 1 (to elicit the patellar reflex, strike the patellar tendon just below the patella. The client can be sitting or lying if the leg being tested hangs freely. The normal response is extension of the leg with contraction of the quadriceps). Why 2 is wrong: down going toes with plantar stimulation is the expected finding. Dorsiflexion of the great toe and tanning of the other toes (babinski's sign) is abnormal in anyone over 2 years and represents the presence of CNS disease. Why 3 is wrong: flexion of the hips and knees when the neck is quickly flexed is abnormal and known as brudzinski's sign. Why 4 is wrong: clonus, an abnormal response is a continued rhythmic contraction of the muscle with continuous application of the stimulus.
The nurse provides care for a postpartum mother who has stopped breastfeeding her newborn. The client reports painful swollen breasts. Which nursing intervention does the nurse include in the client's plan of care? 1. Wear a snug-fitting supportive bra 2. Have the client massage the breasts gently 3. Place warm compresses on the breasts 4. Expel some breast milk
ANSWER: 1 (to relieve discomfort of breast engorgement, the mother can take mild analgesics such as ibuprofen, wear a supportive bra, and apply ice packs or cabbage leaves to the breasts). Why 2 is wrong: Massage would stimulate breast milk production and increase discomfort. Why 3 is wrong: Warm compresses would stimulate breast milk production and increase discomfort. Why 4 is wrong: expelling some breast milk would continue to stimulate milk production and increase discomfort.
The charge nurse receives an unlicensed assistive personnel (UAP) from another unit. Which action does the charge nurse take to ensure safe client care is provided by the UAP? SATA 1. Provide an overview tour of the unit 2. Assess the UAP's skill level in relation to the unit's needs 3. Assign tasks that match the UAP's level. 4. Provide the UAP with specific client condition details/parameters that should be reported to the nurse 5. Assign less complex tasks to the transferred UAP than those assigned to the unit-based UAPs.
ANSWER: 1, 2, 3, 4
The nurse teaches a new parent about childhood immunizations for a 2-month old client. Which immunization does the nurse include in this teaching? SATA. 1. Rotavirus 2. Diphtheria, tetanus, pertussis 3. Varicella 4. Haemophilus influenzae type b 5. Inactivated poliovirus 6. Measles, mumps, rubella
ANSWER: 1, 2, 4, 5 (each of these vaccinations id due at 2 months) Varicella: due at 12-15 months and 4-6 years. MMR: due at 12-15 months and 4-6 years.
A client diagnosed with a head injury undergoes preparation for a lumbar puncture. Which action will the nurse take first? 1. Obtain informed consent 2. Measure pre-procedure vital signs 3. Explain procedure to client 4. Locate a lumbar puncture tray
ANSWER: 2 (a change in vital signs could indicate increasing intracranial pressure (ICP), which is a contraindication for a lumbar puncture).
The nurse assesses a client who is 6 months of age during a well-baby checkup. Which finding does the nurse expect during this assessment? 1. A pincer grasp 2. Sitting with support 3. Tripling of the birth weight 4. Presence of the posterior fontanel
ANSWER: 2 (a client who is 6 months of age should sit up with support). Why 1 is wrong: the pincer grasp appears at 9 months of age. Why 3 is wrong: tripling of the birth weight occurs by age 1 Why 4 is wrong: The posterior fontanel closes by 2-3 months of age.
The home health nurse visits a client diagnosed with dementia. The client lives with an adult child and family. The nurse identifies which stressor as most critical to the family? 1. The client is unwilling to eat with the family 2. The client does not recognized family members 3. The family is not aware of community resources available to them 4. The client is continent
ANSWER: 2 (failure to recognize family members confirms a deteriorating condition on the part of the client. These changes increase the feelings of loss among the family members and compound their existing burden of care with grief).
An older adult client resident of a long-term care facility exhibits inappropraite behaviors such as hugging staff members and attempting to pull young female staff members into empty rooms. When the nurse develops a plan for coping with this behavior, which strategy is considered the last course of action? 1. Tell the resident the behavior is unacceptable. 2. Place the resident in a quiet, secluded area. 3. Set and maintain clear boundaries. 4. Distract and redirect to a different activity.
ANSWER: 2 (if the behavior persists in spite of other interventions, it may become necessary to move the resident to a secluded area for a time. However, as this is a form of a restraint, it should be reserved for last resort).
The nurse provides care for a client diagnosed with septic shock and who has a BP of 70/46, HR of 136 bpm, RR of 32, and a temp of 104. Blood glucose is 296. Which health care provider's prescription does the nurse implement first? 1. Start an insulin drip to maintain the blood glucose at 140 to 180 2. Administer normal saline at 500 mL/hour 3. Start norepinephrine to keep the mean arterial pressure (MAP) at 65 to 75 4. Obtain blood and sputum cultures.
ANSWER: 2 (the client has hypovolemia as indicated by hypotension and tachycardia. Fluid volume resuscitation is the priority in order to improve the client's hemodynamic status). Why 1 is wrong: glycemic control is important in sepsis care. This client is experiencing hyperglycemia however, the priority for this client is to stabilize the hemodynamic status. Why 3 is wrong: Before vasopressors are started, the client requires fluid volume replacement. Why 4 is wrong: since the client is diagnosed with sepsis, blood cultures were most likely already completed to determine the diagnosis.
The nurse provides care for an adult client diagnosed with Cushing syndrome. An UAP reports the client's vital signs to the nurse. Which vital sign is the most concerning? 1. BP 148/92 2. Oral temp 101.6 3. Pulse 60 bpm 4. RR of 20
ANSWER: 2 (the client with Cushing syndrome is at an increased risk of infection due to immune function disturbance related to excess cortisol).
The nurse plans to assess cranial nerve III is a client. Which item does the nurse use to test cranial nerve III? 1. Coffee 2. Cotton ball 3. Penlight 4. Sugar and salt
ANSWER: 3 (a penlight is used to assess CN III (the oculomotor nerve). To test this nerve, assess the pupils for size, equality and reactivity to light). Why 1 is wrong: coffee, tobacco, or other familiar odor is used to assess CN I (olfactory nerve) Why 2 is wrong: A cotton ball is used to assess CN V (trigeminal nerve). This nerve is tested with a pin and wisp of cotton on both sides of face. Why 4 is wrong: Sugar and salt are used to assess CN VII (facial nerve). This determines the ability to differentiate between tastes.
The clinic nurse calls the home of a client diagnosed with type 2 diabetes. The client had blood drawn earlier in the day, and the lab is reporting a blood glucose of 475. The nurse instructs the client to go to the ED immediately, but the client responds, "I feel fine. That lab result must be a mistake". The nurse recognizes this response as associated with which coping or protective mechanism? SATA 1. Repression 2. Displacement 3. Denial 4. Rationalization 5. Projection
ANSWER: 3 (denial is about protecting self from reality) Repression: refers to preventing painful memories from entering one's consciousness. For example "forgetting" information given about chronic illness. Displacement: The person takes feelings out on others. Rationalization: serves to justify inappropriate behavior. Projection: places blame for a behavior on to another person.
The nurse performs a beside swallow evaluation on a client diagnosed with an ischemic stroke. The client drools, swallows the food, and then coughs during the evaluation. Which action does the nurse take? SATA. 1. Allow the client to finish the meal and repeat the evaluation in the morning. 2. Adjust the client's head of the bed from 90 to 45 degrees. 3. Monitor breath sounds 4. Request a speech therapy consultation 5. Monitor for temperature measurement of 100.4 or greater.
ANSWER: 3, 4, 5 (aspiration pneumonia: crackles in the lungs and a low grade fever. if a client shows signs of aspiration, a speech therapy consult is needed).
The nurse reviews the recent laboratory results of a client and notes a sodium level of 158. Which nursing intervention will help correct this electrolyte imbalance? 1. Administer tolvaptan as prescribed. 2. Include cured meats in the client's diet. 3. Limit the client's water intake to 500 mL per day. 4. Infuse 5% dextrose in water.
ANSWER: 4 (the client's sodium level indicates hypernatremia. Administration of 5% dextrose in water corrects this electrolyte imbalance by diluting sodium and decreasing its levels in the blood). Why 1 is wrong: Tolvaptan is a selective vasopressin 2 receptor antagonist, which raises sodium levels in clients with hyponatremia. Why 2 is wrong: This food group is high in sodium which will worsen the client's condition. Why 3 is wrong: the nurse should increase the client's water intake to more than 2 L per day to promote excretion of sodium via urine.
The nurse provides care for clients at the student health clinic. Which data causes the nurse to suspect a client of using cocaine? 1. Reports of frequent sneezing, a sore throat, and a T of 100 degrees. 2. Reports of diarrhea, vomiting, and abdominal pain. 3. Reports of fatigue, dilated pupils, and anorexia. 4. Reports of insomnia, rhinorrhea, and facial pain.
ANSWER: 4 (these are signs and symptoms associated with cocaine use by inhalation. The nose is the most common route for administration of cocaine, which causes rhinorrhea and facial pain). Why 1 is wrong: these symptoms suggest viral infection or allergic rhinitis, not cocaine use. Why 2 is wrong: these symptoms could indicate a GI problem or substance withdrawal. Why 3 is wrong: These symptoms could indicate a type of substance abuse or other illness.
The nurse provides care for a client during the acute phase of a cerebrovascular accident (CVA). In which position will the nurse maintain the client? 1. Semiprone, with the head of the bed elevated 30 to 45 degrees. 2. Lateral, with the head of the bed elevated 30 to 45 degrees. 3. Prone, with the head of the bed flat. 4. Supine, with the head of the bed elevated 15 to 30 degrees.
ANSWER: 4 (this position facilitates venous drainage from the brain, reduced ICP and maintains the head in the midline position. This is the best position for the client post-CVA). Why 1 is wrong: semiprone (sims recumbent) is a position in which the client is placed on the left side with legs flexed to the abdomen. Hip flexion increases intra-thoracic pressure and is not desired for a client post-CVA. Why 2 is wrong: Lateral position is one in which the client is placed on the side. This helps with drainage of respiratory secretions but is not best for a client post-CVA. Why 3 is wrong: Prone position is when the client lays on the abdomen face down. This is not best for a client post-CVA.
