Quizes 1-10
The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery?
Dry off infant with a warm blanket or towel The priority interventions are in recovering a normal newborn. Maintaining the infant's temperature by drying, warming, and removing any wet blankets or towels are the priority interventions. All interventions are correct, but warming and drying would be the priority.
A client tells a nurse, "I have something very important to tell you if you promise not to tell anyone." Which statement by the nurse would be the most appropriate response?
"I can't make such a promise." Secrets are inappropriate in therapeutic relationships and are counterproductive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to a risk for harm to self or others. The nurse should honor and help clients understand the rights, limitations and boundaries of confidentiality.
A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's explanation should include which of these comments?
"It can help identify potential neurological defects." AFP is a substance made in the liver of the fetus. A fetus with neural tube defects, such as spina bifida and anencephaly, loses AFP to the amniotic fluid and, consequently, to maternal blood. The blood test is performed between the 15 and 17 weeks of pregnancy and can be used as part of a screening test to find chromosomal problems, such as Down sydrome.
The nurse is planning the therapeutic milieu and the various activity groups for a client. What is the primary goal for the nurse to consider?
Achieve a client's therapeutic goals Milieu therapy is the scientific planning of an environment for therapeutic purposes. Activity groups are used to enhance the therapeutic milieu and to meet the clinical and social needs of clients, to minimize withdrawal and regression while learning to more effectively interact with and relate to others, to develop self care skills, etc. A successful therapeutic milieu is a safe and trusting environment where all participants have a voice in decision making.
The nurse is caring for a client diagnosed with acute angina. The client reports substernal chest pain, diaphoresis and nausea. What should be the first action by the nurse?
Administer PRN pain medication as ordered In a client with a diagnosis of acute angina, chest pain means the heart is deprived of oxygen. The priority action would be to give the prescribed pain medication, which will improve oxygenation to the heart. Detailed assessment of the pain, lab tests and ECG can be done once the medication is given. Mostly likely this client would also have a standing order for nitroglycerin.
Where should the nurse administer the annual purified protein derivative (PPD) to the client with a left arm Permcath™?
Always avoid using the arm with a shunt so as to prevent restriction of blood flow and possible clotting or rupture of the fistula. Using the opposite forearm for the PPD administration also reduces the chance for infection.
An 80 year-old client is scheduled for a cardioversion. The nurse is reviewing the client's medication administration records for the previous 24 hours. Which medication would prompt the nurse to notify the health care provider?
Digoxin (Lanoxin) Digoxin increases ventricular irritability and increases the risk of ventricular fibrillation following cardioversion. The other medications do not increase ventricular irritability.
A practical nurse (PN) team member identifies that the fundus is boggy for a woman who is gravida 4 para 4 and is two hours after a spontaneous vaginal delivery. The fundus is displaced slightly above and to the right of the umbilicus. What should be the initial nursing action?
Assist the woman to empty her bladder A full bladder can displace the uterus and prevent contraction. After the woman empties the bladder, the fundus should be assessed again. The most common deviation of the fundus by a full bladder is upward and to the right.
A child is admitted to the hospital for emergency surgery. The child's parent reports several allergies. Which of these allergies should all the operative health care personnel be notified about?
Balloons Allergy to balloons often indicates a latex allergy. All personnel during and after surgery that are in contact with the child will need to be aware of this condition. The need to use non-latex gloves or equipment without latex components should be noted on the chart.
The nurse discovers an unresponsive client and determines there is no pulse. This nurse then activates the code notification button to alert all personnel about the code and begins chest compressions. What is the function of the second nurse on the scene?
Bring the code cart Typically, the second person on the scene brings the code cart and then assists with CPR. In larger facilities, a code team assists with the code and each nurse has a specific duty. Cardiopulmonary resuscitation should not be started on a client who is a DNR, but if it is started, then CPR has to be continued.
Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment?
Decreased lethargy Lactulose is a synthetic sugar used to treat constipation and reduce the amount of ammonia in the blood of clients with liver disease. It works by drawing ammonia from the blood into the colon, where it is removed by the body. Hepatic encephalopathy (HE) occurs in people with end-stage liver disease. People with HE may experience problems with memory, concentration and may experience drowsiness and lethargy; lactulose is used to help manage these symptoms. Lactulose is not used to treat edema or jaundice.
A client diagnosed with head trauma is in a non-responsive state. Vital signs are stable and breathing is regular and spontaneous. What should the nurse document to accurately describe the client's status?
Glasgow Coma Scale 8, respirations regular The Glasgow Coma Scale uses a scoring system based on a scale of 3 to 15 points. It is used to assess a client's neurological condition, based on motor response, verbal response and eye-opening. A low score indicates that coma, and its associated neurological impairment, is present. Using the term "comatose" provides vast opportunity for interpretation and is not precise. Avoid using terms such as "appears" or "ventilator required."
A 6 year-old child is hospitalized with findings of moderate edema, gross hematuria and mild hypertension associated with the diagnosis of acute glomerulonephritis (AGN). Which nursing intervention would be appropriate for this client?
Institute seizure precautions If AGN is untreated, renal failure, seizures and heart failure may result. Clients with AGN should restrict salt intake during the acute phase to control edema and volume-related hypertension. A protein-restricted diet may also be indicated. Underlying infections would be treated with antibiotics. Nursing care would include frequent monitoring of blood pressure, daily weights, intake and output, and seizure precautions.
The client with coronary artery disease has a prescription for nitroglycerin transdermal patches. What is the best reason the client should not wear a patch for more than 12 to 14 hours each day?
It may no longer work as well Nitroglycerin patches may not work as intended when they are used continuously. To prevent tolerance to the medication, clients should apply a patch once a day and remove it after 12 to 14 hours. Some of the more common side effects of wearing a nitroglycerin patch may include headache, dizziness, lightheadedness, nausea, redness or irritation of the skin that was covered by the patch.
An 80 year-old client is hospitalized for a chronic condition. The client informs family members that a living will has been prepared and the client wants no life-prolonging measures performed. The client's condition deteriorates and the client becomes unresponsive. Which of the following nursing actions is most appropriate?
Notify the attending physician The first action would be to notify the attending physician for further orders. Then the family member(s) can be contacted about his condition. When a client has an advanced directive, it is not appropriate to perform CPR on him.
A nurse is monitoring the client's initial postoperative condition after a total thyroidectomy. Which findings should the nurse expect as complications and report immediately to the registered nurse (RN)?
Paresthesia and muscle cramping Because the parathyroid gland may be damaged in this surgery, secondary acute hypocalcemia may occur. Findings of hypoparathyroidism include tetany, paresthesia, muscle cramps and seizures. Mild dysphagia and hoarseness is an expected postoperative finding and may last for six to eight weeks after surgery.
A mother asks about expected motor skills for her 3 year-old child. Which activity should the nurse discuss as normal at this age?
Riding a tricycle Coordination is gained through large muscle use. A 3 year-old child has the ability to ride a tricycle, hop and stand on one foot. The other activities would more typically be found in preschoolers.
A newly admitted client reports taking phenytoin for several months. Which of the following assessments should the nurse be sure to include in the admission report? (Select all that apply.) Serum phenytoin levels Report of anorexia, numbness and tingling of the extremities Report of unsteady gait, rash and diplopia Report of any seizure activity
Serum phenytoin levels This is a part of the correct response Report of anorexia, numbness and tingling of the extremities Incorrect Report of unsteady gait, rash and diplopia Correct response Report of any seizure activity Correct response
A pregnant woman in the third trimester reports having severe heartburn. What action should a nurse remind the client to take?
Sleep with head propped on several pillows Heartburn is a burning sensation caused by regurgitation of gastric contents. It is best minimized by sleeping in a semi-upright position, eating small frequent meals, or eating at least three hours before sleeping. Drinking plenty of water will help with digestion but drinking too much water at one time may actually worsen heartburn symptoms. Medications need to be approved by the health care provider.
A child has severe burns to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse should care for this client with the knowledge that the most important reason for such a diet is to achieve which result?
Spare protein catabolism to meet metabolic and healing needs Because of the severe burn injury, the child has an increased metabolism and catabolism. By providing a high-carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then used to restore and aid in the healing of tissues. Notice that the correct response includes a word used in the question ("protein").
A client has chronic renal failure and is being treated at home. During weekly home visits, which factor is the most accurate indicator of fluid balance?
Trends in daily weights The most accurate indicator of changes in fluid balance is the daily weight. A 1-kilogram (or 2.2 pounds) of weight gain is equal to approximately 1000 mL of retained fluid. Other options are considered as part of data collection for fluid balance, but they are not the most accurate indicators of fluid balance.
The client needs to be moved up in bed. The client is able to partially assist and weighs 135 pounds. Which action by the nursing staff best supports an awareness of ergonomics and safe client handling? (Select all that apply.) Pull the client up from the head of the bed Use a friction-reducing device Move the bed into the flat position Adjust the height of the bed for caregivers Coordinate lifting the client by counting to 3
Use a friction-reducing device Correct response Move the bed into the flat position Correct response Adjust the height of the bed for caregivers Correct response -Coordinate lifting the client by counting to 3 Incorrect -Pull the client up from the head of the bed Incorrect
A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye's syndrome?
Varicella Varicella (chicken pox), influenza and the cold virus are viral illnesses that have been identified as increasing the risk for Reye's syndrome in children, particularly when aspirin has been used. Rubeola, meningitis, and hepatitis are not recognized as precursors to Reye's syndrome. The combination of a viral infection and the administration of aspirin to children from birth to 19 years of age can result in the development of Reye's syndrome; therefore, aspirin should be avoided during these ages.
The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement of the G-tube?
When pH strips are available, the priority action is to measure the aspirate's pH. Prior to each intermittent feeding, gastric pH is usually less than or equal to 5. Do not use an auscultation method to check tube placement because it is not reliable. The nurse should also assess bowel sounds; in the absence of bowel sounds, the nurse should hold the feeding and notify the charge nurse. Additionally, the nurse should verify that the external length of the tube has not changed.
The registered nurse is teaching a childbirth education class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed?
"It's common for women with postpartum depression to have delusions about the infant." Postpartum depression symptoms include sleep and appetite disturbances, uncontrolled crying, with feelings of guilt and/or worthlessness. Although postpartum depression typically occurs within the first three months after delivery, it can occur up to a year later. A new mother who has symptoms of postpartum depression should take steps to get help right away. Delusions are associated with postpartum psychosis, not depression.
The nurse assists with the reinforcement of information about breast self-examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement?
"Right after the period, when your breasts are less tender." The best time for a breast self exam (BSE) is at the end of the menstrual cycle, when the breasts are no longer swollen and tender from hormone elevation. BSE is to be avoided during the first two days of the menses.
A client tells a nurse about an Internet site that claims bupropion was taken off the market because it caused seizures. What would be an appropriate response by the nurse?
"There were problems and the recommended dose was changed." Bupropion (Wellbutrin, Zyban) was introduced in the United States in 1985 and was then withdrawn because of the occurrence of seizures in some clients taking the medication. The medication was reintroduced in 1989 with specific recommendations regarding dosage, i.e., a single dose should be no more than 150 mg and each dose should be separated by six hours, in order to limit the occurrence of seizures. The risk of seizure appears to be strongly associated with higher doses.
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What should the nurse understand about the purpose of this procedure?
A process to compress arterial plaque to improve blood flow PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization.
The nurse has an order for a postsurgical client to receive enoxeparin 40 mg subcutaneously once a day as prophylaxis for deep vein thrombosis. Enoxeparin is supplied from the pharmacy as 60 mg/mL.
Desired: 40 mg in ? mL Supplied: 60 mg in 1 mL; 60 mg/1mL = 40 mg/X mL; 60X = 40; (40/60) x 1 = 0.66 or 0.7; x = 0.7 mL
A pregnant client comes to the clinic for a first visit. A nurse gathers data about her obstetric history, which includes: three year-old twins at home and a miscarriage at 12-weeks gestation 10 years ago. Which documentation should the nurse make?
Gravida 3 para 1 Gravida is the number of pregnancies and parity or para is the number of pregnancies that reach viability (which is considered 20 weeks). This woman is now pregnant. She has also had two prior pregnancies, with one of those pregnancies reaching viability (the twins). Remember to simply count the number of pregnancies, as well as the number of pregnancies that reached viability; avoid confusing twins or multiple births with the number of viable births. If asked to document information using the five number system, it would be: 3-1-0-1-2 (gravida, term pregnancies, preterm, abortions, living children).
The licensed practical nurse is caring for a client with advanced cirrhosis of the liver. Which finding should receive immediate follow-up by the charge nurse?
Hematemesis Vomiting of blood may indicate hemorrhage, especially from esophageal varices. This condition can be life-threatening, requiring immediate intervention.
A child is admitted to the unit with findings of nasal congestion and cough with periods of cyanosis and dehydration. The suspected diagnosis is pertussis (whooping cough). What is the priority nursing intervention for this child?
Implement droplet precautions along with standard precautions Although all the responses are correct actions, it is most important to implement strict droplet precautions in addition to standard precautions because pertussis is spread via close contact. Therapeutic management focuses on providing respiratory support and eradicating the bacterial infection (macrolides, such as erythromycin, are the drug of choice). Fluids are encouraged to help thin secretions. Monitoring heart rate and oxygen saturation, especially during coughing paroxysms, is indicated.
A nurse is caring for a client who has been diagnosed with acute sickle cell vaso-occlusive crisis. Which intervention by the nurse would be most important?
Administer analgesic treatment as ordered Pain is very severe in sickle cell crisis, and is a priority in care. The main objectives in the treatment of a sickle cell crisis is providing analgesics for pain, adequate hydration, oxygenation, bed rest, electrolyte and blood replacement, and antibiotics to treat any existing infection that could have contributed to the crisis. Because pain causes sympathetic stimulation, which results in vasoconstriction, pain management is the most important nursing action among the given choices. Clear liquids, bed rest and temperature control measures assist in reducing the ischemia associated with a sickle cell crisis. You will note that this is a specific question, requiring a specific answer. When deciding on which option to select, you should conclude that pain control should take priority over the other options.
A nurse is talking to a group of parents about how to reduce risks in the home. What is the most important factor for the nurse to consider during the discussion?
Age of children in the home Age and developmental level of the child are most important considerations when providing a framework for anticipatory guidance to reduce risks for harm. When considering the answer to this question, look for options that are similar but dissimilar and are the options focusing on children. To decide between these two options, consider the factor that might have a greater impact on risks in the home: age or number of children.
The client is diagnosed with Parkinson's disease (PD) and takes more than one hour to dress for scheduled therapies. Based on this finding, what is the most appropriate nursing intervention
Allow the client the time needed to dress Parkinson's disease is a degenerative neurological disorder resulting from nerve cells in the brain not producing enough dopamine, which regulates movement. People with PD experience tremors, muscle stiffness, slow movement, rigidity and poor balance and coordination. With careful planning and activity modification, the client can maintain his ability to safely care for himself. The nurse should plan for and allow enough time for the client to meet his own needs when dressing, toileting and bathing.
A client is diagnosed with a severe mental illness. What is the priority goal of involuntary hospitalization?
Protection from harm to self and others Involuntary hospitalization may be required for clients considered dangerous to self or others, or for individuals who are considered severely disabled by their illness. Remember that safety is always a priority. Although one of the goals of hospitalization is to restore maximum independent living as quickly as possible, this the reason why a person is involuntarily hospitalized.
A nursing student asks the practical nurse (PN) to explain the forces that drive health care reform. When responding to the student's question, what information should the nurse emphasize?
Increase in health care spending that's growing faster than the economy One of the most significant reasons for health reform is the need to control costs. Health care spending continues to grow at a faster rate than the economy. Other reasons contributing to increased health care spending includes a decrease in the number of people with health care insurance and decreased competition in both insurer and provider markets. End-of-life care is expensive, but it is too narrow a focus to be the correct response.
A parent expresses frustration and anger about the toddler constantly saying "no" and refusing to follow directions. The nurse should help the parent understand that this behavior meets which developmental need?
Independence Negativism is typical of toddlers. Think of the phrase: "No, me do it" when answering this question. Independence and autonomy versus shame and doubt are the developmental tasks of toddlerhood.
The charge nurse reviews nursing roles and functions with a newly-hired licensed practical nurse (LPN). The LPN asks for more information about the role of the Minimum Data Set (MDS) coordinator. Which statement best explains the role of the MDS coordinator?
Interacts with health care staff to coordinate care processes of client assessment and care planning The MDS Coordinator is typically an RN who potentially interacts with staff across the nursing home to coordinate care processes of resident assessment and care planning. This person will complete and submit the federally-mandated MDS form to the Center for Medicare and Medicaid Services (CMS). A utilization review committee reviews admissions, diagnostic procedures, and treatments.
A young adult seeks treatment in an outpatient mental health center. The client tells a nurse, "I am a government official and spies are following me." Upon further questioning, the client reveals that warnings must be heeded to prevent nuclear war. What is the initial therapeutic approach that the nurse should use?
Listen quietly without comment The client's comments demonstrate grandiose ideas. The most therapeutic response is to listen and avoid being drawn into the delusions. Security should be contacted if a client with delusions of grandeur poses a threat to the nurse or to other health care team members.
The nurse is caring for a client who is experiencing a panic attack. Which action would be the nurse's primary intervention for the client?
Maintain safety for the client Clients who display signs of severe anxiety need to be supervised closely until the anxiety is decreased because they may harm themselves or others. A panic attack is suspected when clients have the feeling that something bad will happen or when they experience a feeling of doom.
A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care?
Monitor the infant's urine output Toxicity from aminoglycoside results in increased serum creatinine levels. Decreased urine output is one of the first findings of nephrotoxicity and renal failure. You will note that two of the options focus on "output." Remember that a priority intervention typically begins with data gathering; the word "monitor" is a "data collecting" word.
A client has completed a renal biopsy. Which nursing intervention is appropriate after a renal biopsy?
Monitor vital signs using post-op protocols The potential complication of this procedure is internal hemorrhage. Monitoring vital signs is critical to detect early indications of bleeding. The dressing should have no drainage, nor should it become saturated. No reason exists to keep the client NPO for 24 hours or to walk within four hours.
A 14 month-old child ingests a half a bottle of baby aspirin (81 mg) tablets. Which finding should a nurse expect to see in the child?
Nausea and vomiting Some of the earliest signs of salicylate toxicity include nausea, vomiting, diaphoresis and tinnitus. Other findings include hyperventilation, tachycardia and hyperactivity. As toxicity progresses, there may be agitation, delirium, hallucinations, convulsions, lethargy and stupor. With the large ingestion of the aspirin, which is an acid, the temperature may rise from the severe acidosis that increases metabolic rate. Hyperventilation may be present from the attempt of the body to rid the acid via carbon dioxide.
A 3 year-old child is brought to the health clinic. The grandmother reports that the child is always "scratching his bottom" and is "extremely irritable." Based on this information, which health issue would the nurse assess for initially?
Pinworm Findings of pinworm infection include intense perianal itching. The itching is usually worse at night, which is why the child will also exhibit poor sleep patterns, general irritability, restlessness, bedwetting, distractibility and a short attention span. The eggs will stick to a piece of clear cellophane tape placed against the rectum and the eggs can be seen under a microscope. The nurse can also take some samples from under the child's fingernails to look for eggs. Recall tip: the "P in worms" are found where the "pooh" comes out - the anal/rectal area. Scabies is an itchy skin condition caused by a tiny mite that burrows under the skin, causing small, itchy bumps or blisters; the most commonly affected areas of the body are the hands and feet. Ringworm is a fungus with characteristic round, itchy irritations on the skin.
A nurse discusses the healthy use of both conscious and unconscious defense mechanisms with a group of clients. An appropriate goal for these clients would be to use these mechanisms for which purpose?
Protect the ego and diminish anxiety Ego defense mechanisms are unconscious proactive barriers that are used to manage instinct and affect the presence of stressful situations. Healthy reactions that use both types of defense mechanisms are those in which clients admit that they are feeling various emotions.
A newborn has hyperbilirubinemia and is being treated with a biliblanket. Which intervention is indicated during this therapy?
Provide more frequent feedings A biliblanket consists of a fiber-optic pad and a portable illuminator. This form of phototherapy allows the baby to be diapered, clothed, held, and nursed during treatment. Frequent feedings of breast milk or formula are necessary to help with bowel motility, which, in turn, should increase excretion of bilirubin from the body. Discontinuing breastfeeding will disrupt the establishment of milk production. It is not necessary to rotate the baby during treatment.
A nurse is collecting data about the motor function of a client with a history of acute head injury. What technique should the nurse use?
Squeeze the trapezius muscle firmly If there is no spontaneous movement in an unconscious client, the nurse can provide central pain stimulation to assess motor function. Squeezing the trapezius is the preferred method; the nurse can also gently pinch the earlobe or apply supraorbital pressure. Although rubbing the sternum with the knuckles can be used, this technique can cause bruising and is no longer recommended. Shaking an extremity is inappropriate.
The nurse and client are discussing the client's progress toward understanding the client's behavioral responses to stressful events. This is typical of which phase in the therapeutic relationship?
Working During the working phase of the relationship, alternative behaviors and techniques are explored. The nurse and the client discuss the meaning behind the behavior in this phase of the relationship. The key words in this question are "nurse and client discussing... progress and behavior." Notice that two of the options would have occurred in an earlier stage and another option would happen at the end of the therapeutic relationship (termination). Use common sense and the process of elimination to select the option indicating the current situation - the working phase.
