VN440: HW4
A nurse is caring for a pt that has been admitted with R sided heart failure. The nurse notes that the client has dependent edema around the feet & ankles. In order to characterize the severity of the edema, the nurse presses the medial malleolus area & notes an 8mm depression after release. This nurse understands that the edema should be documented as: A. 1+ B. 2+ C. 3+ D. 4+
4+ ***Rationale: A grease of 4+ indicates an 8mm depression. 1+ = 2mm 2+ = 4mm 3+ = 6mm
A nurse is caring for a pt admitted with cardiovascular disease. During the assessment of the pts BLE, the nurse notes that the client has thin, shiny skin, decreased hair growth, & thickened toenails. The nurse understands that this may indicate: A. Venous insufficiency B. Arterial insufficiency C. Phlebitis D. Lymphedema
Arterial insufficiency ***Rationale: The pt will present with pale colored extremities when elevated & dusky red colored extremities when lowered. Sx: BLE cool to touch, absent/mild pulse, shiny skin & thickened nails.
A pt is admitted to the hospital & benazepril hydrochloride (Lotensin) is prescribed for HTN. Which is an appropriate nursing action for clients taking this rx? A. Monitor for EEG B. Assess for dizziness C. Administer the rx after meals D. Assess for the dark, tarry stools
Assess for dizziness ***Rationale: Dizziness may occur during the first weeks of tx until the pt adapts physiologically to the rx.
HIV positive pt admitted after Orthopedic procedure. The nurse should institute appropriate precautions with awareness that HIV is highly transmissible through: A. Feces B. Blood C. Semen D. Urine E. Sweat F. Tears
Blood & semen ***Rationale: HIV is transmitted through blood, semen, & other body secretions.
A nurse arrives at the scene of an accident & finds a 5-month-old infant unconscious. After performing the initial steps of CPR, the nurse plans to locate the infant's pulse. Which pulse site should be palpated? A. Brachial pulse B. Carotid artery C. Apical pulse D. Hip
Brachial pulse ***Rationale: This site is the most readily accessible for this age group. It can be palpated on the inner aspect of the arm midway between the elbow & the shoulder.
A client who had a tonic-clonic seizure of unknown etiology is to begin taking Phenytoin. The nurse should instruct the pt to: A. Take the rx on an empty stomach B. Brush the teeth & gums 3x/day C. Stop taking the drug if ABD pain occurs D. Note any changes in pulse & RR
Brush the teeth & gums 3x/day ***Rationale: Adequate dental hygiene is essential to control/prevent the common SE of hypertrophy of the gums. Rx should be taken with food/milk to decrease GI SE.
The nurse recognizes that which are important components of a neurovascular assessment? (Select all that apply) A. Orientation B. Capillary refill C. Pupillary response D. Respiratory rate E. Pulse & skin temperature F. Movement & sensation
Capillary refill, pulse & skin temperature, & movement & sensation ***Rationale: A correct neuromuscular assessment should include evaluating of capillary refill, pulses, warmth, & paresthesias, & movement & sensation.
A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by: A. Promoting analgesia & circulation B. Numbing the nerves & dilating the blood vessels C. Promoting circulation & reducing muscle spasms D. Causing local vasoconstriction, preventing edema & muscle spasm
Causing local vasoconstriction, preventing edema & muscle spasm ***Rationale: Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues & prevents swelling & therefore muscle spasm.
A pt presents to ED with a nosebleed. After applying pressure, what is the next nursing action? A. Obtain a rx hx from the pt B. Check BP C. Instruct the pt to avoid picking the nose D. Check the pulse
Check BP ***Rationale: Nosebleeds can be indicative of HTN.
A nurse is preparing to change a pt's dressing. What is the reason for using surgical asepsis during this procedure? A. Keeps the area free of microorganisms B. Confines microorganisms to the surgical site C. Protects self from microorganisms in the wound D. Reduces risk for growing opportunistic microorganisms.
Confining microorganisms to the surgical site & protecting self from microorganisms in the wound applies to PPE & medical asepsis.
The nurse receives a report on a newly admitted pt who is positive for C-Diff. Which category of isolation would the nurse implement for this pt? A. Airborne precautions B. Droplet precautions C. Contact precautions D. Protective environment
Contact precautions ***Rationale: This should be used for colonization of infection with multidrug-resistant organisms: MRSA, C-diff, draining wounds, or scabies
A pt that is scheduled for a surgical resection of the colon & creation of a colostomy for a bowel malignancy asks why preoperative abx have been prescribed. The nurse explains that the primary purpose is to: A. Decrease peristalsis B. Minimize electrolyte imbalance C. Decrease bacteria in the intestines D. Treat inflammation caused by malignancy
Decrease bacteria in the intestines ***Rationale: To decrease the possibility of contamination, the bacteria count in the colon is lowered with abx before surgery
Droplet precautions
Droplets larger than 5mcg & being within 3 ft of the pt: -Streptococcocal pharyngitis -Mumps -Influenza
A pt who had a surgery for a ruptured appendix develops peritonitis. What clinical findings r/y peritonitis should the nurse expect the pt to exhibit? Select all that apply. A. Fever B. Hyperactivity C. Extreme hunger D. Urinary retention E. ABD muscle rigidity
Fever & ABD muscle rigidity ***Rationale: Fever, inflammation, muscle rigidity, malaise, & nausea are signs of peritonitis
A nurse assesses a newly admitted pt with renal colic to determine the signs & symptoms that are present. The nurse assesses the pt for which primary subjective sx? A. Uremia B. Nausea C. Voiding at night D. Flank discomfort
Flank discomfort ***Rationale: A subjective sx must be experienced & described by the pt: flank pain: pain on the side of the body between the ribs & the ileum, accompanies renal colic.
The nurse is teaching a pt about adequate hand hygiene. What component of hand washing should the nurse include that is MOST important of removing microorganisms? A. Soap B. Time C. Water D. Friction
Friction ***Rationale: Friction is necessary for the removal of microorgansisms. Without friction, it has minimal value.
A pt is admitted to the hospital with ureteral calculus. The nurse expects what urinary clinical findings? A. Urgency & mild aching pain B. Foul odor & dark urine C. Hematuria with sharp pain when voiding D. Frequency with small amounts of urine
Hematuria with sharp pain when voiding ***Rationale: These sx may result from damage to ureteral lining as the calculus moves down the urinary tract; can be cloudy or pink tinged.
The nurse is caring for a pt who has just received epidural anesthesia. Which finding would be of the MOST concern? A. Tachycardia B. Hypotension C. Decreased urine production D. Precipitous second stage of labor
Hypotension ***Rationale: Regional anesthesia lowers the BP, which puts the mother & fetus in jeopardy. BP is affected first.
Steroid tx is prescribed for a client with an exacerbation of ulcerative colitis. The nurse evaluates that teaching is effective when the client says, "I should take this medicine: A. At bedtime with a snack B. In the early morning with food C. One hour before or two hours after eating D. By dividing it into equal parts for each meal
In the early morning with food ***Rationale: Taking the drug in the early morning mimics using adrenal secretions; food helps reduce gastric irritation
2 days after delivery, a pt has a temp of 101F, general malaise, anorexia, & chills. What does the nurse expect to identify on the pt's lab report? a. Increased hemoglobin B. Decreased C-reactive protein C. Increased WBC D. R-shift differential WBC count
Increased WBC ***Rationale: Increased WBC is indicative of an infectious process
Airborne precautions
Infected droplets smaller than 5mcg: -Measles -Varicella -Pulmonary TB
After a DVT developed in a postpartum pt, an IV infusion of Heparin tx was instituted 2 days ago. The pt's aPTT is now 98 seconds. What should the nurse do? A. Increase the IV rate of Heparin B. Interrupt the infusion & notify the MD of the aPTT result C. Document the result on the medical record & recheck the aPTT in 4 hrs D. Call the MD to obtain a rx for a low-molecular weight heparin
Interrupt the infusion & notify the MD of the aPTT result ***Rationale: The Heparin should be withheld because it is almost 3x the normal time it takes a fibrin clot to form & prolonged bleeding may result.
Prednisone is prescribed for a pt with an exacerbation of colitis. When administering the first dose of the rx, the nurse should inform the pt that the rx: A. Will protect the pt from getting an infection B. May cause weight loss by decreasing appetite C. Is not curative but does cause a suppression of the inflammatory process D. Is relatively slow in precipitation a response but is effective in reducing sx
Is not curative but does cause a suppression of the inflammatory process ***Rationale: Rx inhibits phagocytosis & suppresses other clinical phenomena of inflammation; symptomatic tx that is not curative
A pt is admitted with the dx of acute pancreatitis. For which clinical manifestations should a nurse assess the pt? (Select all that apply) A. Jaundice B. Acute pain C. HTN D. Hypoglycemia E. Increased amylase
Jaundice, acute pain, & increased amylase ***Rationale: Obstruction of the common bile duct by inflammation leads to jaundice. Autodigestion of the pancreas causes severe ABD pain. Obstruction of the pancreatic duct leads to elevated levels of amylase & lipase.
The nurse is caring for a pt with arthritis. The pt asks, "Can I take Tylenol instead of ASP? ASP irritates my stomach." The nurse explains that Acetaminophen (Tylenol): A. Lacks anticoagulant action B. Has the same action as ASP C. Lacks an anti-inflammatory action D. Has more severe SE than ASP
Lacks an anti-inflammatory action ***Rationale: Although Tylenol reduces pain, it lacks anti-inflammatory action needed to limit joint inflammation with arthritis.
A pt is admitted to the high-risk prenatal unit with the dx of placenta prevue. What should the nurse instruct the pt to do? A. Breathe deeply to ensure that the fetus gets O2 B. Keep movement to a minimum to diminish bleeding C. Remain on her back to minimize pressure on the cervix D. Lie on her side to avoid putting pressure on the vena cava
Lie on her side to avoid putting pressure on the vena cava ***Rationale: This position decreases pressure on the vena cava from the gravid uterus, ensuring adequate oxygenation of the fetus.
A pt with arthritis increases the dose of Ibuprofen to abate joint discomfort. After several weeks the pt becomes increasingly weak. The pt is admitted to the hospital & is dx with severe anemia. What clinical indicators does the nurse expect to identify when performing an admission assessment? (Select all that apply) A. Melena B. Tachycardia C. Constipation D. Clay-colored stools E. Painful BM
Melena & tachycardia ***Rationale: Ibuprofen irritates the GI mucosa & can cause mucosal erosion, resulting in bleeding: blood in the stool (Helena). Hemoglobin, which carries O2 to the body cells is decreased with anemia, which causes the HR to increase to compensate.
A pt being admitted with a dx of pulmonary TB. The nurse should assign the pt to which type of room? A. Private room B. Semi-private C. Room with windows that can be opened D. Negative airflow room
Negative airflow room **Rationale: TB is best contained in negative airflow room & they are always private
A pt at 40 weeks gestation is admitted to the birthing unit in early active labor. She tells the nurse that her membranes ruptured 26 hrs ago. Assessments of the FHR range between 168-174 beats/min. What is the PRIORITY nursing action? A. Obtain maternal VS B. Planning for an emergency birth C. Administering O2 via NC D. Preparing for fetal scalp blood sampling
Obtain maternal VS ***Rationale: This should be assessed for fever & increased pulse & respirations
The nurse caring for a pt with a systemic infection is aware that the assessment finding that is most indicative of a systemic infection is: A. WBC: 8200 B. Bilateral 3+ pitting edema C. Oral temp: 101.3F D. Pale skin & nail beds
Oral temp: 101.3F ***Rationale: An elevated temp is most indicative of a systemic infection.
What are the desired outcomes that the nurse expects when administering a NSAID? Select all that apply) A. Diuresis B. Pain relief C. Antipyresis D. Bronchodilation E. Anticoagulation F. Reduced inflammation
Pain relief, antipyresis, & reduced inflammation ***Rationale: Prostaglandins accumulate at the site of an injury, causing pain; NSAIDs inhibit COX-1 & COX-2 which inhibit the production of prostaglandins, thereby contributing to analgesia. NSAIDs inhibit COX-2 which is associated with fever, thereby causing antipyresis. It also associated to inflammation, which reduces inflammation.
A nurse is teaching a pt to care for her episiotomy after d/c. What PRIORITY instruction should the nurse include? A. Rest with legs elevated at least 2x/day B. Avoid stair climbing for several days after d/c C. Perform perineal care after toileting until healing occurs D. Continue sitz bath 3x/day if they provide comfort
Perform perineal care after toileting until healing occurs ***Rationale: Prevention of infection is the priority. An episiotomy is a surgical cut made at the opening of the vagina during childbirth to aid in difficult delivery
A pt being treated for Influenza A (H1N1) is scheduled for a CT scan. To ensure pt & visitor safety during transport, the nurse should take which precaution? A. Place a surgical mask on the pt B. Other than Standard Precautions, no additional precautions are needed C. Minimize close physical contact D. Cover the pt's legs with a blanket
Place a surgical mask on the pt ***Rationale: Nurses should provide influenza clients with face masks for source control & tissues to contain secretions when outside of their room.
What is the nurse's priority when retrieving these test results below: -RBC: 4.2 -WBC: 3000 -Hb: 12.5 -Hct: 39% -Platelets: 190,000 A. Promoting rest B. Preventing infection C. Avoiding bodily harm D. Maintaining fluid balance
Prevention of infection is the PRIORITY because an infection can be life-threatening for a pt who is immunocompromised.
A pt is experiencing stomatitis as a result of chemotherapy. Which nursing action is MOST appropriate when caring for this client? A. Provide frequent saline mouthwashes B. Use karaya powder to decrease irritation C. Increase fluid intake to compensate for accompanying diarrhea D. Provide meticulous skin care of the ABD with an antiseptic
Provide frequent saline mouthwashes ***Rationale: Saline mouthwashes are soothing to the oral mucosa & help clean the mouth, minimizing infection.
The nurse should place the client in which position to obtain the most accurate reading of JVD? A. Upright at 90 degrees B. Supine position C. Raised to 45 degrees D. Raised to 10 degrees
Raised to 45 degrees ***Rationale: Jugular vein pressure is measures with a centimeter ruler to obtain he vertical distance between the sternal angle & the point of highest pulsation. This is most accurate when the head of the bed is elevated between 30-45 degrees.
18-year-old admitted with an acute onset of R lower quadrant pain at McBurney's point. Appendicitis is suspected. For which clinical indicator should the nurse assess the pt to determine if the pain is secondary to appendicitis? A. Urinary retention B. Gastric hyperacidity C. Rebound tenderness D. Increased lower bowel motility
Rebound tenderness ***Rationale: This is a classic subjective sign of appendicitis.
A pt who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. To maintain sterility when changing the dressing, the nurse should: A. Put the unopened sterile glove package carefully on the sterile field B. Remove the sterile drape from its package by lifting it by the corners C. Don sterile gloves before opening the package containing the field drape D. Pour irrigation liquid from a height of at least 3 inches above the sterile container
Remove the sterile drape from its package by lifting it by the corners ***Rationale: The outer one inch of the sterile field is considered contaminated & can be touched without wearing sterile gloves
A pt undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? A. Respirations of 10 B. Urine output: 30mL/hr C. Lethargy D. Restlessness
Restlessness ***Rationale: In the early stage shock, the pt has increased epinephrine secretion. This causes the pt to become restless, anxious, nervous, & irritable.
A nurse is feeding an infant who recently underwent surgical repair of a cleft lip. What does the nurse plan to do for the infant just after each feeding? A. Burp several times B. Rinse the suture line C. Place on ABD D. Hold for several mins
Rinse the suture line ***Rationale: Meticulous care of the suture line is necessary because inflammation & sloughing of tissue disrupts healing.
A nurse is caring for a pt with acute pancreatitis. Which elevated lab result is MOST indicative of this? A. Blood glucose B. Serum lipase C. Serum bilirubin level D. WBC count
Serum lipase ***Rationale: Lipase is increased in the pancreas & is elevated in the serum when the pancreas becomes acutely inflamed; this distinguishes pancreatitis from other acute ABD problems.
A nurse teaches abt wearing thigh-high anti-embolism elastic stockings. What would be appropriate to include in the instructions? A. You do not need to wear them while you are awake but it is important to wear them at night B. You will need to apply them in the morning before you lower your legs from the bed to the floor C. If they bother you, you can roll them down to your knees while you are resting or sitting down D. You can apply them either in the morning or at bedtime but only after the legs are lowered to the floor.
You will need to apply them in the morning before you lower your legs from the bed to the floor ***Rationale: This prevents excessive blood from collecting & being trapped in the BLE as a result of the force of gravity.
