Adaptive Quizzing
A client is prescribed epoetin injections. To ensure the client's safety, which lab value should the nurse assess before administration?
1 Hemoglobin* 2 Platelet count 3 Prothrombin time 4 Partial thromboplastin time Epoetin is used to treat anemia by increasing production of red blood cells. The lab value the nurse should assess before administration is the hemoglobin because it measures the number of red blood cells.
A client with acquired immunodeficiency syndrome (AIDS) is receiving a treatment protocol that includes a protease inhibitor. When assessing the client's response to this drug, which common side effect should the nurse expect?
Correct 1 Diarrhea 2 Hypoglycemia 3 Paresthesias of the extremities 4 Seeing yellow halos around lights
When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is what? Incorrect1 Sodium Correct2 Potassium 3 Calcium 4 Calcitonin
A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Sodium is the most abundant extracellular cation that regulates serum osmolarity as well as nerve impulse transmission and acid-base balance. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction. Calcitonin is a hormone secreted by the thyroid gland and works opposite of parathormone to reduce serum calcium and keep calcium in the bones. Calcitonin does not have a direct effect on intracellular osmolarity.
Three days after admission to the hospital for a brain attack (cerebrovascular accident, CVA), a client has a nasogastric tube inserted and is receiving continuous tube feedings. Which action should the nurse take to best evaluate whether the feeding is being absorbed? Correct1 Aspirate for a residual volume Incorrect2 Evaluate the intake in relation to the output 3 Instill air into the client's stomach while auscultating 4 Compare the client's body weight with the baseline data
A gastric residual of over 200 mL or as specified by the primary healthcare provider or facility will alert the nurse that the feeding is not being absorbed; conversely, a residual of less than 200 mL indicates the feeding is being absorbed. Evaluation of intake to output gauges fluid balance, not whether feeding is absorbed. Instilling air into the client's stomach is not advocated and does not determine if the feeding is absorbed. Comparing the body weight to the baseline is a fluid issue and is performed on a daily basis, or it is a weight gain/loss issue. Since weight can fluctuate based on fluid, the aspirate is the better choice for absorption.
A client with human immunodeficiency virus-associated Pneumocystis jiroveci pneumonia is to receive pentamidine intravenously once daily. What should the nurse do to ensure client safety? Select all that apply. 1 Monitor for decreased serum potassium levels. Incorrect2 Administer the drug over a period of 30 minutes. 3 Monitor blood pressure for hypertension during therapy. Correct4 Tell the client to report any evidence of bleeding immediately. Correct5 Assess blood glucose levels daily and several times after therapy is completed.
Any signs of bleeding (e.g., bleeding gums or blood in the urine, stool, or emesis), unusual bruising, or petechiae should be reported to the healthcare provider. Pentamidine may cause hypoglycemia or hyperglycemia even after therapy has been discontinued; therefore blood glucose levels should be monitored. Pentamidine may increase, not decrease, serum potassium levels. Administering the drug over a period of 30 minutes is too quick; the drug should be given over at least 60 minutes. Clients should be monitored closely for sudden, severe hypotension; they should lie flat when receiving the drug.
The nurse is assessing a Latino-Caribbean client who was brought to the hospital by family members. The family reports the client started crying, shouting, trembling, had uncontrolled jerking of the extremities, and then fell into a trance-like state. What condition does the nurse suspect? 1 Bulimia nervosa 2 Anorexia nervosa Incorrect3 Shenjing shuairuo Correct4 Ataque de nervios
Ataque de nervios is a Latino-Caribbean culture-bound syndrome that usually happens in response to specific stressors. This culture-bound syndrome is characterized by crying, uncontrollable spasms, trembling, shouting, dissociation, and trance-like states. Bulimia nervosa and anorexia nervosa are culture-bound syndromes in the form of eating disorders, but they are not characterized by crying, spasms, and shouting. Shenjing shuairuo is not associated with the Latino-Caribbean culture; instead, it is associated with Chinese culture.
What should the nurse include when teaching a client with severe Parkinson's Disease about carbidopa-levodopa? 1 Multivitamins should be taken daily. 2 Alcohol consumption should be moderate. Correct3 The medication can be taken with meals. 4 A high-protein diet should be followed.
Carbidopa-levodopa is often taken with meals to reduce the nausea and vomiting commonly associated with this drug. Although the best practice is to take carbidopa-levodopa on an empty stomach, this is often not feasible for many clients who suffer from gastrointestinal disturbances related to this medication. Multivitamins are contraindicated as they often contain pyridoxine (vitamin B6), which diminishes the effects of levodopa. Moderate alcohol consumption can also antagonize the drug effect. A high-protein diet is contraindicated because levodopa is an amino acid that may increase blood urea nitrogen (BUN) levels. Additionally, some proteins contain pyridoxine, which diminishes the desired therapeutic effect by increasing peripheral levodopa metabolism and reducing the amount of bioavailable levodopa crossing the blood-brain barrier.
A registered nurse is educating a nursing student about the different levels of prevention with different scenarios. Which scenario is an example of tertiary prevention? Incorrect1 A nurse educates a community about the proper use of environmental sanitation. 2 A nurse educates a family about how to protect themselves from carcinogens. 3 A nurse provides education to a family regarding the need to pay attention to personality development. Correct4 A nurse educates a community about the need to integrate individuals' limb amputations into the professional sphere.
Educating the public about the use of rehabilitated individuals to their fullest extent is a tertiary prevention. Educating a community about the proper use of environmental sanitation is an example of primary prevention. Educating a family about methods of protecting themselves from carcinogens is an example of primary prevention. Providing education about the need to pay attention to personality development is also an example of primary prevention. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there is usually no pattern to the answers.
A client is receiving fresh frozen plasma (FFP). The nurse would expect to see improvement in which condition? 1 Thrombocytopenia 2 Oxygen deficiency Correct3 Clotting factor deficiency Incorrect4 Low hemoglobin
FFP is an unconcentrated form of blood plasma containing all of the clotting factors except platelets. It can be used to supplement red blood cells (RBCs) when other blood products are not available or to correct a bleeding problem of unknown cause. Thrombocytopenia is a condition of low platelet count and is not treated with FFP. An oxygen deficiency and low hemoglobin may be improved indirectly with FFP, but it is not a definitive treatment. Test-Taking Tip: Survey the test before you start answering the questions. Plan how to complete the exam in the time allowed. Read the directions carefully and answer the questions you know for sure first.
A mother of a seven-month-old infant reports that her baby still cannot sit without support. Upon asking further questions, the nurse realizes that the child's gross-motor skills are not properly developed. Which question did the nurse most likely ask the mother? Correct1 Can your child hold on to furniture? 2 Can your child show hand preference? Incorrect3 Does your child move on his or her hands and knees? 4 Can your child place objects in containers?
Gross-motor skill development features in a seven month old include sitting alone without any support. Another sign is the infant's ability to hold on to furniture. An infant between 8 and 10 months may show hand preference as a part of fine-motor skill development. Moving on hands and knees may represent gross-motor skill development in an 8 to 10 month old. A 10 to 12 months infant may have the ability to place objects in containers; this action is a part of fine-motor skill development.
A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis? Incorrect1 Blood glucose Correct2 Serum lipase 3 Serum bilirubin level 4 White blood cell count
Lipase concentration is increased in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed; this distinguishes pancreatitis from other acute abdominal problems. An elevated blood glucose level is not indicative of pancreatitis but rather diabetes mellitus; however, hyperglycemia and glycosuria may occur in some people with acute pancreatitis if the islets of Langerhans are affected. Serum bilirubin level occurs in other disease processes, such as cholecystitis. White blood cell count is not specific to pancreatitis; white blood cells are elevated in other disease processes.
A client is admitted to the hospital for the implantation of radon seeds in the oral cavity. Which intervention is most important when the nurse is caring for this client after the procedure? 1 Providing a regular diet within two days Correct2 Administering nursing care in a short period Incorrect3 Giving frequent mouth care at least four times daily 4 Having a member of the family stay with the client continually
Nursing care should be organized and administered efficiently so that the nurse's exposure to radiation is kept to a minimum. A regular diet is contraindicated until the radon seeds are removed because chewing can dislodge the seeds. Frequent mouth care is contraindicated because it can dislodge the seeds; drying of the mucous membranes cannot be prevented. A family member should not be in attendance continually because this will expose the family member to excessive radiation.
A client with cholelithiasis is scheduled for a lithotripsy. What should the nurse include in the client's teaching plan? Correct1 Opioids will be available for postoperative pain. Incorrect2 Fever is a common response to this intervention. 3 Heart palpitations often occur after the procedure. 4 Anesthetics are not necessary during the procedure.
Painful biliary colic may occur in the postoperative period as a result of the passage of pulverized fragments of the calculi; this may occur three or more days after the lithotripsy. Fever may indicate pancreatitis, which is a rare occurrence. The delivery of shock waves during the procedure is synchronized with the heartbeat to avoid initiation of dysrhythmias. Light sedation may be used to keep the client comfortable and as still as possible.
A client returns from surgery after an abdominal cholecystectomy for a gangrenous gallbladder. For which postoperative complication, associated with the location of the surgical site, should the nurse assess the client? Correct1 Atelectasis 2 Hemorrhage Incorrect3 Paralytic ileus 4 Wound infection
Subcostal incisional pain causes the client to splint and avoid deep breathing, which impedes air exchange in the alveoli. The location of the incision does not increase the risk of hemorrhage. Paralytic ileus can be a postoperative problem, but it is unrelated to the site of the incision. The subcostal incision site is not specifically vulnerable to infection.
. After a surgical thyroidectomy a client exhibits carpopedal spasm and some tremors. The client complains of tingling in the fingers and around the mouth. What medication should the nurse expect the primary health care provider to prescribe after being notified of the client's adaptations? Incorrect1 Potassium iodide Correct2 Calcium gluconate 3 Magnesium sulfate 4 Potassium chloride
The client is exhibiting signs and symptoms of hypocalcemia, which occurs with accidental removal of the parathyroid glands; calcium gluconate is administered to treat hypocalcemia. Potassium iodide is prescribed for hyperthyroidism because it inhibits the release of thyroid hormones. Magnesium sulfate is prescribed for hypomagnesemia or to treat pregnant women who have preeclampsia. Potassium chloride is prescribed for hypokalemia, not hypocalcemia. Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to identify it. This will permit you to recognize areas that need further review. It will also help you to see how correct your "guessing" can be. Remember: on the licensure examination you must answer each question before moving on to the next question.
1 Develop a diet plan according to the client's food preference. Correct2 Coordinate with the members of the ICU while transferring the client. Correct3 Provide cardiopulmonary resuscitation before transferring the client. Incorrect4 Encourage the client's family members to visit the client frequently. Correct5 Administer digoxin (Cardoxin) to the client according to the prescription.
The major attributes that affect the quality of care are coordinating with the members of different departments during transitions, providing most important services, and acting within the scope of practice. Therefore coordinating with the members of the ICU while transferring the client, providing cardiopulmonary resuscitation, and administering digoxin (Cardoxin) are the major attributes. Considering the client's preference is a minor attribute that affects the quality of care and helps provide patient-centered care. Thus developing a diet plan according to the client's food preference is a minor attribute. The nurse should take measures to prevent the risk of infection. Therefore the nurse should not ask the family members to visit the client frequently because it increases the risk of infection.
A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? Incorrect1 Fatigue related to weight loss secondary to COPD Correct2 Imbalanced nutrition: less than body requirements, related to fatigue 3 Imbalanced nutrition: less than body requirements, related to COPD 4 Ineffective breathing pattern, related to alveolar hypoventilation
The response portion of the nursing diagnosis is Imbalanced nutrition: less than body requirements, and the etiology is fatigue associated with the disease process of COPD. Interventions should be planned to deal with the breathing problem and the fatigue associated with it while implementing actions to combat the weight loss. Weight loss related to COPD is not a NANDA-approved nursing diagnosis. Fatigue associated with the COPD disease process is the cause of the weight loss, not COPD in itself. Altered breathing pattern is also a problem, but does not specifically relate to the weight loss problem.
