AH1 fundamentals- week 9

A nurse is documenting the intake for a client who is scheduled for an abdominal computed axial tomography (CT) scan. Prior to the scan, the client consumes 12 oz sodium diatrizoate and meglumine diatrizoate. The client has an IV of D5½ NS running at 75 mL/hr from 0700 until 1200. The IV runs at 30 mL/hr from 1200 to 1500. At 1500, the client has 6 oz juice. How many mL should the nurse document as the client's intake for the shift? ______ mL

1005 mL Correct Rationale: First, determine the amount of intake for each source.Sodium diatrizoate and meglumine diatrizoate: 12 oz1 oz = 30 mL12 oz x 30= 360 mLD5½ NS IV:75 mL/hr from 0700 until 1200: 75 mL/hr x 5 hr = 375 mL 30 mL/hr from 1200 until 1500: 30 mL/hr x 3 hr = 90 mLTotal IV intake = 90 mL + 375 mL = 465 mLJuice: 6 oz1 oz = 30 mL6 oz x 30 = 180 mLTotal the amounts: 360 mL + 465 mL +180 mL = 1,005 mLThe client's total intake is 1,005 mL.

A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over 24 hr using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ mL/hr

35 mL/hr Correct Rationale: STEP 1: What is the unit of measurement the nurse should calculate? mL/hr STEP 2: What is the volume the nurse should infuse? 840 mL STEP 3: What is the total infusion time? 24 hr STEP 4: Should the nurse convert the units of measurement? No STEP 5: Set up an equation and solve for X. Volume (mL)/Time (hr) = X mL/hr 840 mL/24 hr = X mL/hr X = 35 mL/hr STEP 6: Round if necessary. STEP 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads 840 mL of enteral nutrition to infuse over 24 hr, it makes sense to administer 35 mL/hr. The nurse should set the infusion pump to deliver the enteral formula at 35 mL/hr.

A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; room 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client? A. 208 B. 212 C. 214 D. 216

A. 208 Rationale: A client who has or might have tuberculosis requires airborne precautions. That means a private room with negative-pressure airflow. Room 208 is the only one of these options that fits these requirements.

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8º C (98.2º F). Which of the following actions should the nurse perform? A. Complete a neurological check. B. Administer the prescribed PRN antihypertensive medication. C. Increase the client's fluid intake. D. Hold the client's evening dose of digoxin.

A. Complete a neurological check. Rationale: Neurological assessment is an appropriate nursing intervention when a client displays sudden confusion. Sensory alterations can occur when a client is experiencing multiple sensory stimuli and can result in inappropriate sensory responses. Tolerance to stimuli may be affected by fatigue and emotional and physical well-being.

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.) A. Report of feeling pressure B. Tenderness over the symphysis pubis C. Distended bladder D. Voiding 30 mL frequently E. Dysuria

A. Report of feeling pressure B. Tenderness over the symphysis pubis C. Distended bladder D. Voiding 30 mL frequently Rationale: Report of feeling pressure is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a report of feeling pressure.Tenderness over the symphysis pubis is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include tenderness over the symphysis pubis.Distended bladder is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a distended bladder.Voiding 30 mL frequently is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include frequent voiding of 25 to 60 mL of urine.Dysuria is incorrect. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Dysuria, or painful burning with urination, is not a finding associated with urinary retention

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Use a transfer device to lift the client up in bed. B. Apply cornstarch to keep sensitive skin areas dry. C. Massage the skin over the client's bony prominences. D. Elevate the head of the bed no more than 45°.

A. Use a transfer device to lift the client up in bed. Rationale: Using a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions.

A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching? A. "I will tie restraints in double knots." B. "I will tie a restraint to the portion of the bed that moves when the head of the bed is moved." C. "I will ensure that restraints fit tightly against the client." D. "I will put four side rails up if a client is confused."

B. "I will tie a restraint to the portion of the bed that moves when the head of the bed is moved." Rationale: This statement by the AP indicates an understanding of the teaching. Restraints should be tied to the portion of the bed that moves when the head of the bed is raised or lowered

A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings should the nurse assess first? A. Client's history of previous accidents B. Date of the client's last tetanus immunization C. Client's blood alcohol level D. Signs of wound infection

B. Date of the client's last tetanus immunization Rationale: The greatest risk to this client is injury from infection with Clostridium tetani; therefore, the priority assessment the nurse should perform is to determine whether the client will require a tetanus immunization by identifying the date the client last received one. An adult should have a tetanus booster immunization every 10 years and after any severe or dirty wound.

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? A. Observe client's respiratory status. B. Elevate the head of the client's bed 30° to 45°. C. Monitor intake and output every 8 hr. D. Check residual volume every 4 to 6 hr.

B. Elevate the head of the client's bed 30° to 45°. Rationale: A client who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying flat also increases this risk. The priority action by the nurse is to keep the head of the bed elevated 30o to 45o to promote gastric emptying and reduce the risk of aspiration.

A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed? A. Battery B. Negligence C. Malpractice D. Assault

B. Negligence Rationale:Negligence is the failure to provide the expected standard of care. The expected standard of care was strict bedrest

A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done." Which of the following actions should the nurse take? A. Remind the client that a signed informed consent form is a legally binding document. B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure. C. Inform the surgical team to cancel the client's surgery. D. Proceed with preparation of the patient for the surgical procedure.

B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure. Rationale: The client has the right to withdraw informed consent; therefore, the surgeon who is the one to obtain the informed consent should be notified of the request.

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality? A. Logging out of the computer before leaving a terminal B. Sharing computer passwords with coworkers C. Using a computer terminal in a non-public area D. Preventing an unidentified health care worker from viewing a health record on the computer screen

B. Sharing computer passwords with coworkers Rationale: This action violates client confidentiality by allowing coworkers to access information which they may not be authorized to view.

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent? A. Obtain the client's consent. B. Witness the client's signature. C. Explain the risks and benefits of the procedure. D. Explain the procedure to the client if they do not understand.

B. Witness the client's signature. Rationale: It is the nurse's responsibility to witness the client's signing of the consent form, and to verify that the client is consenting voluntarily and appears to be competent to do so.

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented? A. "I will begin 48 hr before the client's discharge." B. "I will begin once the client's discharge order is written." C. "I will begin upon the client's admission to the facility." D. "I will begin once the client's insurance company approves discharge coverage."

C. "I will begin upon the client's admission to the facility." Rationale: Effective discharge planning must begin upon admission of the client to the facility.

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? A. Pinnae of the ears B. Dorsal surface of the hand C. Conjunctivae D. Dorsal surface of the foot

C. Conjunctivae Rationale: To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of the feet, conjunctivae, and mucous membranes.

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client? A. Lordosis B. Ankylosis C. Kyphosis D. Scoliosis

C. Kyphosis Rationale: Kyphosis, a forward "stooping" posture with a loss of height, is an angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and increases with aging and vertebral fractures.

A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? A. "There were no injuries sustained." B. "An incident report was completed." C. "An incident report was forwarded to risk management." D. "The provider was notified."

D. "The provider was notified." Rationale: Nursing interventions that support factual information should be documented in the health record

A nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide? A. "It is quicker to administer medications intravenously in the hospital." B. "Clients over the age of 65 must have a saline lock according to facility policy." C. "We administer all medications intravenously to clients in this unit." D. "Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours."

D. "Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours." Rationale: Intermittent antibiotic medications are frequently administered parenterally. This allows the client to ambulate between medication administrations, enhances client safety and promotes comfort. The response addresses the client's concern.

A nurse is reviewing a client's prescription for 1,000 mL of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 mL of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution? A. 1500 B. 1600 C. 1700 D. 1800

D. 1800 Rationale: The IV will infuse at 125 mL/hr. The next bag of IV solution will need to be administered at 1800.

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? A. Creatine kinase B. Troponin C. Total bilirubin D. Albumin

D. Albumin Rationale: A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time.

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown? A. An adolescent who has a cervical fracture and is in a halo brace B. A young adult who has a femur fracture and is in skeletal balanced suspension traction C. A middle adult who has a fractured radius and an arm cast D. An older adult who has a hip fracture and is in Buck's traction

D. An older adult who has a hip fracture and is in Buck's traction Rationale: According to evidenced-based practice, this client has multiple risk factors for skin breakdown: the aging process (decreased muscle mass, thin and fragile skin) and the limitation of movement due to traction. Therefore, this client is at the greatest risk for skin breakdown.

A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted? A. Contract the pelvic muscles. B. Take a sip of water. C. Exhale slowly. D. Bear down.

D. Bear down. Rationale: Bearing down gently as if to void relaxes the external sphincter and eases urinary catheter insertion.

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures? A. Trochanter roll B. Sheepskin heel pad C. Abduction pillow D. Footboard

D. Footboard Rationale: Plantar flexion contractures, or foot drop, develop when a client's unsupported feet are constantly in plantar flexion. The nurse should place the soles of the client's feet against a footboard, a flat wooden or plastic panel perpendicular to the bed, to keep them dorsiflexed and, therefore, prevent foot drop.

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care? A. Ask the client to move her arms and legs while applying slight resistance. B. Move the client's limbs through their complete range of motion. C. Have the client move each limb independently through its complete range of motion. D. Instruct the client to tighten muscle groups for a short period, and then relax.

D. Instruct the client to tighten muscle groups for a short period, and then relax. Rationale: Isometric exercises involves static (no movement) contraction of a muscle without any movement of the joint. Isometrics promote increased muscle mass, strength, and tone for clients who are on bedrest.

A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include? A. Perform catheterization when you recognize the urge to void. B. Hold the penis at a 30° to 45° angle when inserting the catheter. C. Inflate the balloon when the urine flow stops. D. Use soap and water to wash the catheter after each use.

D. Use soap and water to wash the catheter after each use. Rationale: The client should wash the catheter using soap and water and store it in a clean container after each use.

A nurse is calculating the intake of a client during the past 9 hr. The client's intake includes lactated Ringer's IV at 150 mL/hr, cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride, two units of packed RBCs of 275 mL and 250 mL; two IV bolus infusions of 250 mL of 0.9% sodium chloride, ranitidine 50 mg IV intermittent bolus in 50 mL of dextrose 5% in water. How many mL of intake should the nurse record? ______ mL

2525 mL Correct Rationale: Lactated Ringer's 150 mL x 9 hr = 1350 mLcefazolin = 100 mLpacked RBCs 275 mL + 250 mL = 525 mL0.9% sodium chloride bolus 250 mL + 250 mL = 500 mLranitidine = 50 mLTotal intake = 2525 mL

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take? A. Apply the bag for 30 min at a time. B. Reapply the bag 30 min after removing it. C. Allow room for some air inside the bag. D. Place the bag directly on the skin.

A. Apply the bag for 30 min at a time. Rationale: The nurse should leave the bag in place for 30 min, but should check the client's skin after 15 min to make sure there are no adverse effects.

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate? A. Gait belt B. Jacket harness C. Four-wheel walker D. Cane

A. Gait belt Rationale: The nurse should use a gait belt to help support the client during ambulation. A gait belt helps keep the client's center of gravity stable and helps maintain balance and prevent falls.

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? A. Lactated Ringer's B. Dextrose 5% in 0.9% sodium chloride C. 0.45% sodium chloride D. Dextrose 10% in water

C. 0.45% sodium chloride Rationale: A client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as 0.45% sodium chloride or 0.225% sodium chloride

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process? A. Planning B. Evaluation C. Assessment D. Implementation

C. Assessment Rationale: The assessment phase includes asking the client about her health history, physical concerns and health care expectations. A review of possible allergies is included in the assessment phase.