Evolve Set 1
When auscultating a client's heart, the nurse understands that the first heart sound is produced by the closure of the: 1. Mitral and tricuspid valves 2. Aortic and tricuspid valves 3. Mitral and pulmonic valves 4. Aortic and pulmonic valves
Correct 1 Mitral and tricuspid valves Closure of the atrioventricular valves, the mitral and tricuspid, produces the first heart sound (S1). Aortic and tricuspid valves and mitral and pulmonic valves do not close simultaneously.
The mother of a 6-year-old boy tells the nurse in the pediatric clinic that her son has become incontinent of stool. The nurse plans to assess the child to determine the cause of his encopresis. In what order should the nurse perform the assessments? 1. Psychosocial factors 2. Physical examination 3. Bowel habits 4. Nutrition history
1. Nutrition history 2. Bowel habits 3. Psychosocial factors 4. Physical examination First, a physical cause of the encopresis should be investigated. This includes the toilet-training process and changes in bowel habits or routines. If there are no changes in bowel pattern, a nutrition history may reveal any changes in the child's eating habits that caused the encopresis. Next, the nurse should explore psychosocial factors that may have influenced the development of the encopresis. Finally, a physical examination should be performed.
A nurse is caring for a pregnant client with type 1 diabetes having amniocentesis. She is in the 37th week of gestation and has been experiencing signs of preeclampsia. The purpose of the amniocentesis is to determine: 1. Gestational age 2. Fetal lung maturity 3. Presence of genetic disorders 4. Glucose level of the amniotic fluid
Correct Fetal lung maturity An amniocentesis at this stage of gestation is performed to determine fetal lung maturity. Gestational age is determined with the less invasive procedure of ultrasonography. Amniocentesis is performed between the 16th and 20th weeks to detect genetic disorders. Glucose level of the amniotic fluid is not the purpose for examining amniotic fluid.
The nurse manager hears a conversation between a nurse and a client that is focused on the details of their impending divorces. What is the nurse manager's response? 1. Waiting until the conversation ends and then telling the nurse that such topics must be discussed in strict privacy to ensure client confidentiality 2. Immediately asking to speak to the nurse privately and stating that sharing such personal information is nontherapeutic and not tolerated 3. Immediately explaining to both nurse and client that such conversations are inappropriate and that the nurse's assignment will be changed 4. Waiting until shift report and using that opportunity to discuss appropriate nurse-client boundaries with the attending nursing staff
Correct Immediately asking to speak to the nurse privately and stating that sharing such personal information is nontherapeutic and not tolerated The nurse-client relationship should always remain client focused. Discussing personal issues with the client, even in an attempt to share similar experiences, is nontherapeutic and should be discussed immediately by the nurse's supervisor. Although the ease with which this conversation was overheard does raise concerns about the nurse's understanding of the client's right to confidentiality and privacy, there is a greater issue that needs immediate attention and should be addressed immediately. The nurse's management of the nurse-client relationship should be discussed privately. It may not be necessary to change the assignment. Although it may be useful to reinforce information on privacy with the entire staff, the situation requires an immediate private discussion between the nurse and the nurse manager to satisfactorily address the problem for the individual nurse.
What should a nurse do immediately when a client returns from the postanesthesia care unit following a subtotal thyroidectomy? 1. Inspect the incision. 2. Instruct the client not to speak. 3. Place a tracheostomy set at the bedside. 4. Place in the supine position for 24 hours.
Correct Place a tracheostomy set at the bedside. Thyroid surgery sometimes results in accidental removal of the parathyroid glands. A resultant hypocalcemia may lead to contraction of the glottis, causing airway obstruction; edema around the operative site also may cause an airway obstruction. A patent airway takes priority over incision inspection. Speaking is important to determine the status of the laryngeal nerve. The semi-Fowler position is indicated to maximize respiratory excursion.
A client is scheduled for a computed tomography (CT) of the brain with contrast. Upon review of the client's medical record, what significant finding should the nurse report to the health care provider before the diagnostic procedure? The client: 1. Takes metformin (Glucophage) daily. 2. Has not been nothing by mouth (NPO). 3. Reports an allergy to gadolinium. 4. Was not prescribed a bowel prep.
Correct Takes metformin (Glucophage) daily A CT often requires a contrast agent to be administered. The contrast agent can cause temporary changes in kidney function. This change in kidney function can cause clients on metformin to have an increased risk of developing a serious side effect called lactic acidosis. NPO status is not required for a brain CT; however, clients may be instructed to be NPO for a CT of the abdomen or chest. Magnetic resonance imaging contrast contains gadolinium; contrast for CT scans contains iodine. A bowel prep is not required for this diagnostic procedure.
A nurse explains to the parents of a 6-year-old child with a pinworm infestation how pinworms are transmitted. What statement indicates that the teaching has been understood? "We need to keep the cat off the bed." "She needs to wash her hands before eating anything." "She needs to cover her mouth whenever she coughs." "We need to tell the school so that the cafeteria can be cleaned."
Correct 2 "She needs to wash her hands before eating anything." Pinworm infestation is transferred by way of the oral-anal route, and effective handwashing is the best way to prevent transmission. Cats do not transmit pinworms. The hands should be kept away from the nose and mouth; the child should be taught to cough into a tissue or the inside the elbow of the arm. Cleaning the cafeteria is not an effective means of preventing the transmission of pinworms.
During auscultation of the heart, the nurse expects the first heart sound (S1) to be the loudest at the: 1. Base of the heart 2. Apex of the heart 3. Left lateral border 4. Right lateral border
Correct 2 Apex of the heart The first heart sound is produced by closure of the mitral and tricuspid valves; it is heard best at the apex of the heart. Base of the heart is where the second heart sound (S2) is best heard; S2 is produced by closure of the aortic and pulmonic valves. Left lateral border covers a large area; the auscultatory areas that lie near it are the pulmonic and mitral areas. Right lateral border covers a large area; the only auscultatory area near it is the aortic area.
A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? 1. Nausea 2. Lethargy 3. Sunset eyes 4. Hyperthermia
Correct 2 Lethargy Lethargy is an early sign of a changing level of consciousness; it is one of the first signs of increased intracranial pressure. Nausea is a subjective symptom, not a sign, that may be present with increased intracranial pressure. Sunset eyes are a late sign of increased intracranial pressure that occurs in children with hydrocephalus. Hyperthermia is a late sign of increased intracranial pressure that occurs as compression of the brainstem increases.
A client's urine specific gravity is being measured. For what condition should the nurse conduct a focused assessment when a client's specific gravity is increased? 1. Fluid overload 2. Low-grade fever 3. Diabetes insipidus 4. Chronic kidney disease
Correct 2 Low-grade fever An elevated temperature can lead to dehydration and an increased urine specific gravity (more than 102.5). When there is edema or fluid overload, the accumulating body fluid will cause a decrease in the specific gravity of the urine. A client with diabetes insipidus excretes a large amount of dilute urine; dilute urine will have a decreased specific gravity. In chronic kidney disease there is an inability to concentrate urine and urine will be dilute.
A client is scheduled for a transurethral needle ablation (TUNA) of the prostate with a continuous bladder irrigation. The client will be discharged from the outpatient unit with a urinary retention catheter in place. What is most important for the nurse to teach the client before discharge? 1 .How to change the abdominal dressing 2. How to maintain tension on the catheter 3. Ensuring urine flows from the catheter 4. Observing for clinical findings of a wound infection
Correct 3 Ensuring urine flows from the catheter Patency promotes bladder decompression, which prevents distention. There is no abdominal dressing with a TUNA surgery performed via the urethra. Tension should not be placed on the urinary catheter. Tension on the catheter may be maintained when a client had a transuretheral resection of the prostate to limit bleeding at the operative site. There is no external wound because there is no abdominal incision.
A jogger sustains multiple fractures of the femur after being hit by a motor vehicle. A nurse responds to the scene of the accident to assist with care. The nurse recalls that, for this type of fracture, immediate life-threatening systemic complications can be minimized by: 1. Elevating the affected limb 2. Encouraging deep breathing and coughing 3. Handling and transporting the client gently 4. Maintaining anatomic alignment of the clients limb
Correct 3 Handling and transporting the client gently Gentle intervention reduces pain and shock and inhibits the release of bone marrow into the system, which can cause a fat embolism. Elevation of the affected limb will not prevent a fat embolus; it may limit edema and pain, which are local effects. Deep breathing and coughing will not prevent a fat embolus; they are not a priority at the scene of an accident. Maintaining the client's limb in the position in which it is found is necessary during transport to the hospital.
During a client's labor the fetal monitor reveals a fetal heart pattern that signifies uteroplacental insufficiency. What is the nurse's first intervention? 1. Inserting a urine retention catheter 2. Administering oxygen by means of nasal cannula 3. Helping the client turn to the side-lying position 4. Encouraging the client to pant with her next contraction
Correct 3 Helping the client turn to the side-lying position Helping the client turn to the side-lying position will improve uterine blood flow, and fetal oxygenation will increase. Inserting a urine retention catheter is unnecessary; in addition, it requires a health care provider's prescription. Oxygen may be administered eventually if necessary, but this is not the first intervention. Encouraging the client to pant with her next contraction will not increase uterine blood flow or oxygen to the fetus.
A client who has cancer of the sigmoid colon is to have an abdominoperineal resection with a permanent colostomy. Before surgery a low-residue diet is prescribed. The nurse explains that this is necessary to: 1. Limit production of flatus in the intestine 2. Prevent irritation of the intestinal mucosa 3. Reduce the amount of stool in the large bowel 4. Lower the bacterial count in the gastrointestinal tract
Correct 3 Reduce the amount of stool in the large bowel This diet is low in fiber; after digestion and absorption there is only a small amount of residue to be eliminated. This diet does not promote peristalsis; the products of digestion remain in the intestine longer, and flatus is increased. Although a low-residue diet is less irritating, this is not the primary reason for its use before surgery. Antimicrobials, such as neomycin, are given to lower the bacterial count in the gastrointestinal tract.
Which nursing action is protected from legal action? 1. Providing health teaching regarding family planning 2. Offering first aid at the scene of an automobile collision 3. Reporting incidents of suspected child abuse to the appropriate authorities 4. Administering resuscitative measures to an unconscious child pulled from a swimming pool
Correct 3 Reporting incidents of suspected child abuse to the appropriate authorities The reporting of possible child abuse is required by law, and the nurse's identity can remain confidential. The nurse is functioning in a professional capacity and therefore can be held accountable. Although the Good Samaritan Act protects health professionals, the nurse is still responsible for acting as any reasonably prudent nurse would in a similar situation.
When discussing a scheduled liver biopsy with a client, the nurse explains that for several hours after the biopsy the client will have to remain in what position? 1. The left side-lying position with the head of the bed elevated 2. A high Fowler position with both arms supported on several pillows 3. The right side-lying position with pillows placed under the costal margin 4. Any comfortable recumbent position as long as the client remains immobile
Correct 3 The right side-lying position with pillows placed under the costal margin In the right side-lying position with pillows placed under the costal margin, the liver capsule at the entry site is compressed against the chest wall and escape of blood or bile is impeded. The left side-lying position with the head of the bed elevated, a high Fowler position with both arms supported on several pillows, and any comfortable recumbent position as long as the client remains immobile are unsafe because pressure will not be applied to the puncture site and the client can bleed from the insertion site.
A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client engages in angry outbursts and places excessive demands on the staff. One day an unlicensed assistive personnel (UAP) tells the nurse, "I've had it. I am not putting up with that behavior. I'm not going in there again." What is the best response by the nurse? 1"You need to try to be patient. The client is going through a lot right now." 2"I'll talk with the client. Maybe I can figure out the best way for us to handle this." 3"Just ignore it and get on with your work. I'll assign someone else to take a turn." Correct 4"The client's frightened and taking it out on the staff. Let's think of approaches we can take."
Correct 4 The correct response interprets the client's behavior without belittling the UAP's feelings; it encourages the UAP to get involved with plans for future care. Telling the UAP to be patient recognizes the client's feelings, but it does not address the UAP's feelings or help the UAP cope with the client's behavior. The nurse should not assume the UAP has nothing to contribute and that only the nurse can deal with the problem. Saying "Just ignore it" does not help the UAP understand the client's behavior, nor does it demonstrate an understanding of the client's feelings.
A client develops iron deficiency anemia. Which of the client's laboratory test results should the nurse expect to be decreased? 1. Ferritin level 2. Platelet count 3. White blood cell count 4 .Total iron-binding capacity
Correct1 Ferritin level Ferritin, a form of stored iron, is reduced with iron deficiency anemia. Platelets will be within the expected range or increased with iron deficiency anemia. Red, not white, blood cells are decreased with iron deficiency anemia. Total iron-binding capacity will be increased with iron deficiency anemia
A client has coronary artery bypass graft (CABG) surgery for the second time via a sternal incision. What should the nurse teach the client to expect when returning home? 1. No further drainage from the incisions 2. Increased edema in the leg that provided the donor graft 3. Mild incisional pain and tenderness for three to four weeks 4. Extreme fatigue and a mild fever occurring for several weeks
Correct2 Increased edema in the leg that provided the donor graft Because the client is out of bed more at home and the leg used for the donor graft is in the dependent position, edema of this extremity usually increases. The internal mammary artery is the graft of choice and was probably used in the first CABG procedure, necessitating retrieval of a vessel from the leg. Serosanguinous drainage may persist after discharge. Mild incisional pain and tenderness may persist longer than 3 to 4 weeks because it takes 6 to 12 weeks for the sternum to heal. Extreme fatigue and a mild fever are not expected; these are associated with postpericardiotomy syndrome and should be reported to the health care provider immediately.
The nurse is providing preoperative teaching to a client that is scheduled for an electromyography of the leg. What should the nurse include in the education? 1. A heart monitor will be in place throughout the procedure 2. The involved area will be shaved before testing 3. A needle will be inserted into the muscle being tested 4. The client will need to be supine for two to three hours after the procedure
Correct3 A needle will be inserted into the muscle being tested The examiner will insert a needle into the muscle being tested to assess electrical activity and determine whether symptoms primarily are musculoskeletal or neurological. No special preparation for an electromyography is required. No special care is required after the procedure.
