Exam 2: part 1/2
1. The nurse emphasizes the need for especially close monitoring in the patient who is taking antitubercular drugs and has a history of 1. 1liver disease. 2. renal disease. 3. heart disease. 4. bowel disease.
1. 1liver disease.
A nurse admits a client to a telemetry unit and obtains the following electrocardiogram (ECG) strip of the client's heart rhythm. What should be the nurse's interpretation of this rhythm strip?
1. Atrial flutter 2. Atrial fibrillation 3. Sinus bradycardia 4. Sinus rhythm with premature atrial contractions
A nurse is reviewing the chart of a client admitted for treatment of a pulmonary embolus. Based on the analysis of the chart information, which conclusion by the nurse is correct? SELECT ALL THAT APPLY Admitting History & Physical Serum Laboratory Data Diagnostic Data Results Medications & Treatments • Allergies: Latex • APTT: 31 seconds • Lung scan: • 0.9% NaCl at 100 mL/hr and sulfonamides • K: 3.2 mEq/L High ventilation- • KCL 10 mEq IV now • Had been on bedrest at • SCr: 0.7 mg/dL perfusion (V/Q) ratio • Metronidazole (Flagyl®) home due to influenza; • WBCs: 18.9 K/μL 500 mg IV q6hr treated with antibiotics • Stool culture positive • Initiate heparin • Severe abdominal for Clostridium difficile intravenous infusion cramping and diarrhea per protocol • Chest pain on • Contact isolation inhalation precautions • Dyspneic • Oxygen 2-4 liters by • Hemoptysis simple face mask • Lung sounds: Pleural friction 1. Infection with Clostridium difficile is likely from the antibiotics used to treat influenza. 2. Contact isolation precautions are appropriate precautions for preventing an allergic reaction to latex. 3. Potassium chloride (KCL) is ordered to treat the client's low serum potassium level. 4. The metronidazole (Flagyl®) order should be questioned. 5. The heparin infusion order should be questioned. 6. The oxygen order should be questioned Clostridium difficile infection causes mild to severe diarrhea and abdominal cramping and can be associated with antibiotic treatment. Normal serum potassium levels are 3.5 to 5.5 mEq/L. Potassium chloride (KCL) is an appropriate treatment. The oxygen flow should be questioned; at least a flow rate of 5 L per minute is needed to prevent accumulation of expired air in the mask.
1. Infection with Clostridium difficile is likely from the antibiotics used to treat influenza. 3. Potassium chloride (KCL) is ordered to treat the client's low serum potassium level. 6. The oxygen order should be questioned
Davis A hospitalized client is being treated for tuberculosis (TB). When administering medications, which medication on the client's medication administration record (MAR) should a nurse conclude is used for the treatment of TB? 1. Isoniazid (Nydrazid®) 2. Fluconazole (Diflucan®) 3. Azithromycin (Zithromax®) 4. Acyclovir (Zovirax®)
1. Isoniazid (Nydrazid®)
1. A patient being treated for TB comes to the clinic after 2 months for a follow-up visit. Sputum smears for AFB are still positive. A sputum specimen is taken for culture and to determine whether the microorganism is sensitive to the drugs. The nurse questions the patient regarding the treatment regimen with the knowledge that 1. directly observed therapy will be necessary if the patient has been noncompliant. 2. a combination product of isoniazid, rifampin, and pyrazinamide (Rifater) is indicated if the patient skips doses 3. treatment protocols involving twice weekly administration of the drugs are not as effective as daily administration. 4. if the drugs are causing side effects, a regimen including the administration of only isoniazid can be substituted
1. directly observed therapy will be necessary if the patient has been noncompliant.
A nurse is planning care for a client admitted with a new diagnosis of persistent atrial fibrillation with rapid ventricular response. Although the client has had no previous cardiac problems, the client has been in atrial fibrillation for more than 2 days. The nurse should anticipate that the health-care provider is likely to initially order: SELECT ALL THAT APPLY. 1. oxygen. 2. immediate cardioversion. 3. administration of amiodarone (Cordarone®). 4. initiation of a IV heparin infusion. 5. immediate catheter-directed ablation of the AV node. 6. administration of a calcium channel antagonist such as diltiazem (Cardizem
1. oxygen. 3. administration of amiodarone (Cordarone®). 4. initiation of a IV heparin infusion. 6. administration of a calcium channel antagonist such as diltiazem (Cardizem
1. A patient with dilated cardiomyopathy is admitted to the hospital with fatigue, orthopnea, and pulmonary crackles. The patient has a left ventricular ejection fraction of 18%, and the physician prescribes continuous intravenous heparin. The nurse explains to the patient that the heparin is used to 1. prevent thrombus formation in the left ventricle. 2. increase the circulation to the skin and skeletal muscles. 3. prevent embolization to the lungs from clots in the legs. 4. decrease the viscosity of the blood to decrease cardiac workload.
1. prevent thrombus formation in the left ventricle.
1. A patient with inoperable coronary artery disease and end-stage cardiomyopathy asks the nurse whether a heart transplant is possible for him. The nurse's best response to the patient is 1. "Candidacy for a heart transplant is a medical decision that should be made between you and your doctor." 2. "There are many factors that determine a patient's candidacy for heart transplant, but the lack of donor hearts is a major problem." 3. "Since so few hearts are available, candidates for transplants must have no other history of heart disease except primary cardiomyopathy." 4. "A heart transplant is still considered an experimental surgery. Are you willing to undergo such a high-risk surgery and the intensive follow-up care that is required?"
2. "There are many factors that determine a patient's candidacy for heart transplant, but the lack of donor hearts is a major problem."
Following a normal chest x-ray for a client who had cardiac surgery, a nurse receives an order to remove the chest tubes. Which intervention should the nurse plan to implement first? 1. Auscultate the client's lung sounds 2. Administer 4 mg morphine sulfate intravenously 3. Turn off the suction to the chest drainage system 4. Prepare the dressing supplies at the client's bedside
2. Administer 4 mg morphine sulfate intravenously
Which intervention should the nurse implement with the client diagnosed with dilated cardiomyopathy? 1. Keep the client in the supine position iwht the legs elevated. 2. Discuss a heart transplant, which is the definitive treatment. 3. Prepare the client for coronary artery bypass graft. 4. Teach the client to take a calcium-channel blocker in the morning.
2. Discuss a heart transplant, which is the definitive treatment.
A client diagnosed with cardiomyopathy is hyponatremic as a result of fluid volume overload. A fluid restriction of 800 mL/24 hours is ordered by a physician. Which action by the nurse is most appropriate? 1. Provide ice chips and refill the glass every 4 hours. 2. Encourage the client to perform mouth care when feeling thirsty. 3. Offer sugary lozenges for the client to hold in the mouth. 4. Replenish the client's water every 2 hours and have the client take small sips.
2. Encourage the client to perform mouth care when feeling thirsty.
A 65-year-old client with a history of coronary artery disease is admitted with fluid volume overload. Bumetanide (Bumex®) is administered, and the client's serum potassium level drops to 3.0 mEq/L; intravenous (IV) potassium replacement is ordered. Which factor should a nurse consider when preparing to administer the IV potassium replacement? 1. The potassium concentration should not exceed 20 mEq/L. 2. Ice or warm packs may be needed to reduce vein irritation. 3. The potassium should be administered IV push. 4. The potassium should be added to the IV solution that is infusing.
2. Ice or warm packs may be needed to reduce vein irritation.
A nurse is responsible for supervising staff on a unit that includes registered nurses (RNs), licensed practical nurses (LPNs), and unlicensed assistive personnel (UAP). Which statement is related to the supervision of staff as opposed to the delegation of tasks? 1. Statement to another RN: "Please start an IV on Mr. Smith in room 458." 2. Statement to a health unit coordinator: "There are new orders on Mr. Jones's chart that need to be entered." 3. Statement to a UAP: "Please answer the call light for the client in 321." 4. Statement to a LPN: "Please give 8:00 a.m. medications to the client in 322."
2. Statement to a health unit coordinator: "There are new orders on Mr. Jones's chart that need to be entered."
Which assessment data indicate that the chest tubes have been effective in treating the client with a hemothorax who has a right-sided chest tube? 1. There is gentle bubbling in the suction compartment. 2. There is no fluctuation (tidaling) in the water-seal compartment. 3. There is 250 mL of blood in the drainage compartment 4. The client is able to deep breathe without any pain
2. There is no fluctuation (tidaling) in the water-seal compartment.
Because a step-down cardiac unit is unusually busy, a nurse fails to obtain vital signs at 0200 hours for a client 2 days postoperative for a mitral valve replacement. The client was stable when assessed at 0600 hours, so the nurse documents the electrocardiogram monitor's heart rate in the client's medical record for both the 0400 and 0600 vital signs. The charge nurse supervising the nurse determines that the nurse's behavior was: SELECT ALL THAT APPLY. 1. the correct action because neither complications nor harmful effects occurred. 2. a legal issue because the nurse has fraudulently falsified documentation. 3. demonstrating beneficence because the nurse decided what was best for the client. 4. an ethical issue of veracity because the nurse has been untruthful regarding the client's care. 5. an ethical legal issue of confidentiality because the nurse disclosed incorrect information. 6. demonstrating distributive justice because the nurse decided other clients' needs were priority.
2. a legal issue because the nurse has fraudulently falsified documentation. 4. an ethical issue of veracity because the nurse has been untruthful regarding the client's care.
1. During assessment of the patient with pneumonia, the nurse recognizes that 1. all patients with pneumonia will have a productive cough. 2. manifestations of pneumonia vary, depending on the causative organism. 3. the typical pneumonia symptoms are usually caused by Mycoplasma pneumoniae. 4. although a variety of microorganisms cause pneumonia, the pathophysiology of the disease is the same, regardless of the cause.
2. manifestations of pneumonia vary, depending on the causative organism.
1. A patient with primary dilated cardiomyopathy is hospitalized with pulmonary edema and hypotension. In planning care for the patient, the nurse knows that 1. aggressive treatment of the patient's heart failure with diuretics will control his symptoms. 2. the patient may need information regarding his grave prognosis and candidacy for heart transplantation. 3. the patient needs to be reassured treatment of the underlying disease process will return normal cardiac function. 4. the clinical manifestations of cardiomyopathy resemble those of congestive heart failure but cardiomyopathy is more responsive to pharmacologic treatment.
2. the patient may need information regarding his grave prognosis and candidacy for heart transplantation.
A client with a suspected pulmonary embolus receives a ventilation and quantification nuclear medicine (VQ) scan to evaluate regional lung ventilation of airflow and regional lung blood flow. In consulting with a physician, a nurse learns that there is a VQ mismatch. Based on this information, which action should be taken by the nurse? 1. Tell the client that tuberculosis treatment will be needed 2. Reassure the client that he/she does not have a pulmonary embolus 3. Explain to the client that further testing will be needed 4. Inform the client that the test was normal
3. Explain to the client that further testing will be needed
1. Four days after admission, a patient with chronic obstructive lung disease is diagnosed with hospital-acquired pneumonia. The nurse recognizes that a common cause of this type of pneumonia is 1. Pneumocystis carinii. 2. Haemophilus influenzae. 3. Pseudomonas aeruginosa. 4. Mycoplasma pneumoniae
3. Pseudomonas aeruginosa.
A registered nurse (RN) is informed by a nursing assistant (NA) that a client, hospitalized last evening with chest pain, plans to leave right now because the pain is gone and "nobody has done anything anyway." Which is the nurse's best action? 1. Thank the NA for the information and then call the client's doctor regarding the situation 2. Tell the NA that the client has the right to leave and send the NA to help the client pack 3. Talk with the client to discuss the client's concerns and explain the plan of care 4. Tell the NA to inform the client that it is unsafe to leave and that the RN will review the test results with the client shortly
3. Talk with the client to discuss the client's concerns and explain the plan of care
1. While the nurse is taking a health history from a patient with hypertrophic cardiomyopathy, information that the nurse recognizes as significant includes 1. a history of chronic alcohol use. 2. a history of a recent viral infection. 3. a family history of cardiomyopathy. 4. a history of multiple myocardial infarctions.
3. a family history of cardiomyopathy.
1. A patient diagnosed with TB is started on initial drug therapy. The nurse plans to teach the patient about the uses and effects of 1. isoniazid, rifampin, and ethambutol. 2. isoniazid, pyrazinamide, and streptomycin. 3. isoniazid, rifampin, pyrazinamide, and ethambutol. 4. para-aminosalicylic acid, ethambutol, rifampin, and pyrazinamide
3. isoniazid, rifampin, pyrazinamide, and ethambutol.
Davis A male client confides to a clinic nurse that he is no longer dyspneic after receiving his new St. Jude's heart valve. He wants to have a vasectomy so that he can enjoy sexual intercourse again without the fear of his wife becoming pregnant. What is the nurse's best response? 1. "That's probably a good idea. The life expectancy after heart valve replacement is 10 to 15 years." 2. "You seem relieved that the heart valve replacement was successful and that you can enjoy a normal life again." 3. "If you have cardiac symptoms such as dyspnea during sexual intercourse, you can take a nitroglycerin tablet before sexual activity to prevent symptoms." 4. "Be sure to inform the physician that you have an artificial heart valve so you are given antibiotics as a preventive measure before the procedure."
4. "Be sure to inform the physician that you have an artificial heart valve so you are given antibiotics as a preventive measure before the procedure."
1. Following discharge teaching, the nurse evaluates that the patient with pneumonia understands measures to prevent a relapse of the pneumonia when the patient states 1. "I will increase my food intake to 2400 calories a day." 2. "I must use home oxygen therapy for 3 months." 3. "I will seek medical treatment for any upper respiratory infections." 4. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks."
4. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks."
A client is admitted to an emergency department with reports of feeling weak and having "passed out." The outside temperature is 100°F (41.3°C), and the client has been gardening. Physical assessment findings reveal poor skin turgor, dry and dull mucous membranes, heart rate (HR) 120 beats per minute, and blood pressure 92/54 mm Hg. Which nursing diagnosis should the nurse include in the client's plan of care? 1. Impaired oral mucous membrane 2. Fluid volume excess 3. Decreased cardiac output 4. Fluid volume deficit
4. Fluid volume deficit
The client has a right-sided chest tube. As the client is getting out of the bed it is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site
4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site
1. A patient tells the nurse that his physician told him he had pneumonia and he wonders whether he will be receiving antibiotics. The nurse's response to the patient is based on the knowledge that 1. antibiotics are usually prescribed only if the patient is a smoker. 2. antibiotics are prescribed only if they have been previously effective. 3. antimicrobial agents are the indicated treatment for all types of pneumonia. 4. the first consideration of treatment by antibiotics is where the pneumonia was acquired.
4. the first consideration of treatment by antibiotics is where the pneumonia was acquired.
1. A patient who has been diagnosed with TB of the bone tells the nurse that he thought TB was a lung disease. The nurse explains to the patient that 1. the tubercular organism is a mild bacteria that spreads only in people who do not have good immune systems. 2. the microorganism that causes TB starts in the lungs but usually spreads from the lungs to other parts of the body. 3. the tuberculosis organism makes a cheesy-like cyst that breaks open and spreads the infection throughout the body. 4. the lungs are the most common site of TB infection but the microorganism can be spread to other organs through the blood and lymph systems
4. the lungs are the most common site of TB infection but the microorganism can be spread to other organs through the blood and lymph systems
PT MOST AT RISK FOR PULMO EMBOLI
73 Y/O WITH HIP PINNING ONE DAY POST OP
The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse give the client? A read area is a positive reading that means the client has tuberculosis The skin test is the only procedure needed to diagnose tuberculosis. A positive reading means exposure to the tuberculosis bacilli. Do not get another skin test for 1 yr if the skin test is positive
A positive reading means exposure to the tuberculosis bacilli.
WHEN SPONTANEOUS PNEUMOTHORAX IS SUSPECTED IN A PT WITH HX OF EMPHYSEMA, THE RN SHOULD CALL THE HCP AND A.GIVE O2 AT 2L/MIN VIA NASAL CANNULA B.ADM HIGH CONCENTRATION O2 90-100% WITH NON REBREATHER MASK C.PLACE THE PT ON UNAFFECTED SIDE D.PREPARE FOR IV ADM OF ELECTROLYTES
A.GIVE O2 AT 2L/MIN VIA NASAL CANNULA
PT WITH DILATED CARDIOMYOPATHY IS ADM TO THE HOSPITAL WITH FATIGUE, ORTHOPNEA AND PULMO CRACKLES. THE PT HAS L VENTRICULAR EJECTION FRACTION OF 18% AND THE PHYSICIAN PRESCRIBES CONTINOUS IV HEPARIN. THE RN EXPLAINS TO PT THAT THE HEPARIN IS USED TO A.PREVENT THROMBUS FORMATION IN L VENTRICLE B.INCREASE THE CIRCULATION TO THE SKIN AND SKELETAL MUSCLES.
A.PREVENT THROMBUS FORMATION IN L VENTRICLE
A PT HAS A TUBE FOLLOWING THORACTOMY. CONTS BUBNLING IN THE SUCTION OF THE CHAMBER COLLECTION DEVICE WOULD ALERT A.THE UNIT IS FUNCTIONING NORMALLY B.A TENSION PNEUMOTHORX IS DVLPING C.THE LUNG HAS FULLY EXPANDED D.AN AIR LEAK MAY BE PRESENT
A.THE UNIT IS FUNCTIONING NORMALLY BUBBLE IN WATER SEAL MEANS LEAK
PAIN RESULTING FROM RESTRICTED BLOOD FLOW TO THE MYOCARDIUM IS CALLED
ANGINA PECTORIS
At 0730 hours, a nurse receives a verbal order for a cardiac catheterization to be completed on a client at 1400 hours. Which action should the nurse initiate first? 1. Initiate NPO (nothing per mouth) status for the client. 2. Teach the client about the procedure. 3. Start an intravenous (IV) infusion of 0.9% NaCl. 4. Ask the client to sign a consent form.
ANSWER: 1 A cardiac catheterization is an invasive procedure requiring the client to lie still in a supine position. The client is usually sedated with medication, such as midazolam (Versed®), during the procedure. To avoid aspiration, the client should be NPO 6 to 12 hours prior to the procedure. Because of the time element, NPO status should be initiated first and then teaching should occur. A consent form should be signed after the cardiologist has spoken with the client, and then an IV infusion order would be received. ➧ Test-taking Tip:The term "cardiac catheterization" in the stem indicates that this is an invasive procedure that has the potential to cause aspiration from sedation. Use the ABCs (airway, breathing, circulation) to determine which action should be first. Any action that pertains to maintaining a patent airway should be first
A nurse is caring for a client following a coronary artery bypass graft. Which assessment finding in the immediate postoperative period should be most concerning to the nurse? 1. No chest tube output for 1 hour when previously it was copious 2. Client temperature of 99.1°F (37.2°C) 3. Arterial blood gas (ABG) results show pH 7.32; Pco2 48; HCO3 28; Po2 80 4. Urine output of 160 mL in the last 4 hours
ANSWER: 1 A copiously draining chest tube that is no longer draining indicates an obstruction. There is an increased risk for cardiac tamponade or pleural effusion. A slight elevation in temperature could be the effects of rewarming after surgery. This should continue to be monitored, but is not immediately concerning. The ABG results show compensated respiratory acidosis. Though the pH is low and the PCO2 is high, the kidneys are compensating by conserving bicarbonate (HCO3). Normal pH is 7.35-7.45, PCO2 32-42 mm Hg, HCO3 20-24 mmol/L, and PO2 75-100 mm Hg. A urine output of 160 mL/4 hr is equivalent to 40 mL/hr; adequate, but it warrants continued monitoring. Less than 30 mL/hr indicates decreased renal function. ➧ Test-taking Tip:The key phrase in the question is "most concerning." Use the process of elimination and eliminate options 3 and 4 because these are normal findings. Of options 1 and 2, determine which option is most concerning
The parent of a child diagnosed with rheumatic heart disease questions the nurse following the doctor's statement that the child has a heart murmur. The nurse explains that a heart murmur is an abnormal or extra heart sound produced by which malfunctioning structure of the heart? 1. Heart valve 2. Heart vessel 3. Heart chamber 4. Heart conduction
ANSWER: 1 A heart murmur is an abnormal or extra heart sound caused by an incomplete closure of the heart valve. In rheumatic fever, the heart valves are damaged by an abnormal response by the immune system. Erosion of the valves makes them leaky and inefficient, and a murmur of backflowing blood will be heard. A malfunctioning vessel, chamber, or conduction would not produce a heart murmur but would likely affect blood flow, contractility, or cardiac rhythm. ➧ Test-taking Tip: Apply knowledge of anatomy and physiology to answer this question.
A normally healthy client has a 5-mm skin induration 72 hours after receiving a tuberculin skin test. Which conclusions should the nurse make regarding the test results? 1. This is negative for a normally healthy person. 2. This indicates that active tuberculosis is present and treatment is needed. 3. This is inconclusive, and a chest x-ray is needed to detect active tuberculosis (TB). 4. This is inaccurate because the assessment was done too long after the injection.
ANSWER: 1 An area of induration measuring 15 mm in diameter or greater in a person with no known risk factors for TB and read 48 to 72 hours after injection is a positive TB test. An induration of 5 mm or greater would be a positive result in HIV-infected persons. A positive test indicates exposure to TB. The result is negative for TB rather than inconclusive. Evidence-based practice guidelines indicate that a reading at 72 hours is more accurate than one at 48 hours. ➧ Test-taking Tip: Note the key phrase "normally healthy" in both the stem and option 1.
A child of African descent has a positive acid-fast bacillus sputum culture after returning to the United States from a trip to Africa to visit relatives. During a nursing assessment, a nurse observes that the parent refers to the child's diagnosis by using the impersonal pronoun "it." Which statement made by the nurse is best? 1. "Tell me how you feel about your child's diagnosis." 2. "If your child takes the prescribed medications, 'it' can be cured." 3. "Why do you call your child's tuberculosis 'it', rather than referring to the diagnosis of tuberculosis?" 4. "I need to find out more information about 'it'. How long has your child been having night sweats and a productive cough?"
ANSWER: 1 Asking the parent about feelings allows the parent time to express feelings and concerns, and a rationale may be provided for referring to the tuberculosis as "it." Some cultures avoid calling the disease by name for fear that it may cause further harm. Telling the parent that if the child takes the prescribed medication, the child will be cured is irrelevant during an assessment. Asking a "why" question is a barrier to therapeutic communication and can result in defensiveness. Although assessing the length of time the child may have had symptoms is important, this question ignores the parent's feelings.
. A nurse is planning care for a client with AIDS who has been hospitalized for a Pneumocystis carinii infection. Which nursing diagnosis should be the nurse's first priority for this client? 1. Fatigue related to hypermetabolism 2. Imbalanced nutrition, more than body requirements related to hypometabolism 3. Ineffective coping related to HIV diagnosis 4. Fluid volume excess related to oral and intravenous fluid intake
ANSWER: 1 Clients hospitalized for a Pneumocystis carinii infection are often acutely ill and fatigued. Hypermetabolism from AIDS and the illness state contribute to fatigue. The client would most likely be too fatigued to eat and would be at risk for nutritional deficit rather than body requirements. The client in this scenario, as stated in the question, has already been diagnosed with AIDS; thus ineffective coping related to HIV diagnosis is not correct. Clients with P. carinii infection are generally hypovolemic because of sweating, diarrhea, and vomiting, thus have a fluid volume deficit and not excess. ➧ Test-taking Tip: Carefully review the stem. Although many of the options may be correct, cues from the stem can help eliminate choices.
. A client is diagnosed with Pneumocystis carinii pneumonia (PCP) secondary to AIDS. Upon assessment for the specific symptoms of PCP, the nurse should expect to find: 1. dyspnea, fever, nonproductive cough, and fatigue. 2. weight loss, night sweats, persistent diarrhea, and hypothermia. 3. dysphagia, yellow-white plaques in the mouth, and sore throat. 4. lung crackles, chest pain, and small, painless purple-blue skin lesions.
ANSWER: 1 PCP is caused by a fungus that produces these symptoms. It is the most common opportunistic infection in HIV/AIDS. Weight loss, night sweats, persistent diarrhea are symptoms of AIDS; hypothermia is not. Dysphagia, yellow-white plaques in the mouth, and sore throat are symptoms of Candida albicans. Although PCP could cause lung crackles and chest pain, the skin lesions are found with Kaposi's sarcoma. ➧ Test-taking Tip: Focus on the key phrase "specific symptoms of PCP." Look for specific symptoms characteristic of the respiratory system. Eliminate options 2, 3, and 4 because these are not specific to PCP
A nurse is interpreting the serum laboratory report below for a client with a diagnosis of acute renal failure (ARF) secondary to cardiac catheterization. Based on the findings of the serum laboratory report, which action should the nurse establish as the priority? BUN 40 5-25 mg/dL Creatinine 4.2 0.5-1.5 mg/dL Na 150 135-145 mEq/L K 6.9 3.5-5.3 mEq/L Cl 99 95-105 mEq/L CO2 16 22-30 mEq/L Phosphate 5.0 1.7-2.6 mEq/L Calcium 7 9-11 mg/dL Hgb 10 13.5-17 g/dL Hct 32% 40%-54% PTH 88 11-54 µg/mL 1. Administer intravenous (IV) calcium gluconate 2. Administer IV furosemide 3. Begin cardiac monitoring 4. Restrict foods high in potassium.
ANSWER: 1 The client has severe hyperkalemia. Calcium gluconate raises the threshold for cardiac muscle excitation, thereby reducing the incidence of life-threatening dysrhythmias. The first action is to protect the heart. Furosemide is a loop diuretic that inhibits reabsorption of sodium and chloride and promotes the excretion of potassium. The amount of potassium excreted in the urine will be insufficient to quickly lower the severely elevated serum potassium levels to protect the heart from the hyperkalemic effects. Though it is important to place the client on cardiac monitoring, the heart needs to be protected from the hyperkalemic effects. Restricting foods high in potassium is not the priority. ➧ Test-taking Tip: Focus on the situation in the stem ARF. Then read the information in the chart carefully, looking for abnormal information that pertains to the situation. Note the key word "priority" in the stem. The most life-threatening problem needs to be addressed first.
A nurse is assigned to care for four clients. Which client should a nurse closely observe for development of Clostridium difficile? 1. Client A, who is 79 years old, takes prednisone for chronic obstructive pulmonary disease and is taking antibiotics for pneumonia. 2. Client B, who is 44 years old, has AIDS. 3. Client C, who is 60 years old, is taking antibiotics after joint replacement surgery. 4. Client D, who is 20 years old, is taking prednisone for Crohn's disease.
ANSWER: 1 The nurse should closely observe client A for the development of a C. difficile infection. Development of C. difficile is usually preceded by antibiotics that disrupt normal intestinal flora. Older adult clients and those who are immunosuppressed are most at risk. Prednisone is a glucocorticoid that suppresses immune responses. Client A has more risk factors than the clients in options 2, 3, and 4.
. A health-care provider (HCP) writes orders to transfuse a unit of red blood cells (RBCs) to a client admitted to an emergency department after a disaster. A nurse is completing the compatibility checks between the client's blood type, noted to be blood type B-positive, and the illustrated unit of blood, which had been donated by the client's spouse and obtained from the blood bank. Which clinical judgment by the nurse preparing to administer the unit of blood is correct? 1. The unit of blood is of a different blood type but compatible with the client's blood. 2. The unit of blood is of a different blood type and incompatible with the client's blood. 3. The unit of blood is not the blood component that the HCP prescribed for the client. 4. The unit of blood will cause a hemolytic transfusion reaction and cannot be administered to the client.
ANSWER: 1 Type O blood is compatible for persons with type A, B, or AB blood because it does not have an antigen on the erythrocyte (RBC). A person with type O blood is considered a universal donor. The Rh positive indicates that the Rhesus antigen is present on the cell, whereas Rh negative indicates that the Rh factor is not present. Rh-positive RBCs can only be administered to persons who are Rh positive, whereas Rh-negative RBCs can be administered to persons who are Rh positive or Rh negative. Although the client and spouse have different blood types, the RBCs are compatible. The unit of blood states that it is red blood cells (RBCs). A hemolytic transfusion reaction will occur if there are ABO or Rh incompatibilities. ➧ Test-taking Tip: Knowledge of blood administration and blood compatibilities is expected on the NCLEX-RN® exam. Recall that type O blood is the universal donor for RBCs, whereas type AB blood is the universal donor for plasma.
A new nurse is managing the care of a pediatric client preparing for a cardiac catheterization under the supervision of an experienced nurse. Which factor identified by the new nurse demonstrates an understanding of the information that can be collected during cardiac catheterization? SELECT ALL THAT APPLY 1. Oxygen saturation of blood within the chambers and great vessels 2. Pressure of blood flow within the heart chambers 3. Cardiac output (CO) 4. Anatomic abnormalities 5. Ankle brachial index (ABI) 6. Ejection fraction
ANSWER: 1, 2, 3, 4, 6 In cardiac catheterization, a small radiopaque catheter is passed through the major vein in the arm, leg, or neck into the heart. Blood specimens can be obtained to determine oxygen saturation levels, and contrast dye can be injected for angiography and to assess for anatomic abnormalities such as septal defects or obstruction of flow. Pressure of blood flow in the heart chambers, CO, stroke volume, and ejection fraction can be evaluated during the procedure. ABI is a ratio of the ankle systolic pressure to the arm systolic pressure and an objective measurement of arterial disease that quantifies the degree of stenosis. It is not related to a cardiac catheterization procedure. ➧ Test-taking Tip: Apply knowledge of a cardiac catheterization procedure to answer this question. Eliminate the one option that is unrelated to a cardiac catheterization
A nurse should anticipate instructing a client scheDULEDa coronary artery bypass graft to: SELECT ALL THAT APPLY. 1. discontinue taking aspirin prior to surgery. 2. perform postoperative cardiac rehabilitation exercises and stress management strategies. 3. wash with an antimicrobial soap the evening prior to surgery. 4. shave the chest and legs and then shower to remove the hair. 5. resume normal activities when discharged from the hospital. 6. expect close monitoring after surgery, several intravenous (IV) lines, a urinary catheter, endotracheal tube, and chest tubes.
ANSWER: 1, 2, 3, 6 Aspirin decreases platelet aggregation and increases the risk of bleeding. It is usually discontinued a few days prior to surgery. A postoperative cardiac rehabilitation program is begun usually on the second postoperative day and includes exercises and stress management. The client should use an antimicrobial soap when showering or bathing the evening before and the day of surgery to decrease the risk of infection. Teaching about expectations of close monitoring, IV lines, a urinary catheter, endotracheal tube, and chest tubes can reduce client and family anxiety. The client may be offered a tour of the critical care unit prior to surgery or be given videos to view. Although the client's skin will be shaved, this will be completed just prior to surgery to avoid nicks and decrease the risk of infection. Activities that stress the sternum, such as lifting, driving, and overhead reaching, will be restricted after surgery. ➧ Test-taking Tip: Use the process of elimination to eliminate options 4 and 5 because these increase surgical risk and the risk of complications after surgery
A school nurse is educating school-aged children on modifiable risk factors for coronary artery disease (CAD). Which modifiable risk factors should the nurse include in the presentation? SELECT ALL THAT APPLY. 1. Diabetes mellitus 2. Hypertension 3. Age 4. Family history 5. Sedentary lifestyle 6. Obesity
ANSWER: 1, 2, 5, 6 Diabetes mellitus, hypertension, sedentary lifestyle, and obesity are modifiable risk factors for CAD. While age and family are risk factors, they are nonmodifiable. ➧ Test-taking Tip:The words "modifiable risk factors" and "CAD" are the key words in the stem. Content Area: Child Health; Category of H
A nurse evaluates that a client understands discharge teaching, following aortic valve replacement surgery with a synthetic valve, when the client states that he/she plans to: SELECT ALL THAT APPLY. 1. use a soft toothbrush for dental hygiene. 2. floss teeth daily to prevent plaque formation. 3. wear loose-fitting clothing to avoid friction on the sternal incision. 4. use an electric razor for shaving. 5. report black, tarry stools. 6. consume foods high in vitamin K, such as broccoli.
ANSWER: 1, 3, 4, 5 A synthetic heart valve requires long-term anticoagulation because of the risk of thromboembolism. Because low-dose aspirin, which prevents platelet aggregation, and oral anticoagulation together are more effective than just oral anticoagulation to reduce the risk of thromboembolism after valve replacement, both are prescribed, which increases the risk for bleeding. Bleeding precautions while on anticoagulation include using a soft toothbrush, avoiding injury (such as can occur with flossing), and using an electric razor. The client will have a sternal incision. Care must be taken to avoid tissue trauma. Black, tarry stools are a sign of bleeding. Flossing should be avoided because it causes tissue trauma, increases the risk of bleeding, and increases the risk of infective endocarditis. The diet should contain normal amounts of vitamin K; excessive amounts antagonize the effects of the anticoagulant. ➧ Test-taking Tip: Focus on the issue: self-care following a synthetic valve replacement. Recall that anticoagulation will be required. Select options that include bleeding precautions and signs of bleeding
A public health nurse is planning a flu shot clinic. The nurse is working on advertising. Which groups should be the highest priority to target when advertising the flu shot clinic? SELECT ALL THAT APPLY. 1. Pregnant women 2. Grade school children 3. Nursing assistants at a nursing home 4. A hypertension clinic population 5. Outpatient psychiatric population 6. Spinal cord-injured population at an assisted living facility
ANSWER: 1, 3, 6 The Centers for Disease Control and Prevention (CDC) provides guidelines for identifying those clients at high risk for influenza-related complications and severe disease. These groups include children aged 6 to 59 months, pregnant women, and clients older than 50 years of age. Those who have chronic respiratory conditions, their caregivers and household contacts, and those in the health-care field are also considered high priorities for vaccination. Clients with spinal cord injury are at high risk for respiratory complications and are prone to complications of flu related to immobilization and difficulty with clearing secretions. Grade school children, clients with hypertension, and persons receiving outpatient psychiatric care are not considered high risk by the CDC. ➧ Test-taking Tip: Select the groups who are at a higher risk for influenza-related complications
8. A nurse is caring for a client with renal insufficiency. In addition to an ordered fluid restriction, the client needs strict monitoring of intake and output. Which actions should the nurse plan to include when caring for the client? SELECT ALL THAT APPLY. 1. Discussing with the client and family the plan of care and fluid restriction 2. Documenting pureed foods as part of the client's liquid intake 3. Eliminating counting ice chips as intake because this represents such a small amount of intake 4. Providing a collection device for measuring the client's urine output 5. Instructing the family to record any intake they provide to the client on the facility intake record 6. Encouraging the family to bring favorite food items from home for the client to eat
ANSWER: 1, 4 Informing the client and family in the plan of care helps to provide reinforcement for the client and to ensure compliance with the fluid restriction and plan. Measurement and collection devices are necessary and beneficial when strict monitoring is required. Pureed foods are not counted as liquid because they are considered solid in a different form. Ice chips are considered fluid; a 200 mL cup of ice is equal to 100 mL of water. Only health care personnel should document on official agency records. The family should be informed to not provide the client with addition liquid intake. Renal insufficiency will warrant food and fluid restrictions. Bringing favorite food items from home should be discouraged to ensure that the client follows the plan of care for fluid and electrolyte restrictions. ➧ Test-taking Tip:Think about the food and fluid restrictions that are likely with renal insufficiency and measures that the nurse can use to ensure that the client adheres to the plan of care.
A client requires intravenous vancomycin (Vancocin®) for antibiotic-resistant pneumonia. The order calls for 500 mg to be administered, and the medication is supplied in a 100 mL piggyback that contains 5 mg per 1 mL to run over 1 hour. In order to administer the correct dose, a nurse should set the infusion pump to run at a rate of _____ mL per hour.
ANSWER: 100 Use the formula for calculating intravenous flow rates. Formula: Infuse rate (in mL/hour) = Volume to be infused Infusion time 100 mL/hr = 100 mL 1 hr ➧ Test-taking Tip: Identify the volume to be infused. The time over which it needs to be infused allows for quick and easy infusion rate calculations using the equation shown
. A client diagnosed with diabetes mellitus is on an insulin infusion drip. The insulin bag indicates there are 100 units of insulin in 1,000 milliliters (mL) of normal saline. Based on the client's blood glucose reading, the client should receive 1.5 units per hour. To ensure that the client receives 1.5 units per hour, the nurse should set the pump at ______ mL/hr.
ANSWER: 15 100 units : 1,000 mL :: 1.5 units : X mL 100X = 1,500 X = 15 ➧ Test-taking Tip: Use a drug calculation formula and the on-screen calculator and double-check the answer if it seems unusually large.
A 33-year-old client reports left leg pain, right-sided chest pain, and a sudden onset of shortness of breath. Which action should be taken immediately by the nurse? 1. Take the client's temperature 2. Auscultate the client's the lung sounds 3. Percuss the client's abdomen 4. Request a stat chest x-ray y
ANSWER: 2 Auscultation of lung sounds should be one of the first assessments performed by the nurse to determine the cause of the client's shortness of breath. Chest x-ray would be helpful in assessing the cause of shortness of breath but would need a physician's order and would not be the first priority. Percussion of abdomen and measurement of the client's temperature are helpful tools when completing a full assessment but are not priority in this situation. ➧ Test-taking Tip:Think about the ABCs: airway, breathing, circulation. Airway is priorit
A nurse is caring for a client with a left-sided chest tube attached to a wet suction chest tube system. Which observation by the nurse would require immediate intervention? 1. Bubbling in the suction chamber 2. Dependent loop hanging off the edge of the bed 3. Banded connections between tubing sections 4. Occlusive dressing over chest tube insertion site
ANSWER: 2 A dependent loop creates pressure back up and prevents fluid from draining; this requires immediate intervention to prevent lung collapse. Bubbling in a wet suction chest tube system indicates that the suction is working and is an expected finding as are banded connections between sections of tubing. An occlusive dressing helps to prevent air from leaking into the subcutaneous space and maintains integrity of the closed drainage system. ➧ Test-taking Tip: Visualize the different parts of a chest tube system and consider which of the options do not fit or seem negative
A 12-year-old child weighing 50 kg is hospitalized with bacterial pneumonia and an upper respiratory tract infection. The child is allergic to penicillin, azithromycin, and cefazolin sodium. A nurse is reviewing a serum laboratory report for the child before administering newly prescribed medications. BUN 36 mg/dL 7-18 mg/dL Creatinine 1.2 mg/dL 0.3-0.7 mg/dL Na 136 mEq/L 138-145 mEq/L K 3.4 mEq/L 3.5-5.0 mEq/L Cl 96 mEq/L 98-106 mEq/L Hgb 11.5 g/dL 11.5-15.5 g/dL Hct 35% 35%-45% WBC 16.2 K/µL 4.5-13.5 K/µL Osmolality 298 mOsm/kg 275-295 mOsm/ kg H2O Based on the findings of the serum laboratory report, which health-care provider prescription is most important for the nurse to question? 1. Dextrose 5% in 0.25 NaCl with 20 mEq/L KCL at 65 mL/hr 2. Amikacin sulfate (Amikin®) 375 mg IVPB q12h 3. Guaifenesin (Robitussin®) 50-100 mg q4h prn for cough 4. Acetaminophen (Tylenol®) 325-650 mg q4-6h prn, not to exceed five doses/24 hr
ANSWER: 2 Amikacin is an aminoglycoside, which is nephrotoxic and should be questioned. The serum creatinine and blood urea nitrogen (BUN) levels are elevated, suggesting decreased renal function. The serum osmolality is high, suggesting dehydration and the potassium level is below normal. Daily fluid requirements may be met when dehydration occurs with dextrose 5% in 0.25 isotonic sodium chloride solution with 20 mEq/L added potassium. If the client weighs more than 20 kg, IV fluid replacement is 1,500 mL/day, plus 20 mL/kg/day for each kilogram over 20 kg, so the rate of 65 mL per hour is appropriate for maintenance. Guaifenesin is used for cough. The dose is within the range for a child of 12 years. The dose of acetaminophen is within the normal range (10-15 mg/kg/dose q4-6h as needed, not to exceed five doses/24 hr), but is also concerning because of the decreased renal function. Because this is a prn medication and amikacin is a timed medication, the amikacin is most important for the nurse to question. ➧ Test-taking Tip: Carefully examine each laboratory value for abnormalities. Consider medications that are nephrotoxic
Following a normal chest x-ray for a client who had cardiac surgery, a nurse receives an order to remove the chest tubes. Which intervention should the nurse plan to implement first? 1. Auscultate the client's lung sounds 2. Administer 4 mg morphine sulfate intravenously 3. Turn off the suction to the chest drainage system 4. Prepare the dressing supplies at the client's bedside
ANSWER: 2 Because the peak action of morphine sulfate is 10 to 15 minutes, this should be administered first. Auscultating the client's lungs before and after the procedure, turning off the suction, and assembling the dressing supplies are all necessary, but administering the analgesic should be first. ➧ Test-taking Tip: Recall that focusing on the client should be the priority
A nurse is evaluating the laboratory findings for a 7-year-old client being treated with isoniazid (INH) for tuberculosis. Which adverse effect of the medication should the nurse consider after reviewing the laboratory results report? BUN 18 5-25 mg/dL Creatinine 0.9 0.4-1.2 mg/dL Na 139 135-145 mEq/L K 4.2 3.5-5.5 mEq/L Cl 99 98-105 mEq/L CO2 28 20-28 mEq/L Phosphate 4.9 4.5-5.5 mg/dL Calcium 10 4.5-5.8 mEq/L Hgb 14 11-16 g/dL Hct 43 31%-43% ALT/SGPT 38 10-35 unit/L 1. Renal insufficiency 2. Hepatotoxicity 3. Aplastic anemia 4. Heart failure
ANSWER: 2 Elevated ALT (alanine transaminase) or SGPT (serum glutamic pyruvic transaminase) suggests hepatotoxicity. Isoniazid (INH) is metabolized by the liver. The laboratory values do not support the other conditions. The serum creatinine level should be elevated (not normal) with renal insufficiency. Aplastic anemia is an adverse effect of isoniazid, but the hemoglobin and hematocrit are normal. A B-type natriuretic peptide (BNP) laboratory value would be needed to determine if heart failure was an adverse effect, but it is not reported. ➧ Test-taking Tip: Eliminate all normal laboratory findings and focus on the abnormal values. Relate the abnormal laboratory value to the conditions listed in the options.
. A client diagnosed with cardiomyopathy is hyponatremic as a result of fluid volume overload. A fluid restriction of 800 mL/24 hours is ordered by a physician. Which action by the nurse is most appropriate? 1. Provide ice chips and refill the glass every 4 hours. 2. Encourage the client to perform mouth care when feeling thirsty. 3. Offer sugary lozenges for the client to hold in the mouth. 4. Replenish the client's water every 2 hours and have the client take small sips.
ANSWER: 2 Frequent mouth care can help to reduce the sensation of thirst. Ice chips are considered fluid and should be included in the intake volume. A full glass of ice chips is equivalent to 120 mL of fluid. If replaced every 2 hours, ice chips alone would equal 1,440 mL of fluid. Lozenges, especially if high in sugar content, can produce the sensation of thirst. Small frequent sips can quickly add up to high volumes that exceed the client's restriction. ➧ Test-taking Tip:The key phrase is "most appropriate." Consider the nurse's action in maintaining the fluid restriction and alleviating the client's thirst.
A nurse assesses the pain level of a Native American pediatric client recovering from cardiac surgery. Knowing that Native American pediatric clients may not express pain, the nurse reviews the child's pulse and blood pressure readings following analgesic administration. Which finding should indicate to the nurse that the client's pain is not well-controlled? 1. Decreased heart rate and decreased blood pressure 2. Increased heart rate and increased blood pressure 3. Increased heart rate and decreased blood pressure 4. Decreased heart rate and increased blood pressure
ANSWER: 2 Increased heart rate and blood pressure may be indicative of postoperative pain in a pediatric client. A decreased heart rate and blood pressure could indicate that analgesics are effective for pain control. An increased heart rate and decreased blood pressure could be signs of bleeding. A decreased heart rate and increased blood pressure could be a sign of a neurological complication associated with cardiac surgery. ➧ Test-taking Tip: Note that options 1 and 2 are opposites and 3 and 4 are opposites. First examine the options that are opposites and eliminate one or both of these.
A 65-year-old client with a history of coronary artery disease is admitted with fluid volume overload. Bumetanide (Bumex®) is administered, and the client's serum potassium level drops to 3.0 mEq/L; intravenous (IV) potassium replacement is ordered. Which factor should a nurse consider when preparing to administer the IV potassium replacement? 1. The potassium concentration should not exceed 20 mEq/L. 2. Ice or warm packs may be needed to reduce vein irritation. 3. The potassium should be administered IV push. 4. The potassium should be added to the IV solution that is infusing. .
ANSWER: 2 Potassium can be irritating to the vein, and the client may complain of burning. Strategies to minimize pain and inflammation include ice or warm packs. Although the usual replacement dose is 20 mEq/100 mL with administration of 10 to 20 mEq/hr, concentrations can safely range from 10 to 40 mEq/L. Potassium is never administered as an IV push; it will cause cardiac dysrhythmias. Adding medication to an already-infusing IV solution is unsafe and can result in a faster or slower rate of administration, depending on the volume of solution remaining. ➧ Test-taking Tip: Note that options 3 and 4 both address methods of administration. Because both cannot be correct, either one or both are incorrect
A nurse is working at a telephone health service. Which advice should the nurse give to a client who has had 3 days of symptoms that strongly suggest influenza? 1. Return to work after another day of rest 2. Rest and increase fluid intake to 3 liters of fluid per day 3. Use over-the-counter antihistamines 4. Make an appointment to get the flu shot
ANSWER: 2 Rest and increased fluid intake are essential. Influenza is generally a self-limiting condition, but one that is also highly contagious, so returning to work should not occur until the client is symptom-free. Antihistamines are not the over-the-counter medications of choice. Generally antitussives and antipyretics are optimal for symptom control. Clients who have an active case of influenza should not get the shot. ➧ Test-taking Tip: Knowledge of the best treatments and course of influenza will help to narrow the options
. A client presents to an emergency department following a motorcycle crash. A nurse assesses the client and notes uncoordinated or paradoxical chest rise and fall as well as multiple bruises across the client's chest and torso, crepitus, and tachypnea. Based on this assessment, the nurse should: 1. assist in the placement of a cervical collar. 2. anticipate the need to intubate the client. 3. provide chest compressions. 4. tape the chest wall.
ANSWER: 2 The assessment data implies a client with multiple broken ribs and potentially flail chest. In the case of flail chest, more invasive interventions are generally required, including management of the client's airway with intubation. The client would most likely already have a cervical collar on, and this is not the intervention that would address the assessment data. There is no evidence to suggest that chest compressions are warranted. Taping the chest wall is an intervention for broken ribs that has proven to not be as effective as once believed. ➧ Test-taking Tip: In emergency situations or in a situation where the client is in distress, the ABCs (airway, breathing, circulation) should be a priority for assessment and intervention.
An 80-year-old client is living in an independent living facility with home health nursing support. The client is diagnosed with pneumonia and started on an oral antibiotic. Which nursing diagnosis would be most appropriate for this client? 1. Risk for imbalanced nutrition 2. Risk for fluid volume deficit 3. Fluid volume deficit 4. Fluid volume excess
ANSWER: 2 The diagnosis of pneumonia may result in fever or increased respiratory rate that increases amount of fluid lost. Additionally, older adults have a decreased sensation of thirst. Nutrition may be affected due to a diagnosis of pneumonia, but fluid volume would be the greatest concern with pneumonia. The client's age and a diagnosis of pneumonia could result in a fluid volume deficit, but there is no information to support that the client is deficient in fluid. There is no information to support an excess fluid volume. ➧ Test-taking Tip:The key phrase is "most appropriate." To have an actual nursing diagnosis, rather than a "risk for," information must be present to support the nursing diagnosis.
A nurse is partnered with a patient care assistant (PCA) on a medical-surgical floor. The PCA provides information about the clients for whom the PCA has been caring. Based on the information from the PCA, which client should the nurse attend to first? 1. The client with a pulmonary embolus who has not had a bowel movement in 2 days 2. The client who underwent a video thoracoscopy with oxygen saturation readings from 88% to 90% on oxygen at 4 L/NC 3. The client who underwent a wedge resection of right lung and has a blood pressure of 100/65 mm Hg 4. The client who has rib fractures and has not voided for 6 hours after the urinary catheter was removed
ANSWER: 2 The most concerning report from the PCA is regarding the client who is not maintaining oxygen saturations despite receiving oxygen. None of the other clients have potentially life-threatening conditions or concerns that could not later be addressed. Although the blood pressure is low in option 3, it is only one data point and obtaining a repeat reading should be delegated to the PCA. ➧ Test-taking Tip: Items requiring care prioritization should start with concerns that deal with the client's airway, breathing, and then circulation.
A nurse is caring for a child who has liver enlargement secondary to infectious endocarditis. For which associated cardiac condition should the nurse assess the client? 1. Dysrhythmia 2. Right-sided heart failure 3. Myocardial infarction (MI) 4. Tetralogy of Fallot
ANSWER: 2 The nurse should assess for the presence of right-sided heart failure. Back pressure in the portal circulation occurs in right-sided heart failure. Dysrhythmias may occur due to impaired cardiac function. Chest pain, dyspnea, and dysrhythmias would be initial signs of a MI. Tetralogy of Fallot occurs as a result of the malformation of the right ventricular infundibulum, which can lead to heart failure. ➧ Test-taking Tip:The key word is liver enlargement. Visualize each of the conditions presented to determine which is likely to result in back pressure and fluid accumulation in the liver.
Because a step-down cardiac unit is unusually busy, a nurse fails to obtain vital signs at 0200 hours for a client 2 days postoperative for a mitral valve replacement. The client was stable when assessed at 0600 hours, so the nurse documents the electrocardiogram monitor's heart rate in the client's medical record for both the 0400 and 0600 vital signs. The charge nurse supervising the nurse determines that the nurse's behavior was: SELECT ALL THAT APPLY. 1. the correct action because neither complications nor harmful effects occurred. 2. a legal issue because the nurse has fraudulently falsified documentation. 3. demonstrating beneficence because the nurse decided what was best for the client. 4. an ethical issue of veracity because the nurse has been untruthful regarding the client's care. 5. an ethical legal issue of confidentiality because the nurse disclosed incorrect information. 6. demonstrating distributive justice because the nurse decided other clients' needs were priority.
ANSWER: 2, 4 Documenting vital signs that the nurse did not obtain is both a legal and ethical concern because documents were falsified and the nurse was untruthful regarding obtaining the vital signs. Veracity is telling the truth and not lying or deceiving others. Even if harm had not occurred, the nurse's behavior of falsifying documentation poses an ethicallegal concern and is never the correct action. Beneficence is doing good. There is no information to indicate the nurse did what was best for the client. Confidentiality relates to privacy and not disclosing private information about another. Documenting incorrect vital signs is not disclosing confidential information. Distributive justice is the distribution of resources to clients. There is no information about the resources available to the nurse. ➧ Test-taking Tip: Focus on the nurse's behavior of falsifying documentation. Avoid reading into the question. Despite the unit being unusually busy, there is no information as to what the nurse was doing during the shift. Eliminate the options that are suggestive of nurse actions other than the behaviors presented
A client is admitted to an emergency department with multiple injuries from a motor vehicle accident. A nurse sees that the client's head had been immobilized at the scene. Prioritize the nurse's management of the client during admission to the emergency department. ______ Control hemorrhage. ______ Evaluate for head and neck injuries and other injuries. ______ Splint fractures. ______ Prevent and treat hypovolemic shock. ______ Carry out a more thorough examination. ______ Establish airway patency and ventilation.
ANSWER: 2, 4, 5, 3, 6, 1 The priority is airway and breathing. First establish the airway and maintain ventilation. Next is circulation: control hemorrhage with direct pressure. Third, prevent and treat hypovolemic shock with intravenous fluids and monitor the urine output, all essential components of circulation. Next is disability: assess for head and neck injuries, evaluate for other injuries, and reassess head and neck. Identify deformities and splint fractures, and finally complete the secondary survey, which is a more thorough examination. ➧ Test-taking Tip: Use ABCD (airway, breathing, circulation, disability) primary survey method and then complete the secondary survey.
. A nurse is working with a certified nursing assistant (CNA) providing care for four clients on a busy telemetry unit. All four clients are in need of immediate attention. The CNA is a senior nursing student who has been administering medications and performing procedures during clinical experiences as a student nurse. The charge nurse supervising care on the telemetry unit determines that care is appropriate when the registered nurse (RN) working with the CNA delegates: SELECT ALL THAT APPLY. 1. administering acetaminophen (Tylenol®) to the client with an elevated temperature. 2. taking vital signs on the client newly admitted with a diagnosis of heart failure. 3. finishing the discharge instructions so the client with a new pacemaker implant can go home. 4. changing a client's chest tube dressing because it got wet when the water pitcher overturned. 5. providing a sponge bath for the client with the elevated temperature. 6. checking the lung sounds of the client whose chest tube drainage system was tipped over and then righted
ANSWER: 2, 5 Legally a student nurse employed as a nursing assistant in a facility is only allowed to perform tasks listed in the job description of a nursing assistant even though the student nurse has received instruction and acquired competence in administering medications and performing sterile procedures. The tasks of a nursing assistant include taking vital signs and bathing clients. Medication administration, teaching, sterile procedures, and assessments are not within the nursing assistant's scope of practice. ➧ Test-taking Tip: Read the information given in the question carefully. The issue of the question is tasks that the RN can legally delegate to a CNA who is also a student nurse. Delegated tasks must be within the job description of the nursing assistant
A client with a suspected pulmonary embolus receives a ventilation and quantification nuclear medicine (VQ) scan to evaluate regional lung ventilation of airflow and regional lung blood flow. In consulting with a physician, a nurse learns that there is a VQ mismatch. Based on this information, which action should be taken by the nurse? 1. Tell the client that tuberculosis treatment will be needed 2. Reassure the client that he/she does not have a pulmonary embolus 3. Explain to the client that further testing will be needed 4. Inform the client that the test was normal
ANSWER: 3 An imbalanced or mismatched VQ scan indicates some type of problem with either ventilation or perfusion. Further testing is required, especially in the case of suspected pulmonary embolus. A chest x-ray, sputum culture, and Gram stain are used to diagnose tuberculosis; treatment should not be initiated. A VQ mismatch is highly suspicious, but not diagnostic of multiple lung diseases, including pulmonary embolus. A VQ mismatch is not a normal finding. ➧ Test-taking Tip: Consider the pathophysiology and complexity of the condition discussed in the question to help narrow down the options. Look at key words so that even if the procedure is unfamiliar, the key descriptions will help to select the correct option.
A nurse is preparing to admit a client with a confirmed case of tuberculosis. Which action is essential to infection control for this client? 1. Providing a positive-pressure airflow room 2. Wearing gown and gloves when handling the client's stool or urine 3. Using a National Institute for Occupational Safety and Health (NIOSH)-approved N95 respirator mask for staff and visitors 4. Keeping the client quarantined in the room until antibiotic therapy has been initiated
ANSWER: 3 Clients with a confirmed or suspected case of tuberculosis are generally placed on some type of isolation precautions when hospitalized. These precautions include the use of high-efficiency particulate masks by those coming in contact with the client to prevent inhalation of potentially infectious respiratory secretions. The client should be placed in a negative-airflow room, which pulls the air out of the room and is vented externally. Gown and gloves may be appropriate if there is expected exposure to respiratory secretions. Although the client's movements around the hospital should be somewhat limited, the client can travel wearing a mask to reduce transmission risk and need not be quarantined. ➧ Test-taking Tip: Carefully review each of the options. In this case, option 2 has elements that are correct, but the entire statement is not correct. Consider what is best psychologically for the client by using Maslow's Hierarchy of Needs, whereby quarantining the client would not be psychologically positive
A nurse is caring for a client in an emergency department who has five fractured ribs from blunt chest trauma. The client is rating pain at 9 out of 10 on a 0 to 10 numeric scale. For which pain management modality should the nurse advocate? 1. NSAIDs 2. Oral analgesics (narcotic + acetaminophen) 3. Regional/local analgesia (epidural or intercostal injection) 4. Intravenous (IV) bolus meperidine (Demerol®)
ANSWER: 3 Epidural analgesics and intercostal nerve blocks are the most optimal modality for blunt chest trauma because they directly target the injury site. Oral analgesics generally are not adequate to manage the pain associated with rib fractures. Meperidine is not the ideal narcotic for managing this type of pain because of its multiple adverse side effects. ➧ Test-taking Tip: Consider the physiological implications of the injury in selecting the best option and the most directed type of intervention.
. Which assessment findings for a client who is status post-thyroidectomy should direct a nurse to check the client's serum calcium level? 1. Fatigue, decreased cardiac function, and tetany 2. Weakness, tachycardia, and disorientation 3. Muscle cramps, paresthesia, and Trousseau's sign 4. Weakness, edema, and orthostatic hypotension.
ANSWER: 3 Muscle cramps, paresthesia, and a positive Trousseau's sign are common manifestations of hypo- or hypercalcemia because of the irritation to the neuromuscular system. Tachycardia is most often associated with abnormal serum magnesium levels. Fatigue is associated with sodium, potassium, and phosphorus imbalances. Hypotension relates most often to volume changes rather than electrolyte imbalances. ➧ Test-taking Tip: Focus on calcium's effect on the neuromuscular system to select the correct option
A nurse is caring for a client admitted with fluid volume overload. The client is receiving diuretic therapy with a loop diuretic. The potassium levels are illustrated in the chart below. On which day should the nurse expect an order for potassium replacement? Day 15.6 mEq/L Day 2 4.4 mEq/L Day 3 3.5 mEq/L Day 4 3.1 mEq/L
ANSWER: 3 Normal potassium level is 3.5 to 5.0 mEq/L. On day 3, the client is on the low end of normal. Because the client's serum potassium level is decreasing and the client is taking a diuretic, supplementation is needed to prevent a reduction of serum potassium levels below normal. The value on day 1 is high and would not require replacement. The value on day 2 is in the midrange of normal. The value on day 4 is low and would require replacement if replacement were not started on day 3. ➧ Test-taking Tip: Recall that a loop diuretic will decrease serum potassium levels. Consider this when selecting an option.
A nurse is preparing to discharge a 10-year-old male client who is hospitalized with the diagnosis of rheumatic fever. The nurse's top priority during the client's discharge teaching should be: 1. providing an avenue for verbalization of feelings regarding illness. 2. providing adequate and appropriate pain medications. 3. ensuring that the client is aware of activity restrictions and the need for adherence. 4. emphasizing the need for long-term prophylactic antibiotic therapy.
ANSWER: 3 Rheumatic fever is a serious illness with many major and minor components. This adolescent is at the developmental age and stage at which it is difficult to ensure compliance with activity level, and the child will want to be very active. Options 1, 2, and 4 are all correct, but option 3 is the priority because nonadherence to activity restrictions can impact cardiac function. ➧ Test-taking Tip: Consider the age of the child and the greatest risk upon returning home after being hospitalized
9.A nurse is caring for a client with heart failure who has been placed on a 2,000-mL fluid restriction. The nurse is responsible for establishing a plan for how that restriction should be distributed over a 24-hour period. Which plan, developed by the nurse, is best? Shift/Time 7-3 3-11 11-7 1. 1,000 mL 1,000 mL 0 mL 2. 900 mL 900 mL 200 mL 3. 1,000 mL 700 mL 300 mL 4. 700 mL 700 mL 600 mL
ANSWER: 3 The general rule is to provide half of the total restriction during the day and the other half between evening and nights, with most fluids offered in the evening. Option 1 is incorrect because fluids should be available during the night. Options 2 and 4 provide for a large amount of fluid intake just before bedtime; this should be avoided because it disrupts sleep. ➧ Test-taking Tip:Think about your own fluid intake and when you likely consume the most amount of fluid. Recall that there are usually two meals provided during a 7 a.m.-to 3-p.m. period that would increase fluid intake during this time period.
. A nurse is interpreting an ECG rhythm strip for a 2-year-old child with heart failure secondary to a congenital heart defect. In analyzing the rhythm, the nurse notes the measurements of PR interval is 0.26 seconds, the QRS is 0.08 seconds, and the QT is 0.28. The ventricular rate is 126 bpm. A nurse interprets the rhythm as: 1. sinus bradycardia. 2. sinus rhythm with a bundle branch block. 3. sinus rhythm with a first-degree AV block. 4. sinus tachycardia with a first-degree AV block.
ANSWER: 3 The normal heart rate for a 2-year-old is 80 to 130 bpm. A normal PR interval measures 0.12 to 0.20 seconds. The QRS is normal (0.6 to 0.10 seconds), and the QT is rate dependent. If the rate is fast, the QT will be shorter. It is within the normal range for the ventricular rate. The ventricular rate in sinus bradycardia for a 2-year-old should be less than 80. In a bundle branch block, the QRS interval should be greater than or equal to 0.12 seconds. In sinus tachycardia, the ventricular rate should be greater than 130 bpm for a 2-year-old. ➧ Test-taking Tip: In order to answer this question, knowledge of the normal ECG waveforms and the measurements is necessary. If this is unknown, then begin to eliminate options. The heart rate is normal for a 2-year-old. Eliminate options 1 and 4. This increases the chance of getting a right answer to 50%
. A nurse is caring for a client following an open thoracotomy for removal of a large tumor. Extensive blood loss during the procedure required fluid resuscitation of the client. The client is cyanotic and in respiratory distress with pink, frothy sputum coming from the mouth. The nurse should immediately: 1. put the client in high Fowler's position. 2. give a 200 mL fluid bolus. 3. activate the respiratory code system. 4. have the client cough and deep breathe.
ANSWER: 3 The scenario is suggestive of pulmonary edema most likely as a result of fluid overload. Calling a respiratory code in this emergency situation is essential so that intubation and appropriate pharmacological intervention such as vasopressors and diuretics can be administered. Sitting the client up does not address the immediate problem, and giving a fluid bolus would exacerbate the problem. Having the client cough and deep breathe would also not address the central issue. ➧ Test-taking Tip: Determine the condition being hinted at in the stem in order to determine the best option.
A nurse checks on a client following lower lobectomy for lung cancer. The nurse finds that the client is dyspneic with respirations in the 40s, is hypotensive, has a SaO2 at 86% on 10 L close-fitting oxygen mask, has a trachea that is deviated slightly to the left, and notes that the right side of chest is not expanding. Which action should be taken by the nurse first? 1. Notify the physician 2. Give the client whatever medication was ordered to decrease anxiety 3. Check the chest tube to make sure it is not obstructed 4. Turn up the oxygen liter flow
ANSWER: 3 The scenario presented implies that the client is suffering from a tension pneumothorax as a result of a kinking of the tubing or other blockage in the chest tube system. Although notifying the physician would be warranted, unkinking tubing would give some immediate relief and would be the best initial action. Neither turning up the oxygen flow nor treating the client for anxiety would correct this problem. ➧ Test-taking Tip: Use the steps of the nursing process; assessment should be considered as the best answer.
A nurse who is beginning a shift on a cardiac stepdown unit receives shift report for four clients. In which order should the nurse assess the clients? Prioritize the nurse's actions by placing each client in order from most urgent (1) to least urgent (4). ______ A 56-year-old client who was admitted 1 day ago with chest pain receiving intravenous (IV) heparin and has a partial thromboplastin time (PTT) due back in 30 minutes ______ A 62-year-old client with end-stage cardiomyopathy, blood pressure (BP) of 78/50 mm Hg, 20 mL/hr urine output, and a "Do Not Resuscitate" order and whose family has just arrived ______ A 72-year-old client who was transferred 2 hours ago from the intensive care unit (ICU) following a coronary artery bypass graft and has new onset atrial fibrillation with rapid ventricular response ______ A 38-year-old postoperative client who had an aortic valve replacement 2 days ago, BP 114/72 mm Hg, heart rate (HR) 100 beats/min, respiratory rate (RR) 28 breaths/min, and temperature 101.2°F (38.4°C)
ANSWER: 3, 4, 1, 2 The client with new onset atrial fibrillation should be assessed first because it is the most life threatening. The postoperative client with the elevated temperature should be assessed next because the elevated temperature, RR, and HR increase the demands on the heart and could be a sign of pulmonary complications. Third, the nurse should assess the client with the heparin infusion. PTT results should be back, and the dose may require adjustment. Last, the client with end-stage cardiomyopathy should be assessed. The family will have had time alone with the client, and the client and family may need emotional support. ➧ Test-taking Tip: When establishing priorities, first determine life-threatening situations and then prioritize remaining clients by using the ABCs (airway, breathing, and circulation). Recall from Maslow's Hierarchy of Needs that physiological problems are priority over psychosocial issues, thus the client with endstage cardiomyopathy should be assessed last.
During resuscitation efforts in an emergency department, the spouse of a trauma victim tells a nurse that her husband has terminal cancer, has completed an advance health care directive (HCD), and does not want cardiopulmonary resuscitation (CPR). What should be the nurse's next action? 1. Contact medical records to see if the client's HCD is on file. 2. In honor of the client's wishes, stop the actions of the resuscitation team. 3. Document the spouse's statement in the client's medical record. 4. Inform the health-care provider (HCP) in charge of the resuscitation team.
ANSWER: 4 A HCP must order whether to withhold or terminate CPR even if it is specified in a client's HCD. Depending on the situation and status of the client, the HCP may want to review the HCD, but this is not the next action because it delays a decision. Even if the client requests no CPR, a HCP's order is required to carry out the request. The spouse's statements should be documented, but this is not the next action. ➧ Test-taking Tip: Note the key phrase "next action." Prioritization is required.
. A male client confides to a clinic nurse that he is no longer dyspneic after receiving his new St. Jude's heart valve. He wants to have a vasectomy so that he can enjoy sexual intercourse again without the fear of his wife becoming pregnant. What is the nurse's best response? 1. "That's probably a good idea. The life expectancy after heart valve replacement is 10 to 15 years." 2. "You seem relieved that the heart valve replacement was successful and that you can enjoy a normal life again." 3. "If you have cardiac symptoms such as dyspnea during sexual intercourse, you can take a nitroglycerin tablet before sexual activity to prevent symptoms." 4. "Be sure to inform the physician that you have an artificial heart valve so you are given antibiotics as a preventive measure before the procedure."
ANSWER: 4 A St. Jude's valve is an artificial heart valve. Antibiotics are required prior to invasive procedures to prevent complications such as endocarditis. The physician also needs to know that the client has an artificial heart valve because the client should be receiving anticoagulants and there is the risk of increased bleeding. As long as the person receives regular follow-up with a health-care provider, the person can expect a normal life expectancy. Although mechanical valves are durable, they may need replacement in 10 to 15 years. Although responding that the client seems relieved is a therapeutic response, it is not the best response, because the client needs teaching. Nitroglycerin is not prescribed for persons with valvular heart disease unless the person also has coronary artery disease; thus he would not have nitroglycerin available. ➧ Test-taking Tip:The key terms in the stem are "vasectomy" and "heart valve." Recall that antibiotics are prescribed prophylactically prior to invasive procedures
. Following an unrestrained motor vehicle crash, a client presents to an emergency department with multiple injuries, including chest trauma. A physician notifies the care team that the client has progressed to acute respiratory distress syndrome (ARDS) and requests that the family be updated on the client's condition. The nurse should plan to discuss with the family that: 1. the condition generally stabilizes with positive prognosis. 2. the client can be discharged with home oxygen. 3. the condition is always fatal. 4. the condition is highly life-threatening and that end-of-life concerns should be addressed. .
ANSWER: 4 ARDS has a reported mortality rate of 50% to 70% and family should be prepared for the possibility that their loved one may not survive the injury or diagnosis. The nurse must be able to discuss the care to be given, the progression of the syndrome, and make appropriate referrals as needed (such as pastoral care). The condition often does not have a positive prognosis and, if the client survives, home oxygen may or may not be needed. ARDS is not always fatal. ➧ Test-taking Tip: Watch for absolute words such as "always" or "never" and eliminate these options
A client has a nursing diagnosis of fluid volume deficit. Which vital sign, if decreased, supports this nursing diagnosis? 1. Temperature 2. Respiratory rate 3. Heart rate 4. Blood pressure
ANSWER: 4 Blood pressure is a sensitive measure of changes in blood volume, decreasing in the presence of fluid volume deficit. Temperature and respiratory rate may contribute to volume status, but do not typically change as a result of volume changes. Heart rate may increase as a compensatory mechanism to decreased blood pressure. ➧ Test-taking Tip:Think about which vital sign measurement would decrease as a result of fluid volume deficit.
A client, hospitalized for a severe case of pneumonia, is asking a nurse why a sputum sample is needed. The nurse should reply that the primary reason is to: 1. complete the first of three samples to be collected. 2. differentiate between pneumonia and atelectasis. 3. encourage expectoration of secretions. 4. help select the appropriate antibiotic.
ANSWER: 4 Culturing the causative organism and testing sensitivities for the most effective antibiotic is the main reason that a sample is collected. Three samples are taken for a client with suspected tuberculosis. A client with atelectasis may get pneumonia, but generally this is not a test used to diagnose atelectasis. Although secretions are expectorated to obtain a sputum sample, the collection itself does not encourage future expectoration of secretions. ➧ Test-taking Tip: Consider the most basic reason why any sample for microorganisms is taken
An initial treatment regimen of isoniazid (Laniazid®), rifampin (Rifadin®), and ethambutol (Myambutol®) are prescribed for a 16-year-old client who has a positive tuberculin skin test. The client confides that she thinks she may have become pregnant since she was diagnosed and asks if she should be taking the medication while pregnant. On which rationale should a nurse base a response to the client's question? 1. These drugs cross the placental barrier and treatment should be withheld until the postpartum period. 2. The medications should be taken but the diagnosis is an indication for termination of the pregnancy. 3. The medications should be postponed because the risk for hepatitis is greatly increased in the intrapartum period. 4. The medications should be taken because untreated tuberculosis represents a far greater hazard to a pregnant woman and her fetus than does the treatment of the disease.
ANSWER: 4 Infants born to women with untreated tuberculosis may be of lower birth weight than those born to women without tuberculosis, and, rarely, the infant may acquire congenital tuberculosis. Isoniazid, rifampin, and ethambutol are all considered safe for use in pregnancy as reported by the Centers for Disease Control and Prevention (CDC). The medications do not cross the placental barrier, so treatment should not be withheld. Administering antituberculosis medications would not be an indication for termination of pregnancy because the medications are safe during pregnancy. The risk of hepatitis is slightly increased with the use of antituberculosis medications in pregnant women; however, the benefits of treatment strongly outweigh postponement of treatment. ➧ Test-taking Tip: Evaluate similar options first (not giving the medication) and eliminate one or both of these. Then examine the two remaining options. Think about the risk to others if the client is not treated.
An emergency department nurse is assessing a pediatric client suspected of having acute pericarditis. Which assessment finding should the nurse conclude supports the diagnosis of acute pericarditis? 1. Bilateral lower extremity pain 2. Pain on expiration 3. Pleural friction rub 4. Pericardial friction rub
ANSWER: 4 Inflammation of the pericardial sac from acute pericarditis produces a pericardial friction rub. Decreased perfusion to the extremities can cause extremity pain, but this does not occur with pericarditis. Pain on inspiration, not expiration, is present with pericarditis. The friction rub is pericardial, not pleural. ➧ Test-taking Tip: Focus on the word "pericarditis." "Peri-" is around, "cardio-" pertains to the heart, and "-itis" is inflammation. Eliminate options 1, 2, and 3 because option 4 pertains to the heart.
A client is admitted to an emergency department with reports of feeling weak and having "passed out." The outside temperature is 100°F (41.3°C), and the client has been gardening. Physical assessment findings reveal poor skin turgor, dry and dull mucous membranes, heart rate (HR) 120 beats per minute, and blood pressure 92/54 mm Hg. Which nursing diagnosis should the nurse include in the client's plan of care? 1. Impaired oral mucous membrane 2. Fluid volume excess 3. Decreased cardiac output 4. Fluid volume deficit
ANSWER: 4 Signs of dehydration and hypovolemia are evident (weakness, syncope, poor skin turgor, dry and dull mucous membranes, hypotension), suggesting a nursing diagnosis of fluid volume deficit. The client has dry, dull mucous membranes, but impaired oral mucous membrane would not be the most appropriate diagnosis. The client's HR is elevated, indicating that it is compensating for the decreased blood volume. There are no symptoms of decreased cardiac output. The client's mean arterial pressure is 67, suggesting adequate cardiac output for tissue perfusion ([SBP + 2 DBP]/3). ➧ Test-taking Tip: Fo
. A nurse is assessing lung sounds on a client with pneumonia who is having pain during inspiration and expiration. The nurse hears loud grating sounds over the lung fields. The nurse should document the client's pain level and should document that: 1. lung sounds were clear upon auscultation. 2. fine crackles were heard upon auscultation. 3. wheezing was heard upon auscultation. 4. pleural friction rub was heard upon auscultation.
ANSWER: 4 The client with pneumonia may have crackles, rhonchi, and wheezes as well as a pleural friction rub. A pleural friction rub has a distinctive sound that tends to be loud and grating and heard easily over the lung fields upon auscultation. Pleural friction rubs are also often associated with painful breathing. Fine or course crackles will have a moist, bubbling, or Velcro-tearing sound. Wheezing tends to have a high-pitched sound. ➧ Test-taking Tip: Consider the expected assessment findings for the condition described in the question
A pediatric client presents with tachycardia, edema, dyspnea, orthopnea, and crackles. A nurse performs a physical assessment of the client and notifies a physician immediately. Which condition does the nurse most likely suspect? 1. Right-sided heart failure 2. Rheumatic fever 3. Kawasaki disease 4. Left-sided heart failure
ANSWER: 4 The nurse suspects that the client has left-sided heart failure. A child in left-sided heart failure will present with pulmonary symptoms of dyspnea, orthopnea, and crackles because of the fluid accumulation in the lungs from the ineffective pumping action of the heart. In right-sided heart failure, the child would present with jugular venous distention, liver enlargement, splenomegaly, or ascites due to a reduced preload to the right side of the heart. In rheumatic fever, the child would present with an elevated temperature and a systolic murmur, mitral insufficiency, and a prolonged PR and QT interval. In Kawasaki disease, the child would present with fever, rash, and lymph node enlargement. ➧ Test-taking Tip: Options 1 and 4 are opposites, so one of these is incorrect. Focus on the client's symptoms and cardiac anatomy and physiology to select the correct option
A nurse is performing a physical assessment of a pediatric client. While auscultating the heart, the nurse hears physiological splitting of S2 when the child takes a deep breath. Which action should be taken by the nurse? 1. Notify the provider of suspected atrial-septal defect. 2. Notify the provider of suspected pulmonary stenosis. 3. Follow institutional policy for initiating an emergency response. 4. Document the findings as a normal finding.
ANSWER: 4 The physiological splitting of S2 on deep inspiration is normal in pediatric clients. Normally, the aortic valve closes just before the pulmonary valve, but the valves are so close together that the S2 sound is uniform and instantaneous. When a person takes in a deep breath, the decrease in intrathoracic pressure increases venous return. The right atrium and ventricle then fill slightly more than usual. With the extra blood, the pulmonary valve stays open slightly longer than usual, and the normally small difference between aortic and pulmonary valve closure becomes a noticeable split S2. If this occurs during normal respiration, it is abnormal and may indicate an atrial-septal defect or pulmonary stenosis. Initiating an emergency response is unnecessary because the findings are normal. ➧ Test-taking Tip: Apply knowledge of normal assessment findings in pediatric clients. Recall that a split S2
A nurse enters a client's room after hearing the pulse oximeter alarm and sees the following tracing on the screen. Which action should be immediately taken by the nurse? 1. Call a code 2. Remove the machine and call maintenance 3. Administer oxygen through a nasal cannula or mask 4. Assess the client's level of consciousness and skin color
ANSWER: 4 The pleth wave tracing pictured is generally the result of artifact that is caused by the client moving the finger rather than signaling that the client is coding or that the machine is broken. By immediately evaluating the client's mental status and skin color, the nurse can quickly determine whether the tracing constitutes an emergency or if it is just artifact. A pulse oximeter, or any other technology should never replace the direct assessment of a client by the nurse. The nurse should always treat the client and not the monitor. Although applying oxygen would be a good choice if the nurse continued to be unable to determine the client's pulse oximetry reading within a few seconds, it may not be necessary or appropriate. ➧ Test-taking Tip: Consider the steps of the nursing process in answering this question. An intervention is generally guided by the nurse's assessment findings.
A nurse is assessing a client who has new onset atrial fibrillation and reports shortness of breath. The client has a history of rheumatic fever as a child and also reports increased exercise intolerance. Place an X where the nurse would best be able to assess the heart murmur associated with these symptoms.
ANSWER: The "X" should be placed on the second intercostal space at the right sternal border to hear a murmur associated with aortic regurgitation. Shortness of breath, atrial fibrillation, and exercise intolerance are often associated with aortic regurgitation, especially in clients with a history of rheumatic fever. ➧ Test-taking Tip: Use the memory aid "all points essential to memorize" to remember the names of the heart valves and auscultation points: aortic, pulmonic, Erb's point, tricuspid, and mitral valve. Note the formation of a "2" on the chest and that the aortic valve is located at the first point
Which patient is most appropriate to assign to a floating nurse from the oncology floor?
Ans: 1) hypoxia, 2) anxiety, 3) acute MI, 4) fever, 5) pain
The nurse knows that the reason insulin is given to the patient to treat hyperkalemia is because:
Ans: It provokes the uptake of potassium ions by cells, decreasing potassium ion concentration in the blood.
Which patient is most appropriate to assign to a floating nurse from the oncology floor?
Ans: The pt. with pulmonary tuberculosis
2. What should a nurse make sure is at the bedside of a patient with a chest tube?
Ans: hemostat
1. While obtaining a nursing history from a 23-year-old man with rheumatic fever, the nurse recognizes that the most significant information related by the patient is that he 1. has used illicit intravenous drugs within the last 3 months. 2. has been unemployed for 6 months and has been eating poorly. 3. suffered chest trauma with a fractured rib during a fight 2 weeks ago. 4. had an upper respiratory infection with a sore throat about 3 weeks ago.
Answer: 4
The patient with a chest tube has bathroom privileges. What does he do with the chest tube?
Answer: Leave it lower while you ambulate
During a physical examination of a patient, the nurse palpates the PMI in the sixth intercostal space lateral to the midclavicular line. The most appropriate action for the nurse to take next will be to: the heart has enlarged, suspect hypertrophy. WHEN performing an assessment of a newly admitted patient, the nurse notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which action will the nurse take next? Palpate the quality of the peripheral pulses Compare the apical and radial pulse rates Assess for murmurs Locate the PMI
Assess for murmurs
The nurse is caring for the client diagnosed with bacterial pneumonia. Which priority intervention should the nurse implement? Assess respiratory rate and depth. Provide for adequate rest period. Administer oxygen as prescribed. Teach slow abdominal breathing
Assess respiratory rate and depth.
A PT BEING TX FOR TB COMES TO THE CLINIC AFTER 2 MONTHS FOR F/U VISIT. SPUTUM SMEARS FOR AFB ARE STILL POSITIVE. A SPUTUM SPECIMEN IS TAKEN FOR CULTURE AND DETERMINE WHETHER THE MO IS SENSITIVE TO DRUGS. THE RN QUESTIONS THE PT REGARDING THE TX REGIMEN WITH KNOWLEDGE THAT A.TX PROTOCOLS INVOLVING TWICE WEEKLY ADM OF THE DRUGS ARE NOT EFFECTIVE METHODS FOR TX B. DOT WILL BE NECESSARY IF PT HAS BEEN NONCOMPLIANT C.IF DRUGS ARE CASUING SE, A REGIMEN INCLUDING THE ADM OF ONLY ISONIAZID CAN BE SUBSTITUTED D.A COMBINATION PRODUCT OF ISONIAZID, RIFAMPIN, PYRAZINAMID IS INDICATED IF THE PT SKIPS DOSES
B. DOT WILL BE NECESSARY IF PT HAS BEEN NONCOMPLIANT
COMPLETE LUNG EXPANSION BEFORE THE REMOVAL OF CHEST TBES IS EVAL BY A.RETURN OF NORMAL TIDAL VOLUME B.COMPARISON OF CHEST XR C.ABSENCE OF ADDITIONAL DRAINAGE D.DECREASED ADVENTITIOUS SOUNDS
B.COMPARISON OF CHEST XR
A THORACENTESIS IS PERFORMED. FOLLOWING PROC IT IS IMPORTANT FOR THE RN TO OBSERVE PT FOR COMPLICATIONS WHICH CAN EXHIBIT A.PERIODS OF CONFUSIONS B.DECREASED RESPIRATORY RATE C.INCREASED BREATH SOUNDS D.EXPECTORATION OF FRANK BLOOD
B.DECREASED RESPIRATORY RATE
THE PT IS TO RECEIVE THE MANTOUX PPD TEST FOR TB. THE RN RECOGNIZES THAT THIS INJECTION IS GIVE A.SQ 30 DEGREES B.INTRADERMALLY 15 DEGREES C.SQ 45 DEGREES D.INTRAMUSCULAR 90 DEGREES
B.INTRADERMALLY 15 DEGREES
DURING A RESPIRATORY ASSESS OF CHEST TRAUMA PT WITH MULTI RIB FRACTURES (FLAIL CHEST) THE RN FINDING WILL INCLUDE A.WHEEZING AND STRIDOR B.NORMAL ASSESS C.DYSPNEA AND PARADOXICAL CHEST MVMTS D.MIDLINE TRACHEA
C.DYSPNEA AND PARADOXICAL CHEST MVMTS
CHEST TUBE BOTTLE WITH CONTINUOUS BUBBLE
CHECK FOR LEAK IN WATER SEAL CHAMBER
THE RN RECOGNIZES THAT GOALS OF TEACHING REGARDING TRANSMISSION OF TB HAVE BEEN MET WHEN PT WITH TB A.COVERS MOUTH AND NOSE WITH TISSUE WHEN COUGHING OR SNEEZING B.WEARS A MASK WHEN IN CONTACT WITH OTHERS C.BOILS DISHES AND PERSONAL ITEMS BETWEEN USES D.REPORTS DAILY TO THE PUBLIC HEALTH DEPT
COVERS MUTH AND OSE WITH TISSUE WHEN COUGHING
The nurse is caring for a client diagnosd with a pneumothorax who had chest tubes inserted four hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse take first? Milk the chest tube. Check the tubing for kinks. Instruct the client to cough. Assess the insertion site.
Check the tubing for kinks.
The test for pulmonary embolism is:
D-Dimer
YOUR PT WAS THE DRIVER IN A MOTOR VEHICLE ACCIDENT AND SUFFERED A CHEST TRAUMA FROM THE IMPACT AGAINST THE STEERING WHEEL. S/S INCLUDE DYSPNEA, DECREASED BREATH SOUNDS, DULLNESS ON PERCUSSION, SHOCK AND HYPOVOLEMIA. YOUR CARE WILL BE BASED ON THE FACT THAT THE PT IS EXHIBIING S/S OF A.FLAIL CHEST B.CARDIAC TAMPONADE C.PNEUMOTHORAX D.HEMOTHORAX
D. HEMOTHORAX
THE RN EMPHASIZES THE NEED FOR ESPECIALLY CLOSE MONITORING IN THE PT WHO IS TAKING ANTI-TB DRUGS HAS HX OF A.BOWEL DX B.HEART DX C.RENAL DX D.LIVER DX
D.LIVER DX
Cause of atrial flutter: ·
Decreased blood flow to the heart (ischemia) due to coronary heart disease, atherosclerosis, or a blood clot · High blood pressure(hypertension) · Disease of the heart muscle (cardiomyopathy) · Abnormalities of the heart valves (especially the mitral valve) · An abnormally enlarged chamber of the heart (hypertrophy) · After open heart surgery
The nurse is caring for a client diagnosed with pneumonioa who is having shortness of breath and difficulty breathing. Which intervention should the nurse implement first? Take the client's vital signs. Check the client's pulse oximeter reading. Elevate the client's head of the bed. Notify the respiratory therapist STAT
Elevate the client's head of the bed.
PT WITH PNEUMONIAL BEST THING TO DO FIRST
FIND OUT WHAT IS CAUSING PNEUMONIA
Sinus tachycardia Answers:
Fever anxiety pain hypoxia
If the tube disconnects from the disconnector what do you do?
Form a water seal and get another connector
PT ON STRIPTOMYCIN C/O TAKING SO MANY MEDS AND HIS EARS ARE RINGING
HE NEEDS TO BE FURTHER EVALUATED
WHAT CONDITION IS CONTRAINDICATED BY INH
HEPATITIS C
A 60 yr old homeless man has a cough, late afternoon fever, and night sweats. The patient's response to a purified protein derivative (PPD) skin test is 10mm. The nurse recognizes that his response indicates that the patient has tuberculosis inly if abnormal chest x-ray findings are present. Has a latent tubercular infection Has been exposed to the tuberculosis organism Has class #3 clinically active tuberculosis
Has class #3 clinically active tuberculosis
TB PRIMARY DRUG USED FOR PROPHYLACTIC REASONS
INH
The client with pneumonia that has the following arterial blood gases: PH 7.33, Pao2 94, Paco2 47, HCO3 25. Which intervention should the nurse implement? Administer sodium bicarbonate Administer oxygen via nasal cannula Have the client cough and deep breathe Instruct the client to breathe in a paper bag.
Instruct the client to breathe in a paper bag.
Pt comes in from a car accident with a cervical injury what is the first thing the nurse does?
Intubate him.
The athlete has bradycardia
It's normal
Which of these assessment data obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider? Blood pressure of 166/96 Jugular vein distension(JVD) to the level of the jaw Pulsus paradoxus 8 mm Hg Level 6/10 chest pain with deep inspiration
Jugular vein distension(JVD) to the level of the jaw
BEST PREVENTION FOR PNEUMONIA
MAINTAIN GENERAL HEALTH AND NUTRITION
A RN SHOULD DO WHAT FIRST WHEN PT COMES FROM SX WITH CHEST TUBE
MARK LEVEL WIT TUBE AND OBSERVE AMT OF DRAINAGE
Cardiac tamponade is suspected in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should substract the diastolic blood pressure from the systolic blood pressure SBP auscultate for a pericardial friction rub that increases in volume during inspiration. Note when Korotkoff sounds are audible during both inspiration and expiration. Check the ECG for variations in rate in relation to inspiration and expiration
Note when Korotkoff sounds are audible during both inspiration and expiration.
Chest tube comes out of patient PLEURAL space What do you do?
Occlusive petroleum dressing on 3 sides.
BEST TEST FOR TB
POSITIVE SPUTUM CULTURE
PT WITH TB AND POSITIVE MONTAUX TEST
PT IS INFECTED WITH TB
HIV PT WITH INDURATION OF 7MM WITH MONTAUX TEST
PT IS POSITIVE
Which patient is at risk for pulmonary embolism?
Pt with total hysterectomy
The client diagnosed with deep vein thrombosis suddenly complains of severe chest pain and a feeling of impending doom. Which complication would the nurse suspect the client has experienced? Myocardial infarction Pneumonia Pulmonary embolus Pneumothorax
Pulmonary embolus
HEPARIN
SHOULD BE ON PUMP
PT WHO IS DOING THORACENTESIS WHAT POSITION RN PLACE THE PT
SITTING ON BED WITH ARMS OVER BEDSIDE TABLE
PT COMPLAINING OF PAIN WHEN COUGHING WHAT SHOULD RN DO
SPLINT AB WITH PILLOW
BREAK IN WATER SEAL IN CHEST TUBE WHAT SHOULD THE RN HAVE HANDY
STERILE WATER
The cause of rheumatic fever
Sequela Strep A
The CNA loses a patient on her floor and can't see other patients because she is . What should the charge nurse do?
Talk to the CNA about her feelings about death
Which patient do you see first?
The 60 yr old with dyspnea
The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client diagnosed with a pulmonary embolus. Which data would cause the nurse to question administering the medication? The client's partial thromboplastin time (PTT) is 38. The client's International Normalized Ratio (INR) is 5 The client's prothrombin time (PT) is 22 The client's erythrocyte sedimentation rate is 10
The client's International Normalized Ratio (INR) is 5
The client diagnosed with tuberculosis has been treated with antitubercular medications for 6 weeks. Which data would indicate the medication has been effective? A decrease in the WBC in the sputum The client's symptoms are improving No change in the chest x-ray The skin test is now negative
The client's symptoms are improving
The public health department nurse is caring for the client diagnosed with active tuberculosis who has been placed on DOT. Which statement best describes this therapy? The nurse accounts for all medications administered to the client. The nurse must complete federal, state, and local forms for this client. The nurse must report the client to the Centers for Disease Control. The nurse must watch the client take the medication daily.
The nurse must watch the client take the medication daily.
Pt has hyperkalemia and receving 20% dextrose and is on insulin
The potassium binds to the glucose and pulls it into the cells
How do you know the procedure was effective?;
The tidaling
RIMFAMPINE
URINE BODY SECRETIONS AND LACRIMAL TURN ORANGE
The chest tube comes out...what do you not do?
You don't stick it back in.
What do you give for community acquired pneumonia?
Zithromax
During the assessment of a patient with IE, the nurse would expect to find substernal chest pain and pressure splinter hemorrhages of the lips dyspnea and a dry, hacking cough a new regurgitant murmur
a new regurgitant murmur
Hypoxia is the #1 cause of
atrial flutter
While assessing a patient with heart failure, the nurse notes that the patient has jugular venous distension (JVD) when lying flat in bed. The nurse's next action will be to a. have the patient perform the Valsalva maneuver and observe the jugular veins. b. Palpate the jugular veins and compare the volume and pressure on the both sides. c. use a centimeter ruler to measure and document accurately the level of the JVD. d. elevate the patient gradually to an upright position and examine for continued JVD.
d. elevate the patient gradually to an upright position and examine for continued JVD.
Peaked t wave has
hyperkalemia
Sore throat and upper respiratory infection with
rheumatic fever
What finding would confirm Ineffective airway clearance?
tachapynea Sonorous wheezes and crackles
THE PHYSICIAN INSERTS A CHEST TUBE IN A PT WHO HAS A STAB WOUND IN THE CHEST AND ATTACHES IT TO A CLOSDE-DRAINAGE SYSTEM. WHEN CARING FOR THE PT AFTERWARDS, RN INTERVENTIONS WILL INCLUDE A.OBSERVE FOR FL FLUCTUATIONS IN THE WATERSEAL CHAMBER B.APPLY THORACIC BINDER TO PREVENT TENSION ON THE TUBE C.CLAMP TUBING TO PREVENT RAPID DECLINE IN PRESSURE D.ADM SEDATIONS BECAUSE THE CLIENT WILL BE AGITATED
A.OBSERVE FOR FL FLUCTUATIONS IN THE WATERSEAL CHAMBER
A nurse is caring for a client following a coronary artery bypass graft. Which assessment finding in the immediate postoperative period should be most concerning to the nurse? 1. No chest tube output for 1 hour when previously it was copious 2. Client temperature of 99.1°F (37.2°C) 3. Arterial blood gas (ABG) results show pH 7.32; Pco2 48; HCO3 28; Po2 80 4. Urine output of 160 mL in the last 4 hours
ANSWER: 1 A copiously draining chest tube that is no longer draining indicates an obstruction. There is an increased risk for cardiac tamponade or pleural effusion. A slight elevation in temperature could be the effects of rewarming after surgery. This should continue to be monitored, but is not immediately concerning. The ABG results show compensated respiratory acidosis. Though the pH is low and the PCO2 is high, the kidneys are compensating by conserving bicarbonate (HCO3). Normal pH is 7.35-7.45, PCO2 32-42 mm Hg, HCO3 20-24 mmol/L, and PO2 75-100 mm Hg. A urine output of 160 mL/4 hr is equivalent to 40 mL/hr; adequate, but it warrants continued monitoring. Less than 30 mL/hr indicates decreased renal function. ➧ Test-taking Tip:The key phrase in the question is "most concerning." Use the process of elimination and eliminate options 3 and 4 because these are normal findings. Of options 1 and 2, determine which option is most concerning.
. A nurse is caring for a client suspected of having a pulmonary embolism. The client's arterial blood gas (ABG) results indicate respiratory alkalosis. Which findings support this diagnosis? 1. pH = 7.54; PaCO2 = 25; HCO3 = 24 2. pH = 7.35; PaCO2 = 35; HCO3 = 22 3. pH = 7.50; PaCO2 = 40; HCO3 = 28 4. pH = 7.32; PaCO2 = 48; HCO3 = 24
ANSWER: 1 Because pulmonary emboli interfere with gas exchange, the respiratory center is stimulated to meet oxygenation demands. The tachypnea produces respiratory alkalosis. Thus, the pH is increased above normal of 35 to 45 and the PaCO2 is lower than the normal level of 35 to 45 mm Hg. The HCO3 is normally 22 to 26 mEq/L. The blood gas in option 2 is normal, option 3 represents metabolic alkalosis, and option 4 is indicative of respiratory acidosis. ➧ Test-taking Tip: First look at the pH and eliminate the option with a decreased pH because this indicates acidosis. Of the remaining options, look at the PaCO2 because it is the respiratory component for arterial blood gases (ABG) analysis. Select the option with the decreased PaCO2 because a low PaCO2 is present in respiratory alkalosis.
An adult client taking warfarin (Coumadin®) for treatment of atrial fibrillation presents to an emergency department complaining of weakness and fatigue. The client's skin is pale and diaphoretic, and the blood pressure is 85/58 mm Hg. When the client is attached to a cardiac monitor, the client's rhythm is atrial flutter with a ventricular rate of 140 beats per minute. A nurse should expect to initiate health-care provider's orders to treat: 1. noncoronary cardiogenic shock. 2. coronary cardiogenic shock. 3. hypovolemic shock. 4. neurogenic shock.
ANSWER: 1 Cardiogenic shock occurs as a result of inadequate supply of oxygen to the heart and tissues due to the heart's inability to contract and pump blood. Noncoronary cardiogenic shock results from conditions that stress the myocardium or result in ineffective myocardial function, such as dysrhythmias. Coronary cardiogenic shock occurs when there is significant damage to the left ventricle such as from an anterior wall myocardial infarction. Though the client is taking warfarin, which can cause bleeding and hypovolemic shock from a decrease in intravascular volume, bleeding is not reported. In neurogenic shock, vasodilatation occurs from a loss of balance between parasympathetic and sympathetic stimulation. ➧ Test-taking Tip: Both the client's symptoms and the options suggest shock. Because the cardiac monitor shows a change in rhythm and there is no evidence of bleeding, the shock is likely cardiac in origin. Eliminate options 3 and 4. Use the word "coronary" to eliminate one of the remaining two options. The coronary vessels supply blood to the heart. Because atrial flutter does not involve vessels, eliminate option 2
Ciprofloxacin (Cipro-XR®) is prescribed for a client to treat a urinary tract infection. Which point should a nurse stress when teaching the client about the medication? 1. Avoid taking ciprofloxacin with milk or yogurt. 2. Treat diarrhea, a side effect of ciprofloxacin, with bismuth subsalicylate (Pepto-Bismol®). 3. Avoid fennel because it will increase the absorption of the ciprofloxacin. 4. Take dietary calcium tablets 1 hour before or 2 hours after ciprofloxacin.
ANSWER: 1 Ciprofloxacin is a fluoroquinolone antibiotic. Milk or yogurt decreases its absorption and should be avoided. Bismuth subsalicylate also decreases the absorption of ciprofloxacin and should be avoided. Extended release ciprofloxacin significantly reduces the frequency of nausea and diarrhea. Fennel will decrease the absorption of the ciprofloxacin. Dietary calcium can be taken at any time; it is unaffected by ciprofloxacin. ➧ Test-taking Tip: Eliminate actions that will cause a decrease in the absorption of ciprofloxacin
A nurse takes a client's blood pressure with an automatic blood pressure machine. The blood pressure is 86/56 mm Hg with a pulse rate of 64 beats per minute. Which action should the nurse do first? 1. Assess the client for dizziness and assess the skin on the extremities for warmth 2. Obtain a manual blood pressure cuff and retake the client's blood pressure 3. Elevate the head of the client's bed 4. Read the client's medical record and determine the client's normal range of blood pressure
ANSWER: 1 Initially, the nurse should assess the condition of the client and ascertain if there are physical signs consistent with hypotension resulting in decreased perfusion to the brain and peripheral circulation. After assessing the client's condition, the nurse should recheck the blood pressure to verify the accuracy of the reading. The nurse should not elevate the head of the client's bed since this action would further lower the blood pressure. Determining the normal range of blood pressure is indicated after condition assessment and verification of the reading. ➧ Test-taking Tip: Read the scenario in the stem carefully. The key word is "first." Use the nursing process; assessment is the first step in the process.
A hospitalized client is being treated for tuberculosis (TB). When administering medications, which medication on the client's medication administration record (MAR) should a nurse conclude is used for the treatment of TB? 1. Isoniazid (Nydrazid®) 2. Fluconazole (Diflucan®) 3. Azithromycin (Zithromax®) 4. Acyclovir (Zovirax®)
ANSWER: 1 Isoniazid (INH) is an antimycobacterial medication affecting bacterial cell wall synthesis; it is used in the treatment of TB or other mycobacterial infections. Fluconazole is an antifungal agent that inhibits synthesis of fungal sterols, a necessary component of the cell membrane. Azithromycin is a macrolide antibiotic that is bacteriostatic against susceptible bacteria and is usually used for treating lower respiratory tract infections, skin infections, acute otitis media, tonsillitis, or Mycobacterium avium. Acyclovir is an antiviral agent limited to treatment of herpes viruses. ➧ Test-taking Tip: Read each medication name carefully. Use key letters in each medication to determine the medications use ("-azone" is antifungal; "-vira" is antiviral) and eliminate options that do not pertain to a mycobacterium
A nurse receives the following medication orders while caring for multiple clients. Which medication should the nurse plan to administer first? 1. Nitroglycerin (Nitrostat®) 0.4 mg sublingually (SL) stat for the client experiencing chest pain 2. Morphine sulfate 4 mg intravenously (IV) now for the client experiencing incisional pain 3. Lorazepam 2 mg IV now for the client experiencing restlessness and picking at tubing 4. One unit packed red blood cells stat for the client with a hemoglobin of 9.5 g
ANSWER: 1 Nitroglycerin increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic areas of the heart. Increasing collateral blood flow reduces anginal pain and the potential of myocardial infarction. This action has the greatest potential of changing client outcomes and can be performed more quickly than the other actions. Both morphine and lorazepam are controlled substances, requiring the nurse to retrieve and sign these out from a secure location. Administering IV medications takes longer than SL medications. Obtaining blood from the blood bank will take longer than the time it takes to administer a SL medication.
A client is admitted with a diagnosis of acute infective endocarditis (IE). Which findings during a nursing assessment support this diagnosis? SELECT ALL THAT APPLY. 1. Skin petechiae 2. Crackles in lung bases 3. Peripheral edema 4. Murmur 5. Arthralgia 6. Decreased erythrocyte sedimentation rate (ESR)
ANSWER: 1, 2, 3, 4, 5 Vegetations that adhere to the heart valves can break off into the circulation, causing embolism, valve incompetence, and a murmur. A vascular sign of microembolism is skin petechiae. Crackles and peripheral edema occur due to heart failure secondary to IE. Arthralgia (joint pain) can occur from microembolism and inadequate perfusion. The ESR (rate at which red blood cells settle) should increase, not decrease, during an inflammatory process. ➧ Test-taking Tip:The issue of the question is signs and symptoms of infective endocarditis. Recall that the endocardium is the inner surface and cavities of the heart and that in IE microorganisms and debris from the inflammatory process can adhere to heart valves. Select signs and symptoms indicating the heart valves are affected and also those that can occur if portions of the vegetation should break off into the circulation
A nurse is teaching a client, who is 24 hours post-abdominal surgery, how to use an incentive spirometer. Which instructions should the nurse include in the teaching? SELECT ALL THAT APPLY. 1. Inhale slowly and deeply through mouth 2. Seal lips tightly around mouthpiece 3. After inhaling, hold breath for 2 to 3 seconds 4. Sit with head of bed down and bed almost flat 5. Splint incision with pillows 6. Exhale forcefully, fast, and hard
ANSWER: 1, 2, 3, 5 Inhaling slowly and deeply through the mouth and holding the breath prevent hyperventilation and provides maximal inflation of the alveoli. Sealing the lips around the mouthpiece prevents leakage of air. Splinting of the incision promotes comfort and encourages the client to take larger volume breaths. Exhaling forcefully, fast, and hard may lead to hyperventilation and is the technique used to measure peak expiratory flow rate. Sitting with the head of bed down or flat does not promote lung expansion. The desired position for maximum lung expansion is a high Fowler's position or a sitting position. ➧ Test-taking Tip: Use process of elimination to rule out incorrect options. Recall the physiology of lung expansion
A nurse should evaluate the hydration status of an older adult client by assessing: SELECT ALL THAT APPLY. 1. urine color. 2. serum blood urea nitrogen (BUN) and creatinine. 3. serum white blood cell (WBC) and differential count. 4. urine specific gravity. 5. 24-hour fluid intake and urine output.
ANSWER: 1, 2, 4, 5 Urine color indicates the concentration of the urine and varies with specific gravity. With overhydration, the urine will be dilute and light in color with a low specific gravity. With dehydration, the urine will be concentrated and dark in color with a high specific gravity. The BUN and creatinine tests are interpreted together and are directly proportional to renal excretory function; thus, overhydration tends to dilute the urine, resulting in lower levels, and dehydration tends to concentrate the urine, resulting in higher levels. Comparing intake and output measurements of the client's fluids for 24 hours assesses actual or potential imbalances. WBC and differential count evaluate infection, neoplasm, allergy, or immunosuppression, not hydration. ➧ Test-taking Tip: Look for the correct indicators of fluid status and avoid reading into the question. Although the causes of elevated WBC and differential may result in fluid loss, this laboratory value is not used to evaluate hydration status
A nurse evaluates that a client understands discharge teaching, following aortic valve replacement surgery with a synthetic valve, when the client states that he/she plans to: SELECT ALL THAT APPLY. 1. use a soft toothbrush for dental hygiene. 2. floss teeth daily to prevent plaque formation. 3. wear loose-fitting clothing to avoid friction on the sternal incision. 4. use an electric razor for shaving. 5. report black, tarry stools. 6. consume foods high in vitamin K, such as broccoli.
ANSWER: 1, 3, 4, 5 A synthetic heart valve requires long-term anticoagulation because of the risk of thromboembolism. Because low-dose aspirin, which prevents platelet aggregation, and oral anticoagulation together are more effective than just oral anticoagulation to reduce the risk of thromboembolism after valve replacement, both are prescribed, which increases the risk for bleeding. Bleeding precautions while on anticoagulation include using a soft toothbrush, avoiding injury (such as can occur with flossing), and using an electric razor. The client will have a sternal incision. Care must be taken to avoid tissue trauma. Black, tarry stools are a sign of bleeding. Flossing should be avoided because it causes tissue trauma, increases the risk of bleeding, and increases the risk of infective endocarditis. The diet should contain normal amounts of vitamin K; excessive amounts antagonize the effects of the anticoagulant. ➧ Test-taking Tip: Focus on the issue: self-care following a synthetic valve replacement. Recall that anticoagulation will be required. Select options that include bleeding precautions and signs of bleeding.
A nurse is planning care for a client admitted with a new diagnosis of persistent atrial fibrillation with rapid ventricular response. Although the client has had no previous cardiac problems, the client has been in atrial fibrillation for more than 2 days. The nurse should anticipate that the health-care provider is likely to initially order: SELECT ALL THAT APPLY. 1. oxygen. 2. immediate cardioversion. 3. administration of amiodarone (Cordarone®). 4. initiation of a IV heparin infusion. 5. immediate catheter-directed ablation of the AV node. 6. administration of a calcium channel antagonist such as diltiazem (Cardizem®).
ANSWER: 1, 3, 4, 6 The ineffective atrial contractions or loss of atrial kick with atrial fibrillation can decrease cardiac output. Administering oxygen enhances tissue oxygenation. Amiodarone is used for pharmacological cardioversion of the atrial fibrillation rhythm. The client is at risk for thrombi in the atria from stasis. Anticoagulant therapy is used to prevent thromboembolism. Diltiazem, a calcium channel antagonist, is prescribed to slow the ventricular response to atrial fibrillation. An alternative to a calcium channel antagonist would be the use of a beta blocker, such as esmolol, metoprolol, or propranolol. Cardioversion would only be considered if medications were ineffective in converting the client's rhythm and only after the presence of an atrial clot has been ruled out. Ablation of the AV node would only be considered if medications were ineffective in controlling the client's heart rate. ➧ Test-taking Tip: Carefully read the information provided in the stem. The key phrase is "initially order." The nurse should direct interventions at the client's potential complications from the arrhythmia. Note that both options 2 and 5 contain the words "immediate." Eliminate one or both of those options, because both procedures cannot be immediate.
A nurse approaches a client who needs nasotracheal suctioning. The nurse explains the procedure to the client and washes hands. Which steps should be taken by the nurse when performing nasotracheal suctioning? Prioritize the nurse's actions by placing each step in the correct order. ______ Prepare suction equipment; open watersoluble lubricant ______ Place finger over suction control port of catheter and suction intermittently while withdrawing the catheter ______ Put on sterile gloves ______ Lubricate catheter, insert into nare, and advance into pharynx ______ When client inhales, advance catheter into trachea ______ Pick up suction catheter with dominant hand and attach it to connection tubing ______ Place tip into sterile saline container while applying suction to clear secretions from the tubing
ANSWER: 1, 6, 2, 4, 5, 3, 7 The nurse would prepare equipment first and then put on sterile gloves. The nurse would then connect the suction tubing to the catheter, lubricate the end of the catheter, and insert the catheter into the nare and then the pharynx. The nurse should wait for the client to inhale and then advance the catheter into the trachea. The nurse would then apply suction by placing a finger over the suction-control port and withdraw the catheter while suctioning intermittently. After the catheter is withdrawn from the nare, the tip should be placed in sterile saline, with suction applied, to clear the catheter. ➧ Test-taking Tip: Visualize the steps required to perform nasotracheal suctioning
A nurse receives a serum laboratory report for six different clients with admitting diagnoses of chest pain. After reviewing all of the lab reports, in which order should the nurse address each lab value? Prioritize the order in which the nurse should address each of the clients' results. ______ Troponin T 42 ng/mL (0.0-0.4 ng/mL) ______ WBC 11,000 K/µL ______ Hgb 7.2 g/dL ______ SCr 2.2 mg/dL ______ K 2.2 mEq/L ______ Total cholesterol 430 mg/dL
ANSWER: 1, 6, 3, 4, 2, 5 The nurse should address the elevated troponin level first. Cardiospecific troponins (troponin T, cTnT, and troponin I, cTnI) are released into circulation after myocardial injury and are highly specific indicators of myocardial infarction. Since "time is muscle," the client needs to be treated immediately to prevent extension of the infarct and possible death. The nurse should address the decreased serum potassium level (K) second. The normal serum K level is 3.5 to 5.8 mEq/L. A low serum K level can cause life-threatening dysrhythmias. The normal hemoglobin (Hgb) is 13.1 to 17.1 g/dL. A low Hgb can contribute to inadequate tissue perfusion and contribute to myocardial ischemia. The normal serum creatinine (SCr) is 0.4 to 1.4 mg/dL. Impaired circulation may be causing this alteration and further client assessment is needed. Medication doses may need to be adjusted with impaired renal perfusion. The normal total serum cholesterol should be less than 200 mg/dL. This is a risk factor for development of coronary artery disease. The client needs teaching. The normal white blood cell (WBC) count is 3.9 to 11.9 K/µL. Because the finding is normal, it can be addressed last
. A client is receiving continuous heparin therapy. The infusion is 25,000 units of heparin in 500 mL of 5% dextrose and is infusing at 12 mL per hour. The aPTT laboratory test result is 92 seconds. According to the heparin infusion protocol, the nurse should administer the heparin infusion at a rate of _____ mL/hr. Heparin Infusion Protocol Adjustment Table aPTT Bolus Stop Rate Repeat Results Dose Infusion Change aPTT Less than 5,000 0 minutes +3 mL/hr 6 hr 50 units 50-59 0 0 minutes +2 mL/hr 6 hr 60-85 0 0 minutes No change Next a.m. 86-100 0 0 minutes -1 mL/hr Next a.m. 101-120 0 30 minutes -2 mL/hr 6 hr 120-150 0 60 minutes -3 mL/hr 6 hr Greater 0 60 minutes -5 mL/hr 6 hr than 150
ANSWER: 11 According to the protocol, with an aPTT value of 92 seconds, the rate should be decreased by 1 mL per hour. If the infusion was previously infusing at 12 mL per hour, the new rate is 11 mL/hr.
. A nurse is evaluating the blood pressure (BP) results for multiple clients with cardiac problems on a telemetry unit. Which BP reading suggests to the nurse that the client's mean arterial pressure (MAP) is abnormal and warrants notifying the physician? 1. 94/60 mm Hg 2. 98/36 mm Hg 3. 110/50 mm Hg 4. 140/78 mm Hg
ANSWER: 2 A MAP of less than 60 mm Hg indicates that there is inadequate perfusion to organs. The mean arterial pressure is calculated by the sum of the SBP + 2DBP and then divided by 3 [MAP = (SBP + 2DBP)/3]. Thus the MAP of 98/36 mm Hg is (98 + 72)/3 = 170/3 = 56.7. The mean arterial pressure of 94/60 is 71.3. The mean arterial pressure of 110/50 is 70. The mean arterial pressure of 140/78 is 98.7. ➧ Test-taking Tip: Focus on the issue of the question, a BP reading with a MAP of less than 60. Though a BP of 94/60 mm Hg and 140/78 mm Hg may warrant notifying the physician, the question is asking for a BP with an abnormal MAP (less than 70). Normal MAP is 70 to 100.
A nurse is caring for a client with a left-sided chest tube attached to a wet suction chest tube system. Which observation by the nurse would require immediate intervention? 1. Bubbling in the suction chamber 2. Dependent loop hanging off the edge of the bed 3. Banded connections between tubing sections 4. Occlusive dressing over chest tube insertion site
ANSWER: 2 A dependent loop creates pressure back up and prevents fluid from draining; this requires immediate intervention to prevent lung collapse. Bubbling in a wet suction chest tube system indicates that the suction is working and is an expected finding as are banded connections between sections of tubing. An occlusive dressing helps to prevent air from leaking into the subcutaneous space and maintains integrity of the closed drainage system. ➧ Test-taking Tip: Visualize the different parts of a chest tube system and consider which of the options do not fit or seem negative.
On the first postoperative day for a 74-year-old client who had a transurethral resection of the prostrate (TURP), a nurse assists the client to ambulate several times to maintain muscle strength. The nurse's action is based on knowing that: 1. passive exercises are not effective on aging muscles. 2. immobile gerontological clients can lose as much as 5% of muscle strength per day. 3. active exercise is the only type of exercise that aids in healing of the incision. 4. the weight-bearing exercise of walking increases deconditioning by 10%.
ANSWER: 2 Deconditioning and loss of muscle mass of hospitalized older adults can occur in brief periods of immobility. Passive exercise is effective with all age groups, and both passive and active exercise aids in the healing process by increasing circulation. Walking, a weight-bearing exercise increases "conditioning," not "deconditioning." Deconditioning describes the decrease in muscle mass and other physiological changes resulting in overall weakness. ➧ Test-taking Tip: Focus on functional decline in older adults and the value of exercise
THE MONITOR FOR THE COMPLICATION OF SQ EMPHYSEMA AFTER INSERTION OF THE CHEST TUBES, THE RN SHOULD A.AUSCULTATE THE BREATH SOUNDS FOR CRACKLES AND RHONCHI B.COMPARE LENGHT OF INSPIRATION WITH LENGTH OF EXPIRATION C.ASSESS FOR THE PRESENCE OF A BARREL SHAPE CHEST D.PALPATE AROUND THE CHEST TUBE INSERTION SITES FOR CREPITUS
D.PALPATE AROUND THE CHEST TUBE INSERTION SITES FOR CREPITUS
A nurse is evaluating the laboratory findings for a 7-year-old client being treated with isoniazid (INH) for tuberculosis. Which adverse effect of the medication should the nurse consider after reviewing the laboratory results report? BUN 18 5-25 mg/dL Creatinine 0.9 0.4-1.2 mg/dL Na 139 135-145 mEq/L K 4.2 3.5-5.5 mEq/L Cl 99 98-105 mEq/L CO2 28 20-28 mEq/L Phosphate 4.9 4.5-5.5 mg/dL Calcium 10 4.5-5.8 mEq/L Hgb 14 11-16 g/dL Hct 43 31%-43% ALT/SGPT 38 10-35 unit/L 1. Renal insufficiency 2. Hepatotoxicity 3. Aplastic anemia 4. Heart failure
ANSWER: 2 Elevated ALT (alanine transaminase) or SGPT (serum glutamic pyruvic transaminase) suggests hepatotoxicity. Isoniazid (INH) is metabolized by the liver. The laboratory values do not support the other conditions. The serum creatinine level should be elevated (not normal) with renal insufficiency. Aplastic anemia is an adverse effect of isoniazid, but the hemoglobin and hematocrit are normal. A B-type natriuretic peptide (BNP) laboratory value would be needed to determine if heart failure was an adverse effect, but it is not reported. ➧ Test-taking Tip: Eliminate all normal laboratory findings and focus on the abnormal values. Relate the abnormal laboratory value to the conditions listed in the options
. A client diagnosed with cardiomyopathy is hyponatremic as a result of fluid volume overload. A fluid restriction of 800 mL/24 hours is ordered by a physician. Which action by the nurse is most appropriate? 1. Provide ice chips and refill the glass every 4 hours. 2. Encourage the client to perform mouth care when feeling thirsty. 3. Offer sugary lozenges for the client to hold in the mouth. 4. Replenish the client's water every 2 hours and have the client take small sips.
ANSWER: 2 Frequent mouth care can help to reduce the sensation of thirst. Ice chips are considered fluid and should be included in the intake volume. A full glass of ice chips is equivalent to 120 mL of fluid. If replaced every 2 hours, ice chips alone would equal 1,440 mL of fluid. Lozenges, especially if high in sugar content, can produce the sensation of thirst. Small frequent sips can quickly add up to high volumes that exceed the client's restriction. ➧ Test-taking Tip:The key phrase is "most appropriate." Consider the nurse's action in maintaining the fluid restriction and alleviating the client's thirst
Which finding should indicate to a nurse that acyclovir (Zovirax®), administered orally for treatment of herpes zoster, is effective? 1. Drying and crusting of genital lesions 2. Crusting and healing of vesicular skin lesions 3. Urticaria decreased and pruritus relieved 4. Decrease in intensity of chickenpox lesions
ANSWER: 2 Herpes zoster produces painful vesicular skin eruptions along the course of a nerve. Crusting and healing of the vesicular skin lesions indicates that the medication is effective. Drying and crusting of genital lesions would indicate the medications effectiveness for treating genital herpes, not herpes zoster. Urticaria (swollen, raised areas) and pruritus (itching) are not symptoms of herpes zoster. The lesions of chickenpox are generalized, whereas herpes zoster lesions occur along the course of a nerve. Herpes zoster occurs when the chickenpox (varicella zoster) virus that has incorporated itself into nerve cells is reactivated years after the initial infection, but it is not chickenpox. 2187_Ch08_T21-27_385-488.qxd 3/5/10 11:36 AM Page 487 ➧ Test-taking Tip: Apply knowledge of herpes zoster (shingles) to answer this question. Recall that herpes zoster, herpes simplex, and genital herpes are all caused by a virus and develop vesicles, but these occur in different body locations.
An experienced nurse is supervising a new nurse caring for a hospitalized child who is receiving intravenous (IV) therapy. Which action should indicate to the experienced nurse that the new nurse needs additional orientation regarding IV therapy for children? 1. Determines that the current solution has been infusing for 24 hours and should be changed 2. Selects a 1,000-mL bag of the prescribed IV solution and checks it against the orders 3. Prepares new tubing and the prescribed IV solution 1 hour before it is due to be changed 4. Removes the plastic cover, spikes the bag with the tubing spike, and squeezes the drip chamber
ANSWER: 2 IV solutions in 250- and 500-mL containers should be selected to guard against circulatory overload. IV solutions are considered medications and errors in administration can have negative consequences. IV solutions open longer than 24 hours are no longer considered sterile. Tubing is changed every 72 to 96 hours, depending on agency policy. The procedure for spiking the bag is correct. The bag could be either hung first or after being spiked. ➧ Test-taking Tip:The key words are "needs additional orientation." Read each option carefully to determine which option has the greatest potential for producing harm.
A client experiences cardiac arrest at home and is successfully resuscitated. Following placement of an implantable cardioverter-defibrillator (ICD), a nurse is evaluating the effectiveness of teaching for the client. Which statement, if made by the client, indicates that further teaching is needed? 1. "The ICD will monitor my heart activity and provide a shock to my heart if my heart goes into ventricular fibrillation again." 2. "When I feel the first shock I should tell my family to start cardiopulmonary resuscitation (CPR) and call 911." 3. "I am fearful of my first shock since my friend stated his shock felt like a blow to the chest." 4. "I will need to ask my physician when I can resume driving because some states disallow driving until there is a 6-month discharge-free period."
ANSWER: 2 If the first shock is unsuccessful, the device will recycle and continue to deliver shocks. If the device fires more than once, the emergency medical services (EMS) system should be activated. The ICD continues to deliver shocks if indicated; CPR should only be initiated after the shocks have been delivered and only if the client is unresponsive and pulseless. The ICD monitors the client's heart rate and rhythm, identifies ventricular tachycardia or ventricular fibrillation, and delivers a 25-joule or less shock if a lethal rhythm is detected. Various sensations have been described when the device delivers a shock, including a blow to or kick in the chest. State laws vary regarding drivers with ICDs. The decision regarding driving is also based on whether dysrhythmias are present, the frequency of firing, and the client's overall health. ➧ Test-taking Tip:The key phrase "further teaching is needed" indicate a false-response item. Select the client's statement that is not correct
S/S OF PNEUMONIA
DULL SOUND CRACKLES
A nurse is caring for a client immediately following insertion of a permanent pacemaker via the right subclavian vein approach. The nurse best prevents pacemaker lead dislodgement by: 1. inspecting the incision site dressing for bleeding and the incision for approximation. 2. limiting the client's right arm activity and preventing the client reaching above shoulder level. 3. assisting the client with getting out of bed and ambulating with a walker. 4. ordering a stat chest x-ray following return from the implant procedure.
ANSWER: 2 Limiting arm and shoulder activity initially and up to 24 hours after the pacing leads are implanted helps prevent lead dislodgement. Often an arm sling is used as a reminder to the client to limit arm activity. The dressing should not be removed to check the incision immediately after insertion but should be checked for bleeding to monitor for potential complications. The nurse should assist the client the first time out of bed following a pacemaker implant, but the client should not use a walker for 24 hours after the procedure, and out of bed activity would not resume until the client is stable. A postinsertion chest x-ray is done to check lead placement and to rule out a pneumothorax. It does not promote the intactness of pacing leads. ➧ Test-taking Tip: Focus on the issue of the question: measures to promote intactness of the pacing leads. Analyze the options to determine which would impact the desired result, maintaining intactness of the pacing leads
5. A 62-year-old female client is attending a community health fair. A health fair nurse recommends that the client make an appointment with a physician and ask that a DEXA (dual-energy x-ray absorptiometry) scan be done to evaluate for osteoporosis because the client has many risk factors. Which risk factor likely influenced the health fair nurse's decision to recommend a DEXA scan? 1. Diabetes mellitus 2. Postmenopausal 3. Overweight 4. African American
ANSWER: 2 Major risk factors for osteoporosis include increased age, female sex, White or Asian race, family history of osteoporosis, and a thin body structure. Since osteoporosis is the most common metabolic disease, affecting 50% of women during their lifetime, it is important for women to be screened and begin appropriate treatment, if needed. Diabetes mellitus and being overweight are not risk factors for osteoporosis. Being overweight can contribute to the development of osteoarthritis. ➧ Test-taking Tip: Focus on what the question is asking: risk factors of osteoporosi
. A community health nurse is planning a follow-up visit to a family after their firstborn child died from sudden infant death syndrome (SIDS). Which action is most important for the nurse to include in the initial visit? 1. Help the family in making a plan for future children. 2. Allow time for the parents to express their anger and grief. 3. Make a referral for genetic counseling and education. 4. Educate the family on the causes of sudden infant death syndrome.
ANSWER: 2 Many families are unable to express their grief and loss openly. Helping the parents understand SIDS and that they are not to blame for the death of their child is the most important action at the current time. Helping families make plans for future children is essential once the grieving process resolves. There is no definitive etiology for SIDS, and making a referral for genetic counseling and education is not necessary. Educating the family on what are associated incidences of children who have died from SIDS can help the parents plan for and use safety precautions for their future children. ➧ Test-taking Tip: Consider the stage of grief for the parents when selecting an option
A nursing assistant (NA), who is taking routine vital signs, tells a nurse that the small adult cuff is nowhere to be found and that a client's arm is too small to use an adult-size cuff. In response to the NA's report, which direction should the nurse give to the NA? 1. Document the other vital signs and note that proper blood pressure (BP) equipment is not available 2. Contact the nursing supervisor, obtain a small, adult BP cuff, and take the client's BP with the small, adult-size cuff 3. Use the adult size BP cuff to obtain the blood pressure, add 10 to both the diastolic and systolic readings, and document on the client's record the BP was obtained with an adult cuff 4. Take the client's BP using any available cuff
ANSWER: 2 The BP must be taken with the correct BP cuff. The NA should not omit the BP or adjust the numbers of the reading from an improperly sized cuff. Palpating a BP with an improperly sized cuff will not obtain the correct measurement. ➧ Test-taking Tip: Read the scenario in the stem carefully. Consider that a correct measurement is the only acceptable option and select option 2.
A client presents to an emergency department following a motorcycle crash. A nurse assesses the client and notes uncoordinated or paradoxical chest rise and fall as well as multiple bruises across the client's chest and torso, crepitus, and tachypnea. Based on this assessment, the nurse should: 1. assist in the placement of a cervical collar. 2. anticipate the need to intubate the client. 3. provide chest compressions. 4. tape the chest wall.
ANSWER: 2 The assessment data implies a client with multiple broken ribs and potentially flail chest. In the case of flail chest, more invasive interventions are generally required, including management of the client's airway with intubation. The client would most likely already have a cervical collar on, and this is not the intervention that would address the assessment data. There is no evidence to suggest that chest compressions are warranted. Taping the chest wall is an intervention for broken ribs that has proven to not be as effective as once believed. ➧ Test-taking Tip: In emergency situations or in a situation where the client is in distress, the ABCs (airway, breathing, circulation) should be a priority for assessment and intervention
A nurse administers 15 units of glargine (Lantus®) insulin at 2100 hours to a Hispanic client when the client's fingerstick blood glucose reading was 110 mg/dL. At 2300 hours, a nursing assistant reports to the nurse that an evening snack was not given because the client was sleeping. Which instruction by the nurse is most appropriate? 1. "You will need to wake the client to check the blood glucose and then give a snack. All diabetics get a snack at bedtime." 2. "It is not necessary for this client to have a snack because glargine insulin is absorbed very slowly over 24 hours and doesn't have a peak." 3. "The next time the client wakes up, check a blood glucose level and then give a snack." 4. "I will need to notify the physician because a snack at this time will affect the client's blood glucose level and the next dose of glargine insulin."
ANSWER: 2 The onset of glargine is 1 hour, it has no peak, and it lasts for 24 hours. Glargine lowers the blood glucose by increasing transport into cells and promoting the conversion of glucose to glycogen. Because it is peakless, a bedtime snack is unnecessary. Options 1 and 3 are unnecessary and option 4 is incorrect. Glargine is administered once daily, the same time each day, to maintain relatively constant concentrations over 24 hours. ➧ Test-taking Tip: Apply knowledge of the action of glargine insulin.
A nurse is discussing healthy lifestyle practices with a client who has chronic venous insufficiency. Which practices should be emphasized with this client? SELECT ALL THAT APPLY. 1. Avoid eating an excess of dark green vegetables. 2. Elevate the legs while sitting. 3. Wear elastic stockings (TEDS®) daily, applying them before getting out of bed. 4. Increase standing time and shift weight from one leg to the other when standing in one place. 5. Sleep with legs elevated above the level of the heart.
ANSWER: 2, 3, 5 Chronic venous insufficiency develops because of damaged valves in the veins, resulting in venous hypertension. Interventions focus on management of edema by elevating the legs and wearing elastic stockings. Eating excessive amounts of dark green vegetables could affect the anticoagulant effect of warfarin, but there is no indication the client is taking an anticoagulant. Clients who have chronic venous insufficiency should avoid prolonged standing. ➧ Test-taking Tip: Recall that venous insufficiency impairs return of blood to the heart. Select options that will improve venous return
. A client is hospitalized for heart failure secondary to alcohol-induced cardiomyopathy. The client is started on milrinone (Primacor®) and placed on a transplant waiting list. The client has been curt and verbally aggressive in expressing dissatisfaction with the medication orders, overall care, and the need for energy conservation. A nurse should interpret that the client's behavior is likely related to the client's: 1. denial of the illness. 2. reaction to milrinone (Primacor®). 3. fear of the diagnosis. 4. response to cerebral anoxia.
ANSWER: 3 A threatening situation (need for heart transplant) can produce fear. Fear and helplessness may cause a client to verbally attack health team members to maintain control. There is no supporting evidence that the client denies the existence of a health problem. Minimizing symptoms or noncompliant behaviors would indicate denial. Milrinone is used in short-term treatment of congestive heart failure unresponsive to conventional therapy with digoxin, diuretics, and vasodilators. It increases myocardial contractility and decreases preload and afterload by direct dilating effect on the vascular smooth muscle. It does not cause behavior changes. Although a low cardiac output may lead to cerebral anoxia, there is insufficient evidence in this situation to support the conclusion of cerebral anoxia causing the client's reaction. ➧ Test-taking Tip: Focus on the issue, the client's reaction to the illness and hospitalization.
A nurse is caring for a client in an emergency department who has five fractured ribs from blunt chest trauma. The client is rating pain at 9 out of 10 on a 0 to 10 numeric scale. For which pain management modality should the nurse advocate? 1. NSAIDs 2. Oral analgesics (narcotic + acetaminophen) 3. Regional/local analgesia (epidural or intercostal injection) 4. Intravenous (IV) bolus meperidine (Demerol®)
ANSWER: 3 Epidural analgesics and intercostal nerve blocks are the most optimal modality for blunt chest trauma because they directly target the injury site. Oral analgesics generally are not adequate to manage the pain associated with rib fractures. Meperidine is not the ideal narcotic for managing this type of pain because of its multiple adverse side effects. ➧ Test-taking Tip: Consider the physiological implications of the injury in selecting the best option and the most directed type of intervention
A client diagnosed with class II heart failure according to the New York Heart Association Functional Classification has been taught about the initial treatment plan for this disease. A nurse determines that the client needs additional teaching if the client states that the treatment plan includes: 1. diuretics. 2. a low-sodium diet. 3. home oxygen therapy. 4. angiotensin-converting enzyme (ACE) inhibitors.
ANSWER: 3 In class II heart failure, normal physical activity results in fatigue, dyspnea, palpitations, or anginal pain. The symptoms are absent at rest. Home oxygen therapy is unnecessary unless there are other comorbid conditions. Diuretics mobilize edematous fluid, act on the kidneys to promote excretion of sodium and water, and reduce preload and pulmonary venous pressure. Dietary restriction of sodium aids in reducing edema. ACE inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II, prevent the degradation of bradykinin and other vasodilatory prostaglandins, and increase plasma renin levels and reduce aldosterone levels. The net result is systemic vasodilation, reduced systemic vascular resistance, and improved cardiac output. ➧ Test-taking Tip:The key phrase "needs additional teaching" indicates that this is a false-response item. Select the option that is incorrect for treating class II heart failure.
Which assessment findings for a client who is status post-thyroidectomy should direct a nurse to check the client's serum calcium level? 1. Fatigue, decreased cardiac function, and tetany 2. Weakness, tachycardia, and disorientation 3. Muscle cramps, paresthesia, and Trousseau's sign 4. Weakness, edema, and orthostatic hypotension
ANSWER: 3 Muscle cramps, paresthesia, and a positive Trousseau's sign are common manifestations of hypo- or hypercalcemia because of the irritation to the neuromuscular system. Tachycardia is most often associated with abnormal serum magnesium levels. Fatigue is associated with sodium, potassium, and phosphorus imbalances. Hypotension relates most often to volume changes rather than electrolyte imbalances. ➧ Test-taking Tip: Focus on calcium's effect on the neuromuscular system to select the correct option.
A nurse is caring for a client admitted with fluid volume overload. The client is receiving diuretic therapy with a loop diuretic. The potassium levels are illustrated in the chart below. On which day should the nurse expect an order for potassium replacement? Day 1 Day 2 Day 3 Day 4 5.6 mEq/L 4.4 mEq/L 3.5 mEq/L 3.1 mEq/L 1. Day 1 2. Day 2 3. Day 3 4. Day 4
ANSWER: 3 Normal potassium level is 3.5 to 5.0 mEq/L. On day 3, the client is on the low end of normal. Because the client's serum potassium level is decreasing and the client is taking a diuretic, supplementation is needed to prevent a reduction of serum potassium levels below normal. The value on day 1 is high and would not require replacement. The value on day 2 is in the midrange of normal. The value on day 4 is low and would require replacement if replacement were not started on day 3. ➧ Test-taking Tip: Recall that a loop diuretic will decrease serum potassium levels. Consider this when selecting an option
. A nurse admits a client to a telemetry unit and obtains the following electrocardiogram (ECG) strip of the client's heart rhythm. What should be the nurse's interpretation of this rhythm strip 1. Atrial flutter 2. Atrial fibrillation 3. Sinus bradycardia 4. Sinus rhythm with premature atrial contractions (PACs)
ANSWER: 3 Sinus bradycardia is a regular rhythm with a ventricular rate less than 60 beats per minute (bpm), and one discernable P wave prior to each QRS. Atrial flutter is either a regular or an irregular rhythm with multiple discernable P waves prior to each QRS complex and no measurable PR interval. Atrial fibrillation is an irregular rhythm with multiple nondiscernable, fibrillatory P waves prior to each QRS and no measurable PR interval. Sinus rhythm with PACs is an irregular rhythm with a ventricular rate between 60 and 100 bpm, one discernable P wave prior to each QRS, and a PR interval between 0.12 and 0.20 seconds, with the presence of premature atrial beats that occur early in the cardiac cycle. The PACs also have one discernable P wave prior to each QRS and a PR interval between 0.08 and 0.20 seconds. ➧ Test-taking Tip: Use the steps in interpreting an ECG rhythm to select the correct option. Note that the rhythm is regular, so eliminate option 4, which is an irregular rhythm. Recall that atrial fibrillation and atrial flutter do not have a measurable PR interval, so eliminate options 1 and 2.
A nurse admits a client to a telemetry unit and obtains the following electrocardiogram (ECG) strip of the client's heart rhythm. What should be the nurse's interpretation of this rhythm strip? 1. Atrial flutter 2. Atrial fibrillation 3. Sinus bradycardia 4. Sinus rhythm with premature atrial contractions (PACs)
ANSWER: 3 Sinus bradycardia is a regular rhythm with a ventricular rate less than 60 beats per minute (bpm), and one discernable P wave prior to each QRS. Atrial flutter is either a regular or an irregular rhythm with multiple discernable P waves prior to each QRS complex and no measurable PR interval. Atrial fibrillation is an irregular rhythm with multiple nondiscernable, fibrillatory P waves prior to each QRS and no measurable PR interval. Sinus rhythm with PACs is an irregular rhythm with a ventricular rate between 60 and 100 bpm, one discernable P wave prior to each QRS, and a PR interval between 0.12 and 0.20 seconds, with the presence of premature atrial beats that occur early in the cardiac cycle. The PACs also have one discernable P wave prior to each QRS and a PR interval between 0.08 and 0.20 seconds. ➧ Test-taking Tip: Use the steps in interpreting an ECG rhythm to select the correct option. Note that the rhythm is regular, so eliminate option 4, which is an irregular rhythm. Recall that atrial fibrillation and atrial flutter do not hhave a measurable PR interval, so eliminate options 1 and 2.
. A nurse is caring for an 11-month-old infant diagnosed with bronchopulmonary dysplasia. The infant has a tracheostomy with 30% supplemental oxygen being provided via the tracheostomy. The infant has a decline in oxygen saturations from 96% to 87% and appears anxious and restless. Which action should be taken by the nurse? 1. Obtain arterial blood gases (ABGs) 2. Increase oxygen rate from 30% to 50% 3. Suction the tracheostomy tube 4. Medicate for anxiety and pain
ANSWER: 3 Suctioning the tracheostomy should be the first priority in caring for this infant. Many tracheostomies require frequent suctioning to remove secretions and mucous plugs. Increasing the oxygen rate will not be effective if the airway is occluded by secretions. Obtaining ABGs may be helpful if oxygen saturations remain low after suctioning and the infant remains in distress, but clearing the airway should be priority. Medicating for anxiety and pain would not improve oxygen saturations if the airway is not patent due to secretions. Medicating the infant may reduce respiratory drive and cause further distress. ➧ Test-taking Tip:Think about the ABCs: airway, breathing circulation. Airway management is priority
. A client is admitted with diabetic ketoacidosis (DKA) associated with type 1 diabetes mellitus. The client's blood sugar is 320 mg/dL. The respiratory assessment reveals respiratory rate of 32, with a deep, regular respiratory effort. Which acid-base imbalance is this client most likely experiencing? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
ANSWER: 3 The elevated blood glucose level is a finding associated with DKA. Kussmaul respirations allow the body to "blow off" excess CO2 to compensate for the acidotic state and the decreased HCO3. DKA is a metabolic, not a respiratory, acid-base imbalance. As DKA implies, it is an acidotic, not an alkalotic, imbalance. ➧ Test-taking Tip: Recognize that DKA is a metabolic acid-base imbalance and eliminate options that pertain to the respiratory system
8. Two hours after admitting a client to a postsurgical unit following a nephrectomy, the client states feeling nauseated. A nurse notes minimal drainage from the nasogastric (NG) tube. Which action should the nurse take first? 1. Notify the physician 2. Administer an antiemetic medication listed on the client's medication record 3. Pull the NG tube out about an inch to release it suctioning against the wall of the stomach 4. Irrigate the NG and check to see if the fluid returns to the drainage-collection container
ANSWER: 4 Nausea and minimal returns from the NG tube suggest possible occlusion of the tube. The tube should be irrigated per agency policy or physician's order, especially if the surgical area involved the gastrointestinal system. It is unnecessary to notify the physician as the first action; nurses are responsible for maintaining the patency of the tube. Administering an antiemetic is important with nausea, but is not the first action because a functioning NG should relieve the nausea by decompressing the stomach contents. In a Salem sump-type NG with a vent lumen, air may need to be injected to release the tube from suctioning against the wall of the stomach, but the tube should not be partially withdrawn unless it has been determined that intestinal and not gastric drainage is returning. ➧ Test-taking Tip: Focus on the situation and the type of surgery to determine the appropriate action
. On the first postoperative day following right-sided thoracotomy, a nurse is assisting a client with arm and shoulder exercises. The client reports pain with the exercises and wants to know why they must be performed. The nurse should explain that the exercises: 1. promote respiratory function. 2. increase blood flow back to the heart and venous system. 3. improve muscle mass to compensate for muscle removed during the procedure. 4. prevent stiffening and loss of function.
ANSWER: 4 Because of the location of the incision, disuse can cause contractures and loss of muscle tone. The exercises help to preserve function of the arm and shoulder. Activity will promote respiratory function and improve venous return, but these are not the reasons for the exercises. Although the girdle muscles are cut, they are generally not removed. ➧ Test-taking Tip:The key words "right-sided thoracotomy" points to the main reason for the exercises
. A male client confides to a clinic nurse that he is no longer dyspneic after receiving his new St. Jude's heart valve. He wants to have a vasectomy so that he can enjoy sexual intercourse again without the fear of his wife becoming pregnant. What is the nurse's best response? 1. "That's probably a good idea. The life expectancy after heart valve replacement is 10 to 15 years." 2. "You seem relieved that the heart valve replacement was successful and that you can enjoy a normal life again." 3. "If you have cardiac symptoms such as dyspnea during sexual intercourse, you can take a nitroglycerin tablet before sexual activity to prevent symptoms." 4. "Be sure to inform the physician that you have an artificial heart valve so you are given antibiotics as a preventive measure before the procedure."
ANSWER: 4 A St. Jude's valve is an artificial heart valve. Antibiotics are required prior to invasive procedures to prevent complications such as endocarditis. The physician also needs to know that the client has an artificial heart valve because the client should be receiving anticoagulants and there is the risk of increased bleeding. As long as the person receives regular follow-up with a health-care provider, the person can expect a normal life expectancy. Although mechanical valves are durable, they may need replacement in 10 to 15 years. Although responding that the client seems relieved is a therapeutic response, it is not the best response, because the client needs teaching. Nitroglycerin is not prescribed for persons with valvular heart disease unless the person also has coronary artery disease; thus he would not have nitroglycerin available. ➧ Test-taking Tip:The key terms in the stem are "vasectomy" and "heart valve." Recall that antibiotics are prescribed prophylactically prior to invasive procedures.
. Following an unrestrained motor vehicle crash, a client presents to an emergency department with multiple injuries, including chest trauma. A physician notifies the care team that the client has progressed to acute respiratory distress syndrome (ARDS) and requests that the family be updated on the client's condition. The nurse should plan to discuss with the family that: 1. the condition generally stabilizes with positive prognosis. 2. the client can be discharged with home oxygen. 3. the condition is always fatal. 4. the condition is highly life-threatening and that end-of-life concerns should be addressed.
ANSWER: 4 ARDS has a reported mortality rate of 50% to 70% and family should be prepared for the possibility that their loved one may not survive the injury or diagnosis. The nurse must be able to discuss the care to be given, the progression of the syndrome, and make appropriate referrals as needed (such as pastoral care). The condition often does not have a positive prognosis and, if the client survives, home oxygen may or may not be needed. ARDS is not always fatal. ➧ Test-taking Tip: Watch for absolute words such as "always" or "never" and eliminate these options.
A nurse assesses a client who has just returned to a telemetry unit after having a coronary angiogram using the left femoral artery approach. The client's baseline blood pressure (BP) during the procedure was 130/72 mm Hg and the cardiac rhythm was a normal sinus throughout. Which assessment finding should indicate to the nurse that the client may be experiencing a complication? 1. BP 144/78 mm Hg 2. Pedal pulses palpable at +1 3. Left groin soft with 1 cm ecchymotic area 4. Apical pulse 132 beats per minute (bpm) with an irregular-irregular rhythm
ANSWER: 4 An apical pulse of 132 (bpm) with an irregular-irregular rhythm could indicate atrial fibrillation or a rhythm with premature beats. Dysrhythmias are a complication that can occur following coronary angiogram. The client should be placed on a cardiac monitor to determine the rhythm. A slight elevation of blood pressure could be related to pain at the incision site. It is not indicative of a complication without additional data. Usually pulses are palpable at +2, but without additional baseline data on the clients' pulses, this warrants monitoring but is not indicative in itself of a complication. A soft groin area where the puncture site is located is a normal finding. Ecchymosis (bruising) does not indicate a complication. ➧ Test-taking Tip:Think about the potential complications that can occur after a coronary angiogram. Review each option to determine if the findings suggest a complication. Select the option that would be the most abnormal finding
A nurse assesses a client who has just returned to a telemetry unit after having a coronary angiogram using the left femoral artery approach. The client's baseline blood pressure (BP) during the procedure was 130/72 mm Hg and the cardiac rhythm was a normal sinus throughout. Which assessment finding should indicate to the nurse that the client may be experiencing a complication? 1. BP 144/78 mm Hg 2. Pedal pulses palpable at +1 3. Left groin soft with 1 cm ecchymotic area 4. Apical pulse 132 beats per minute (bpm) with an irregular-irregular rhythm
ANSWER: 4 An apical pulse of 132 (bpm) with an irregular-irregular rhythm could indicate atrial fibrillation or a rhythm with premature beats. Dysrhythmias are a complication that can occur following coronary angiogram. The client should be placed on a cardiac monitor to determine the rhythm. A slight elevation of blood pressure could be related to pain at the incision site. It is not indicative of a complication without additional data. Usually pulses are palpable at +2, but without additional baseline data on the clients' pulses, this warrants monitoring but is not indicative in itself of a complication. A soft groin area where the puncture site is located is a normal finding. Ecchymosis (bruising) does not indicate a complication. ➧ Test-taking Tip:Think about the potential complications that can occur after a coronary angiogram. Review each option to determine if the findings suggest a complication. Select the option that would be the most abnormal finding.
A nurse collects the following assessment data on a client who has no known health problems: blood pressure (BP) 135/89 mm Hg; body mass index (BMI) 23; waist circumference 34 inches; serum creatinine 0.9 mg/dL; serum K 4.0 mEq/L; low-density lipoprotein (LDL) cholesterol 200 mg/dL; high-density lipoprotein (HDL) cholesterol 25 mg/dL; and triglycerides 180 mg/dL. Which order from the client's health-care provider should the nurse anticipate? 1. 1,500-calorie regular diet. 2. No added salt, low saturated fat, low-potassium diet. 3. Hydrochlorothiazide (HydroDIURIL®) 25 mg twice daily. 4. Atorvastatin (Lipitor®) 20 mg daily.
ANSWER: 4 Atorvastatin is used to manage hypercholesterolemia. It lowers the total serum LDL cholesterol and triglycerides and slightly increases HDL cholesterol by inhibiting 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, an enzyme that is responsible for catalyzing an early step in the synthesis of cholesterol. For persons with 0-1 risk factors, the goal for LDL is less than 160 mg/dL (4.14 mmol/L), and drug therapy is considered when LDL is greater than or equal to 190 mg/dL (4.91 mmol/L). Normal triglycerides are 40 to 150 mg/dL (0.45-1.69 mmol/L). A low-calorie diet is not indicated. The normal BMI is 18.5 to 24.9. While a low-saturated-fat diet in option 2 is indicated, a low-potassium diet is not because the serum K of 4.0 mEq/L is normal. The client's BP is slightly elevated but would be initially treated with lifestyle changes, not a diuretic. ➧ Test-taking Tip: Focus on the data provided in the situation and identify the abnormal findings. If unable to identify the abnormal data because of lack of knowledge of normal lab values, note that the client's serum cholesterol level analysis includes more data than other problems. Conclude that these are abnormal data and then use "lipids" as a key to identifying the correct option. Review laboratory values and cardiac medications if you had difficulty with this question.
A nurse receives a change-of-shift report for four assigned clients. Which clients should the nurse attend to first? Prioritize the nurse's actions by placing each client in the correct order. _____ A 44-year-old client who has questions about how to empty the Jackson-Pratt drain at home after being discharged tomorrow _____ A 33-year-old client who has a new order to insert a nasogastric (NG) tube and connect to low intermittent suction _____ A usually oriented 76-year-old client diagnosed with thrombophlebitis who has new-onset confusion _____ A 58-year-old client requesting a pain medication for abdominal incision pain rated at a 6 on a 0-10 scale
ANSWER: 4, 3, 1, 2 The client who is confused needs immediate assessment because confusion may be a sign of a complication, such as a stroke or pulmonary embolism. The client in pain should be attended to next because pain can interfere with necessary postoperative activities, such as deep breathing, coughing, and ambulating. The client who has an order for a NG tube insertion should be attended to next. There is no information indicating that this client is nauseated or the purpose of the NG. The last client to be seen is the client who needs teaching. ➧ Test-taking Tip: Use the ABCs (airway, breathing, circulation) to establish the priority client who should be attended to first. Confusion can be indicative of a breathing or circulatory problem. Then follow Maslow's Hierarchy of Needs to address comfort and psychosocial concerns
diagnosis of left-sided heart failure and mitral regurgitation. Identify the area with an X where the nurse should place the stethoscope to best auscultate the murmur associated with mitral regurgitation.
ANSWER: The mitral valve is best heard with the bell of the stethoscope at the fifth intercostal space, left midclavicular line. The bell is used to auscultate low-pitched sounds. Abnormalities, such as S3 or S4, are best heard with the bell of the stethoscope. ➧ Test-taking Tip:The words "best" and "mitral" are key words in the stem. A mnemonic for remembering the auscultation points and the location of the heart valves is: "All Points To Monitor." The first letter of each word represents the auscultation point: Aortic valve, Pulmonic valve, Tricuspid valve, and Mitral valve.
THE RN ESTABLISHES THE PRESENCE OF A TENSION PNEUMOTHORAX WHEN ASSESS FINDINGS REVEAL A.ABSENCE OF LUNG SOUNDS BILATERALLY UPON AUSCULTATION B.DEVIATION OF THE TRACHEA/TOWARD THE SIDE OPPOSITE THE PNEUMOTHORAX C.SHIFT OF THE POINT OF MAXIMAL IMPULSE TO THE LEFT WITH BOUDING PULSES D.INABILITY TO AUSCULTATE TRACHEAL BREATH SOUNDS
B.DEVIATION OF THE TRACHEA/TOWARD THE SIDE OPPOSITE THE PNEUMOTHORAX
A PT WHO HAS BEEN DX WITH TB OF THE BONE TELLS THE RN THAT HE THOUGHT TB WAS A LUNG DX . THE RN EXPLAINS TO THE PATIENT A.MO THAT CAUSE TB STARTS IN THE LUNGS BUT USUALLY SPREADS FROM LUNGS TO OTHER PARTS OF BODY B.THE LUNGS ARE THE MOST COMMON SITE OF TB INFECTION BUT THE MO CAN BE SPREAD TO OTHER ORGANS THROUGH BLOOD/LYMPH C.THE TB ORGANISM MAKES CHEESY-LIKE CYST THAT BREAKS OPEN AND SPREADS THE INFECTION THROUGHOUT THE BODY D. THE TB ORGANISM IS A MILD BACTERIAL THAT SPREADS ONLY IN PEOPLE WHO DO NOT HAVE A GOOD IMMUNE SYSTEM
B.THE LUNGS ARE THE MOST COMMON SITE OF TB INFECTION BUT THE MO CAN BE SPREAD TO OTHER ORGANS THROUGH BLOOD/LYMPH
AFTER CARING FOR A PT ADM WITH FEVER AND COUGH WHO WAS LATER DX WITH TB, A RN HAS A NEW POSITIVE TB SKIN TEST OF 8MM INDURATION. A CHEST XR IS NEGATIVE, AND THE RN IS CONSIDERED TO HAVE LATEN TB INFECTION. THE RECOMMENDED INTERVENTION FOR THE RN INCLUDES A.A REPEAT OF SKIN TEST IN 3 WEEKS B.ADM OF THE BACILLE CALMETTE-GUERIN VACCINE C.ADM OF ISONIZID DAILY FOR 6-9 MONTHS D.COMBO THX OF ANTI-TB DRUGS FOR 6 MONTHS
C.ADM OF ISONIZID DAILY FOR 6-9 MONTHS
A PT DX WITH ACTIVE TB STARTED INITIAL DRUG THX. THE RN PLANS TO TEACH THE PT ABOUT THE USES AND EFFECTS OF A.ISONIAZID, PYRAZINAMIDE, STREPTOMYCIN B.ISONIAZID, PYRAZINAMIDE, STREPTOMYCIN C.ISONIAZID, RIFAMPIN, PYRAZINAMIDE, ETHAMBUTOL D.PARA-AMINOSALICYLIC ACID, ETHAMBUTOL, RIFAMPIN, PYRAZINAMIDE
C.ISONIAZID, RIFAMPIN, PYRAZINAMIDE, ETHAMBUTOL
A PT EXPERIENCES A FLAIL CHEST AS A RESULT OF AN AUTO ACCIDENT. DURING THE RESPIRATORY ASSESS THE RN WOULD EXPECT TO FIND A.DEEP IRREGULAR RESPIRATIONS B.BLOODY SPUTUM C.PARADOXIC CHEST MVMT D.LARYNGEAL STRIDOR
C.PARADOXIC CHEST MVMT
COMMUNITY HEALTH RN INVOLVED IN PROGRAMS TO PREVENT RHEUMATIC FEVER KNOWS THE MOST IMPORTANT INTERVENTION TO DECREASE THE INCIDENCE OF THE DISEASE INCLUDES A.IMMUNIZING SUSCEPTIBLE GROUPS OF PEOPLE WITH STREPTOCOCCAL VACCINE B.PROVIDING PROPHYLATIC ANTIBIOTICS TO PEOPLE WITH A FAMILY HX OF RHEUMATIC FEVER C.TEACHING PEOPLE TO SEEK MEDICAL DX AND TX FOR STREPTOCOCCAL PHARYNGITIS D.PROMOTE HYGEINE MEASURES TO PREVENT THE TRANSMISSIONS OF STREPTOCOCCAL INFECTIONS
C.TEACHING PEOPLE TO SEEK MEDICAL DX AND TX FOR STREPTOCOCCAL PHARYNGITIS
THE COMMUNITY HEALTH RN INVOLVED IN PROGRAMS TO PREVENT RHEUMATIC FEVER KNOWS THAT THE MOST IMPORTANT INTERVENTION TO DECREASE THE INCIDENCE OF DX A.IMMUNIZING SUSCEPTIBLE GROUPS OF PEOPLE WITH STREPTOCOCCAL VACCINE B.PROVING PROPHYLATCI ANTIBIOTICS TO PEOPLE WITH A FAMILY HX OF RHEUMATIC FEVER C.TEACHING PEOPLE TO SEEK MEDICAL DX AND TX FOR STREPTOCOCCAL PHARYNGITIS D.PROMOTING HYGIENCE MEASURES TO PREVENT TRANSMISSION OF STREPTOCOCCAL INFECTIONS
C.TEACHING PEOPLE TO SEEK MEDICAL DX AND TX FOR STREPTOCOCCAL PHARYNGITIS
A 60 Y/O HOMELESS MAN HAS A COUGH LATE AFTERNOON FEVER, AND NIGHT SWEATS. THE PT RESPONSE TO A PURIFIED PROTEIN DERIVATIVE SKIN TEST IS 10MM. THE RN RECOGNIZES THAT THIS RESPONSE INDICATES THAT THE PT A.TB ONLY IF ABNORMAL CHEST XRAY B.LATEN TB INFECTION C.PT EXPOSED TO THE TB ORGANISM D.CLASS 3, CLINICALLY ACTIVE TB
D.CLASS 3, CLINICALLY ACTIVE TB
A 61 Y/O WOMAN WHO IS 5FT3 AND WEIGHS 125LB TELLS THE RN THAT SHE HAS A GLASS OF WINE TWO OR THREE TIMES A WEEK. THE PT WORKS FOR THE POST OFFICE AND HAS 5 MILE MAIL DELIVERY ROUTE. THIS IS HER FIRST CONTACT WITH THE HEALTH CARE SYSTEM IN 20 YEARS. WHICH OF THESE TOPICS WILL THE RN PLAN TO INCLUDE IN PT TEACHING ABOUT CANCER A.ETHO USE B.PHYSICAL ACTIVITY C.BODY WT D.COLORECTAL SCREENING E.TOBACCO USE F.MAMMOGRAPHY G.PAP TESTING H.SUNSCREENUSE
D.COLORECTAL SCREENING F.MAMMOGRAPHY G.PAP TESTING H.SUNSCREENUSE
WHEN A PT SUFFERS COMPLETE PNEUMOTHORAX THERE IS A DANGER OF A MEDIASTINAL SHIFT. IF SUCH A SHIFT OCCURS IT MAY LEAD TO A.INFECTION OF SUBPLEURAL LINING B.RUPTURE OF PERICARDIUM OR AORTA C.INCREASED VOLUME OF THE UNAFFECTED SIDE D.DECREASED FILLING OF THE RIGHT HEART AND CARDIOVASCULAR COMPROMISE
D.DECREASED FILLING OF THE RIGHT HEART AND CARDIOVASCULAR COMPROMISE
WHILE OBTAINING A RN HX FROM 23Y/0 MAN DX RHEUMATIC FEVER, THE RN RECOGNIZES THAT THE MOST SIGNIFICANT INFO RELATED BY THE PT IS THAT HE A.HAS USED ILLICIT IV DRUGS WITHIN THE LAST 3 MONTHS B.HAS BEEN UNEMPLOYED FOR 6 MONTHS AND HAS BEEN EATING POORLY C.SUFFERED CHEST TRAUMA WITH A FRACTURE RIB DURING A FIGHT 2 WEEKS AGO D.HAD AN UPPER RESPIRATORY INFECTION WITH A SORE THROAT ABOUT 3 WEEKS AGO.
D.HAD AN UPPER RESPIRATORY INFECTION WITH A SORE THROAT ABOUT 3 WEEKS AGO.
