exam 3 - chosen prep U questions

The nurse is administering oxygen to an older adult client who has been assessed to have increased work of breathing. If the intervention has been effective, what findings will the nurse expect on evaluation of the client? Select all that apply. 1. The client is able to state the date, time and their location 2. The clients' mucous membranes are pink and moist 3. The client's oxygen saturation reads 88% on 5L of oxygen 4. The client's heart rate is assessed at 64 beats per minute 5. The clients' respiratory rate is 33 per minute at rest

1, 2, 4 rationale: A normal resting heart rate indicates a tolerable work of breathing. When in respiratory distress, clients will also experience tachycardia or a heart rate higher than 100 beats per minute. Skin color and mucous membranes are another indicator of the client's oxygenation status. When hypoxic, a client will present as pale skinned, sometimes with bluish-ness around the mouth called cyanosis. Mucous membranes can also appear pale or blanched due to poor circulation. A client with normal work of breathing will have pink and moist mucous membranes. Level of consciousness is another indicators or normal oxygenation. If the client is oriented to day, time and place, they have an intact level of consciousness, a sign of normal oxygenation. A respiratory rate of 33 respirations per minute indicates tachypnea related to increased work of breathing. This is a sign of hypoxia. The nurse will oxygenate the client with an aim to bring the client's oxygen saturation above 90% to ease the work of breathing. An oxygen saturation of 88% with oxygen supplementation is too low and the nurse will need to re-evaluate the effectiveness of the intervention.

A nurse is providing care to a client with an extracellular fluid (ECF) volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply. 1. slow-filling peripheral veins 2. orthostatic hypotension 3. dry mucous membranes 4. decreased urine output 5. poor skin turgor

1, 2, 4 rationale: The signs and symptoms of an ECF volume deficit reflect decreases in fluid volume in the vascular and interstitial spaces. The signs and symptoms of a decrease in vascular volume include orthostatic or postural changes in pulse rate and blood pressure (i.e., an increase in pulse rate and decrease in blood pressure when the person moves from a lying to a standing position); weak, rapid pulse; decreased urine output; and slow-filling peripheral veins. The signs and symptoms of decreased interstitial volume include dry mucous membranes and poor skin turgor.

A client experienced a fight-or-flight response immediately following a car accident. What clinical symptoms would the nurse expect to assess? Select all that apply. 1. heightened awareness 2. increased heart rate 3. relaxed muscle tone 4. pallor 5. pupil constriction 6. decreased digestion

1, 2, 4, 6 rationale: When a situation occurs that the mind perceives as dangerous, the sympathetic nervous system prepares the body for a fight-or-flight response. Increased heart rate, decreased digestion, heightened awareness, and pallor are all clinical presentations of the sympathetic nervous system. Pupil constriction and relaxed muscle tone are associated with the parasympathetic nervous system, which restores equilibrium when danger is no longer present.

A nursing student is studying the normal physiologic changes of older adults. The faculty member knows that the student comprehends the information when the student makes which statements? Select all that apply. 1. "Height may decrease 1 to 3 in (2.5 to 8 cm)." 2. "Fluids and electrolytes remain within normal ranges." 3. "Rate of reflex responses increase." 4. "There is an increased sensitivity to glare." 5. "The senses of taste and smell are decreased, sour taste diminishes first."

1, 3, 5 Rationale: Normal physiologic changes of older adults include height may decrease 1 to 3 in (2.5 to 8 cm), there is an increased sensitivity to glare, and fluids and electrolytes remain within normal ranges. Rate of reflex responses decrease and the senses of taste and smell are decreased. Sweet and salty tastes diminish first.

Nurses must be aware of the danger of using abbreviations that may be misunderstood and compromise patient safety. The Joint Commission has compiled a list of do-not-use abbreviations, acronyms, and symbols to avoid the possibility of errors that may be life threatening. Of the following, which are acceptable? (Select all that apply.) 1)Daily 2)QD 3)qod 4)0.X mg 5)X mg

1, 4

A client has been admitted with fluid volume excess related to right-sided heart failure. Which assessment data would the nurse document related to the fluid volume excess? Select all that apply. 1 .crackles in the lungs 2. poor skin turgor 3. blood pressure 100/48 mmHg 4. excessive urination 5. distended neck veins

1, 5 rationale: Right sided heart failure leads to a back up of volume which is unable to effectively flow back to the left side of the heart. The result is fluid volume excess in the peripheral circulation which eventually leads to fluid overload. Fluid excess or hypervolemia will manifest in clinical symptoms that lead the nurse to hear crackles in the lungs upon chest auscultation. Fluid volume excess leads to translocation of large volumes of intravascular fluid to the interstitial compartment or to areas with only potential spaces such as the peritoneal cavity, pericardium, and pleural space- such as in the lungs. Circulatory overload from fluid volume excess will lead to the client having distended neck veins. Fluid volume deficit causes a low BP where as excess would result in the client becoming hypertensive. Poor skin turgor is often seen in clients with fluid volume deficits or in dehydration. A client with a fluid volume excess would more likely have edema. A client who is hypervolemic is retaining fluid in the intravascular space preventing urinary elimination from occurring. Urinary retention rather than excessive elimination would be seen in this case.

A nurse is developing a plan of care for a client with a negative self-concept. The nurse implements the interventions based on the understanding that a positive self-concept is most important for the client to meet which need? Select all that apply. 1. Self-actualization 2. Love and belonging 3. Safety 4. Physiologic 5. Self-Esteem

1, 5 rationale: Self-concept is the frame of reference that influences how a person handles situations and relationships. It is crucial to esteem and self-actualization, the highest needs in Maslow's hierarchy of needs. Although safety, love and belonging, and physiologic are needs, self-concept is not most important for meeting these needs.

The physician orders Bacitracin 6000 units IM q.AM. The pharmacy send the following drug: (the drug label states, "each vial contains 50,000 units of bacitracin.") 1. How much diluent will be added to the bacitracin for infection powder? 2. What is the dosage strength of the mixed medication? 3. How many mL of the bacitracin for injection will the nurse give to the patient?

1. 9.8ml 2. 5,000 units/ml 3. 1.2ml

A nurse is caring for an older adult client who fell and sustained a hip fracture. Which intervention needs to be included in the nursing care plan? Select all that apply. 1. Monitor daily weights. 2. Cough and deep breathe every 2 hours. 3. Auscultate breath sounds every 1-2 hours. 4. Turn the client every 4 hours. 5. Avoid massaging over bony prominences.

2, 3, 5 rationale: An older adult is more likely to develop complications after illness occurs. An older adult with a hip fracture is at high risk for pneumonia and skin breakdown because of immobility, a decreased ability to expel pulmonary secretions, and thinner, more fragile skin. Coughing, deep breathing, and auscultating breath sounds are interventions used in preventing and detecting impaired gas exchange (pneumonia). Maintaining skin integrity can be achieved by the avoidance of massage over bony prominences. Repositioning the client every 4 hours is not frequent enough; it should be done every 2 hours. Monitoring daily weights is not an intervention useful in pneumonia or skin breakdown.

An older adult client tells the nurse, "I just don't seem to have an appetite and food just doesn't taste as good as it used to." The nurse understands that which factor may be playing a role in this client's lack of appetite? Select all that apply. 1. missing teeth 2. decreased saliva production 3. ill-fitting dentures 4. decreased number of taste buds 5. swallowing difficulties

2,4 rationale: As people age, changes in the gastrointestinal tract can affect nutrition. For example, a decrease in the number of taste buds and saliva production can decrease taste sensation and appetite. Dental problems (e.g., poorly fitting dentures, difficulty chewing, and broken teeth) and difficulty swallowing make effective eating difficult, but would not affect a client's appetite or taste.2,

The nurse observes that a client frequently experiences urine loss when being transferred from a chair to the bed. Which type of incontinence does the nurse identify that the client is experiencing? 1. urge 2. functional 3. reflex 4. total

2. rationale: Functional incontinence takes place when attempting to overcome obstacles, such as transferring from the wheelchair to the bed. Other types of incontinence have different causative factors.

The nurse is caring for a patient from a culture that is unfamiliar. The patient nodded her head "yes" when asked if she will take her prescriptions as ordered, but the nurse discovers the patient does not take the medication, but uses herbs for treatment. What actions by the nurse is best? select all that apply. 1) Warn the patient of the consequences on non-compliance. 2) Tell the patient how the medication will help the condition. 3) Ask the patient why herbal preparations are preferred. 4) Ask the patient to explain the meaning of the herbal products

3 , 4

The nurse is performing a health history for a client who presents to the clinic with abdominal discomfort. Which statements made by the client indicate that the client is at risk for the development of constipation? Select all that apply 1. "I do not regularly take laxatives." 2. "I drink about 16 ounces of fluids a day." 3. "Sometimes I don't have the opportunity to defecate when I need to while I am at work." 4. "I eat foods high in fiber every day." 5. "I don't like to exercise because I am tired all of the time."

3, 2, 5 rationale: A client may be considered at risk for the development of constipation when he or she has insufficient fluid intake, when he or she delays having a bowel movement when the urge is present, and if there is inactivity. A client is also at risk for constipation if abusing laxatives or eating low-fiber foods as part of a daily diet. The use of high-fiber foods adds bulk to the stool and helps with passage of stool through the intestine.

A nurse is caring for older adult clients in an assisted living facility. Which lifespan considerations does the nurse identify that should be applied to practice when caring for this population? Select all that apply. 1. Urinary incontinence is a normal part of aging. 2. Symptoms of a urinary tract infection in an older adult include painful urination and a high fever. 3. Older men may experience urinary hesitancy and difficulty starting the urinary stream. 4. Men have a higher risk of developing urinary incontinence than women. 5. Older adults may try to manage incontinence by restricting intake of fluids. 6. Because of decreased arterial perfusion, kidney function progressively decreases later in life.

3, 5, 6 rationale: Older men experience urinary hesitancy and delayed urinary stream related to prostatic hypertrophy. Older adults may attempt to manage incontinence by restricting fluid intake, using absorbent pads in clothing, and changing clothing. Kidney function decreases with age due to cardiovascular changes. Urinary incontinence is not usually a health problem in the early to middle adult years. Women have a higher risk of developing urinary incontinence due to lower estrogen levels and weakened perineal muscles.

A nurse is monitoring a patient who is receiving intravenous fluid. Which clinical findings indicate that the patient has a fluid overload? 1. Chills, fever, and generalized discomfort 2. Blood in the tubing close to the insertion site 3. Dyspnea, headache, and increased blood pressure 4. Pallor, swelling, and discomfort at the insertion site

3.

A group of nursing students is reviewing information about the older adult and mobility. The students demonstrate a need for additional study when they identify which statement as accurate? 1. Older adults are faced with challenges related to the fear of falling and striving for independence. 2. An older adult experiences numerous factors that increase the risk for falls. 3. Falls are the leading cause of death due to injury in individuals who are over the age of 75 years. 4. Medications in the older adult play a major contributing role to the risk for falling.

3. rationale: For people over the age of 65 years, falls are the leading cause of injury leading to death, with hip fractures resulting in significant morbidity and mortality. Numerous factors place the older adult at risk for falls, including a history of falls, fear of falling, cognitive and mood impairments, dizziness, functional impairments, and environmental hazards. Older adults are faced with dealing with the fear of falling and striving for independence. Medications often play a major role in contributing to falls and other complications in the older adult.

A new graduate nurse has accepted a staff position on a geriatric unit. The preceptor determines that the new nurse understands gerontologic nursing when which statement is made? 1. "The focus of care for the elderly with chronic disorders should be on helping them through the acute disease process." 2. "All older adult clients are treated the same. There are really no differences in care" 3. "Normal changes that occur with aging result from complex interactions." 4. "Gerontologic nursing is not a specialty area of nurse."

3. rationale: Normal changes that occur with aging result from complex interactions among genetics, biologic systems, and physical and social environments. For an older client with chronic disorders, the focus of care should include the client's and family's goals and promote functional health and independent living to the greatest extent possible. Gerontologic nursing combines the basic knowledge and skills of nursing with a specialized knowledge of both illness and health.

A client's intake and output is being measured and recorded each shift. The client has had the following intake: 3 oz apple juice 4 oz tea 5 oz pureed chicken 2 oz mashed potatoes 4 oz orange gelatin 2 oz vanilla ice cream Calculate the amount, in milliliters, the nurse documents as fluid on the intake sheet. Record your answer using a whole number.

390mL rationale: Intake measurements include all oral and parenteral fluids. Oral fluids include any liquids ingested or any foods that become liquid at room temperature. Gelatin and ice cream are examples of solid foods to include. Pureed foods is not considered fluid intake nor is mashed potatoes. Based on the measurements, the client consumed 13 oz of fluid. One ounce is equal to 30 ml, so 13 oz of fluid is equal to 390 mL.

A nurse is assessing a client after surgery and obtains the client's vital signs: pulse rate is 65 bpm, blood pressure is 122/76 mm Hg in the supine position. The nurse then obtains the client's vital signs on standing. Which finding would alert the nurse to the possibility of a an ECF volume deficit? Select all that apply. 1. Blood pressure 126/80 mm Hg 2. Blood pressure 112/70 mm Hg 3. Pulse rate 72 bpm 4. Pulse rate 90 bpm 5. Blood pressure 104/68 mm Hg

4, 5 rationale: An increase in pulse rate of more than 20 beats per minute is a more sensitive indicator of ECF volume deficit than is a decrease in blood pressure. A drop of more than 15 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure with an increase in pulse rate frequently means the client is experiencing ECF volume depletion.

The medical record: 1) serves as a major communication tool but is not a legal document. 2) cannot be used to assess quality of care issues. 3) is not used to determine reimbursement claims. 4) can be used as a tool for biomedical research and provide education.

4.

Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care? 1. 1230—Client's vital signs taken. 2. 0700—Client drank adequate amount of fluids. 3. 0900—Demerol given for lower abdominal pain. 4. 0830—Increased IV fluid rate to 100 mL/hr according to protocol

4.

A home care client reports weakness and leg cramps. Per order, the nurse draws blood and requests a potassium level. What is the rationale for this request? 1. The nurse is concerned that the client's diet has caused sodium loss. 2. The client is actively seeking increased attention. 3. The client had bananas and orange juice for breakfast. 4. The nurse recognizes these symptoms of hypokalemia.

4. rationale: Hypokalemia is a potassium deficit in the ECF. When the ECF potassium falls, potassium moves out of the cells, creating an intracellular potassium deficiency. Typical symptoms include muscle weakness and leg cramps. Hyponatremia is manifested by confusion, hypotension, edema, muscle cramps and weakness, and dry skin. The client is not actively seeking attention but has a physiological issue that should be assessed. Bananas and orange juice are high in vitamin C, which is a water soluble vitamin.

A 90-year-old woman is admitted to a nurse's unit status post CVA. The client is alert and oriented to person, place, and time but has limited mobility and hemiparesis of the left side of her body. She is experiencing urinary incontinence. What is the most appropriate nursing action? 1. Use disposable padding (Chux) to keep the bedding dry. 2. Assist the client once per shift to use the commode. 3. Insert a Foley catheter to prevent incontinence. 4. Use the Braden scale to assess for pressure injuries.

4. rationale: The Braden scale is an evidence-based tool used to assess for pressure injuries. Pressure injuries can result from urinary incontinence, particularly if the skin is moist and skin integrity is impaired. The client would likely require assistance every time she uses the toilet. A Foley catheter is an extreme solution to this problem.

Symptoms such as facial twitches, shakiness, narrowed focus of attention, and slightly impaired learning are indicators of which type of Anxiety? A) Moderate Anxiety B) Mild Anxiety C) Severe Anxiety D) Stress Anxiety

a.

There are many different treatment methods when it comes to urinary incontinence. Which form of treatment would you first recommend to a patient experiencing reflex incontinence? a)Kegel exercises b)Surgical intervention c)Pessaries d)External Barrier

a.

A newly admitted patient with congestive heart failure has a potassium level of 5.7 mEq/L. How does the nurse identify contributing factors for the electrolyte imbalance? (Select all that apply.) a. Assess the patient for hypokalemia. b. Obtain a list of the patient's home medications. c. Assess the patient for hyperkalemia. d. Ask about the patient's method of taking medications at home. e. Evaluate the patient's appetite.

b, c, d

An older adult is admitted to the intensive care unit. For which common behavioral adaptation to sensory overload should the nurse monitor the patient? A. Dementia B. Confusion C. Drowsiness D. Bradycardia

b.

Which statement indicates a need for further teaching of a home care client with a long term indwelling catheter? (a) I will keep the collecting bag below the level of the bladder at all times (b) Intake of cranberry juice may help decrease the risk of infection (c) Soaking in a warm tub bath may ease the irritation associated with the catheter (d) I should use clean technique when emptying the urinary bag

c.

Your patient has not had a bowel movement in 3 days as a side effect of his continuous morphine drip. You prepare to administer a large volume enema. What position do you place the patient? A. Supine B. Low Fowlers C. On stomach with bed flat D. Left side Sims Position

d.