Exam #3 Prep U
A nurse is completing a home visit to an older adult receiving regular dressing changes for treatment of a venous ulcer. As a provider of home healthcare, the nurse recognizes that the primary goal of this practice is: a) To prevent recurrent admissions to hospitals and other inpatient settings. b) To maximize the independence and health of clients. c) To limit the progression of chronic health problems. d) To enable clients to make informed choices about their health.
b) The goal of helping the client reach maximum independence and health is central to the philosophy and practice of home healthcare. This goal may encompass enabling client choices, preventing future admissions, or limiting the progression of existing diseases, but each of these measures is an expression of the larger goal of maximizing health and independence.
A neonate is to receive an I.V. infusion of normal saline solution at 3 ml/hour. The nurse is setting the alarms on an I.V. infusion pump. How should the nurse set the alarms? a) To sound when the infusion is infiltrating. b) At 5% above and 5% below the keep-vein-open rate. c) Within a 15% range of the keep-vein-open rate d) At the exact drip rate as prescribed.
b. Alarms on infusion pumps should be set at 5% above and 5% below the prescribed infusion rate. A wider range is not safe. The alarms must be set to indicate a change in the drip rate, not infiltration. Setting the alarms for the exact drip rate will cause the alarms to trigger when the client moves, and this exact range is not needed to alert the nurse to an unsafe rate.
When a nurse tries to administer medication, the client refuses it, saying, "I don't have to take those pills if I don't want to." What intervention by the nurse would have the highest priority? a) Explaining the consequences of not taking the medication, such as a negative outcome b) Insisting that the client take the medication because it is specifically ordered for the client c) Exploring how the client's feelings affect his/her decision to refuse medication d) Reporting the client's comments to the physician and the treatment team
c.
The nurse is planning care for a group of clients. Which client should the nurse identify as needing the most assistance in accepting being ill? a) A 32-year-old woman diagnosed with depression related to lupus erythematosus who discusses her medication's adverse effects with the nurse. b) A 45-year-old man who just suffered a severe myocardial infarction and talks to the nurse about concerns regarding resuming sexual relations with his wife. c) A 60-year-old woman diagnosed with chronic obstructive pulmonary disease who refuses to wear an oxygen mask even though poor oxygenation makes her confused. d) An 8-year-old boy who alternately cries for his mother and is angry with the nurse about being hospitalized after a bike accident.
C. The 60-year-old woman is acting in a way that worsens her physical and mental condition because she does not want to be sick. The 8-year-old child is acting normally for someone his age who is unexpectedly hospitalized. The cooperation demonstrated by the client with lupus and the client who had a myocardial infarction indicates a level of acceptance of their illnesses and of their role as being ill.
The nurse uses Montgomery straps primarily to achieve which of the following client outcomes? a) The client is free from falls. b) The client is free from bruises. c) The client is free from wandering. d) The client is free from skin breakdown.
D) The nurse uses Montgomery straps primarily to avoid the removal of long-term abdominal dressing tape and ultimate skin breakdown
When assessing a client's incision one day after surgery show redness and warmth around the incision site. What action by the nurse is best? a) Culture the wound. b) Apply a cool compresses TID. c) Assess for blanching. d) Note the wound edges in the client's chart.
D) Warmth and redness are normal signs of an inflammatory response, and do not require interventions such as a cool compress. There are no infectious processes that would require a culture. Blanching would not demonstrate issues with the wound infection.
While caring for a client who's immobile, a nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information? a) Constipation related to immobility b) Impaired skin integrity related to immobility c) Disturbed body image related to immobility d) Risk for impaired skin integrity related to immobility
D. The information documented in the client's chart reflects the risk for impaired skin integrity. Because the client's skin is intact, the problem is only a potential one, not an actual one, which makes the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If body image disturbance were a problem, interventions would focus on the client's feelings about himself and his disease.
When positioned properly, the tip of a central venous catheter should lie in the: a) superior vena cava. b) basilic vein. c) jugular vein. d) subclavian vein.
a
A client receives morphine for postoperative pain. Which of the following assessments should the nurse include in the client's plan of care? a) Assess urinary output every 8 hours. b) Assess mental status every shift. c) Check for pedal edema every 4 hours. d) Take apical heart rate after each dose of morphine.
a.
The nurse is preparing to give a subcutaneous injection to an elderly, emaciated client. Which needle length and angle should the nurse plan to use to administer the injection safely? a) A ½-inch (1.3-cm) needle at a 15-degree angle. b) A 5/8-inch (1.6-cm) needle at a 45-degree angle. c) A 5/8-inch (1.6-cm) needle at a 90-degree angle. d) A 3/8-inch (0.95-cm) needle at a 90-degree angle.
a.
The nurse explains to the client that the primary reason a back rub is used as therapy to relieve pain is because the massage: a) Blocks pain impulses from the spinal cord to the brain. b) Stimulates the release of endorphins. c) Distracts the client's focus on the source of the pain. d) Blocks pain impulses from the brain to the spinal cord.
A) A back rub stimulates the large-diameter cutaneous fibers, which block transmission of pain impulses from the spinal cord to the brain. It does not block the transmission of pain impulses or stimulate the release of endorphins. A back rub may distract the client, but the physiologic process of fiber stimulation is the main reason a back rub is used as therapy for pain relief.
A nurse who works on an obstetrical inpatient unit has been assigned to the Client Safety Committee. What client safety goals are most applicable to this setting? Select all that apply. a) Involving clients in education to prevent cesarean sections, episiotomies, and cord infections b) Ensuring that health care providers complete preprocedure verification for any invasive procedure c) Providing effective and timely hand-off reports between labor and birth staff and mother-baby staff d) Giving car seat instructions that allow infants to ride facing backward in the front seat e) Identifying safety risks specific to the unit, such as infant abduction
A) B) C) E) Specific safety concerns on an obstetrical unit include providing very specific hand-off reports after completion of childbirth and recovery and the couplet transition to mother-baby care. In an invasive procedure (eg, tubal ligation, circumcision), preprocedure verification is standard. Education concerning the potential for infection in obstetrics is essential for clients with any incision. Infant abduction is an ever-present concern for those working in a mother-baby unit. Car seat instructions for new parents involve the infant facing backward in the back seat of a car, not in the front seat. Education for the family includes this important area.
A nurse is caring for a client with emphysema. Which nursing interventions are appropriate? Select all that apply. a) Administer low-flow oxygen. b) Teach use of postural drainage and chest physiotherapy. c) Keep the client in a supine position as much as possible. d) Encourage alternating activity with rest periods. e) Reduce fluid intake to less than 2,500 ml/day. f) Teach diaphragmatic, pursed-lip breathing.
A) B) D) F) Diaphragmatic, pursed-lip breathing strengthens respiratory muscles and enhances oxygenation in clients with emphysema. Low-flow oxygen should be administered because the client with emphysema has chronic hypercapnia and a hypoxic respiratory drive. Alternating activity with rest allows the client to perform activities without excessive distress. If the client has copious secretions and has difficulty mobilizing secretions, the nurse should teach him and his family members how to perform postural drainage and chest physiotherapy. Fluid intake should be increased to 3,000 ml/day, if not contraindicated, to liquefy secretions and facilitate their removal. The client should be placed in high Fowler's position to improve ventilation.
A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal? a) Inadequate protein intake b) Low calcium level c) Inadequate massaging of the affected area d) Inadequate vitamin D intak
A) Clients on bed rest suffer from lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren't factors in poor healing for this client. A pressure ulcer should never be massaged.
The client tells the nurse that he is allergic to shellfish. The nurse should ask the client if he is also allergic to: a) Iodine skin preparations. b) All other seafood. c) Caffeine. d) Alcohol-based skin preparations.
A) Clients who are allergic to shellfish are allergic to iodine skin preparations (Iodophor and Betadine) or any other products containing iodine, such as dyes. Clients who are allergic to shellfish do not necessarily have an allergy to any other substances or seafood.
A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: a) Use an alternating air pressure mattress. b) Elevate the lower extremities. c) Massage the abdomen once a shift. d) Institute range-of-motion (ROM) exercise every 4 hours.
A) Edematous tissue is easily traumatized and must receive meticulous care. An alternating air pressure mattress will help decrease pressure on the edematous tissue ROM exercises are important to maintain joint function, but they do not necessarily prevent skin breakdown. When abdominal skin is stretched taut due to ascites, it must be cleaned very carefully. The abdomen should not be massaged. Elevation of the lower extremities promotes venous return and decreases swelling.
Following surgery, a client is receiving 1000 ml normal saline (IV) with 40 mEq (40 mmol/l) KCl which has been ordered to be infused at 125 ml/hr. The client states, "My IV hurts." What should the nurse do first? a) Assess the IV site for signs of phlebitis, extravasation, or IV-related infection. b) Contact the client's physician for a different IV order. c) Check the hanging parenteral fluid and administration set for documentation as to when they were last changed. d) Slow down the infusion to a keep-open rate (20-50 ml/hr).
A) Potassium in an IV solution may be irritating to a vein. The nurse should assess the IV site before taking any of the other actions listed. The infusion may have to be slowed and/or stopped, and the physician contacted. An outdated parenteral fluid setup does not cause pain, but may be a source of infection.
A client is being admitted with a nursing home-acquired pneumonia. The unit has four empty beds in semiprivate rooms. The room that would be most suitable for this client is the one with a: a) 60-year-old client admitted for investigation of transient ischemic attacks. b) 24-year-old client with non-Hodgkin's lymphoma. c) 55-year-old client with alcoholic cirrhosis. d) 45-year-old client with an abdominal hysterectomy.
A) The client with a possible transient ischemic attack is the only client who has not had surgery and is not immunocompromised. The client with a recent surgery and incision should not be exposed to a client with infection. Clients with cancer or alcoholic cirrhosis are very susceptible to infection, and it would not be safe to expose them to a client with a respiratory infection.
A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care? a) Clean the area around the drain moving away from the drain. b) Gently irrigate the drain to remove exudate. c) Remove the drain if wound drainage is minimal. d) Remove the dressing and leave the incision open to air.
A) The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated.
A severe winter storm has prevented most staff members from getting to work on a busy medical-surgical unit. One registered nurse, two licensed practical nurses, and three nursing assistants have been able to get to work. A nurse-manager must decide which nursing care delivery system (model) (NCDS) should be implemented for the best possible client care during this staffing crisis. The nurse-manager directs the staff to implement which NCDS (NCDM)? a) Functional nursing b) Team nursing c) Primary nursing d) Case management
A) Functional nursing best uses the skills of all staff in a timely manner during this crisis. This delivery system (model) requires the fewest staff and delegates tasks to those who can best perform them. Team nursing doesn't allow for the best use of a limited number of staff who must care for a large number of clients. Primary nursing and case management require more registered nurses than are currently available.
A client is being admitted with a nursing home-acquired pneumonia. The unit has four empty beds in semiprivate rooms. The room that would be most suitable for this client is the one with a: a) 60-year-old client admitted for investigation of transient ischemic attacks. b) 24-year-old client with non-Hodgkin's lymphoma. c) 55-year-old client with alcoholic cirrhosis. d) 45-year-old client with an abdominal hysterectomy
A) The client with a possible transient ischemic attack is the only client who has not had surgery and is not immunocompromised. The client with a recent surgery and incision should not be exposed to a client with infection. Clients with cancer or alcoholic cirrhosis are very susceptible to infection, and it would not be safe to expose them to a client with a respiratory infection.
The nurse is changing the dressing of a client after an abdominal hysterectomy. Which of the following nursing measures would be most appropriate if the dressing adheres to the client's incisional area? a) Moisten the dressing with sterile normal saline solution and then remove it. b) Lift an easily moved portion of the dressing and then remove it slowly. c) Remove part of the dressing and then remove the remainder gradually over a period of several minutes. d) Pull off the dressing quickly and then apply slight pressure over the area.
A) When a dressing sticks to a wound, it is best to moisten the dressing with sterile normal saline solution and then remove it carefully. Trying to remove a dry dressing is likely to irritate the skin and wound. This may contribute to tension or tearing along the suture line.
A client receives an I.V. dose of gentamicin sulfate (Garamycin). How long after the completion of the dose should the peak serum concentration level be measured? a) 30 minutes. b) 10 minutes. c) 20 minutes. d) 40 minutes.
A.
A nurse is monitoring a client who is receiving moderate sedation during a breast biopsy. Which symptom should the nurse assess first? a) Coarse crackles in both upper lobes b) Mild bleeding at the surgical site c) Lower back pain d) Heart rate of 84 beats/minute
A. Coarse crackles may indicate aspiration — a potentially life-threatening complication of conscious sedation. A heart rate of 84 beats/minute is within the normal range. Mild bleeding is expected at the surgical site. Poor positioning during surgery commonly causes lower back pain. Although the nurse should ultimately assess this pain, it isn't her first priority
Which of the following is an expected outcome when a client is receiving an I.V. administration of furosemide? a) Increased urine output. b) Increased blood pressure. c) Decreased premature ventricular contractions. d) Decreased pain.
A. Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias
The nurse notices redness, swelling, and induration at a surgical wound site. What should the nurses next action be? a) Assess the clients temperature b) Clean with antiseptic material and re-dress the site c) Notify the health care provider d) Evaluate the clients white blood cell count
A. Infection produces signs of redness, swelling, induration, warmth, and possibly drainage. Since there could be a worsening situation occurring, further evaluation of the client is needed to determine the urgency of the situation. Assessment of the temperature should be the next step to determine how the client is responding to the infection. The white blood cells can also determine patient's response but the priority should be the temperature. The wound needs to be re-dressed but his would occur after speaking with the health care provider in case a culture may be ordered with would be inaccurate if the wound was cleaned first.
The client has been managing episodes of angina with nitroglycerin. Which of the following indicates the drug is effective? a) Decreased chest pain (angina). b) Increased blood pressure. c) Decreased heart rate. d) Decreased blood pressure.
A. Nitroglycerin acts to decrease myocardial oxygen consumption. Vasodilation makes it easier for the heart to eject blood, resulting in decreased oxygen needs. Decreased oxygen demand reduces pain caused by the heart muscle not receiving sufficient oxygen. While blood pressure may decrease ever so slightly as a result of the vasodilating effects of nitroglycerin, it is only secondary and not related to the client's angina. Increased blood pressure would mean the heart would work harder, increasing oxygen demand and thus angina. Decreased heart rate is not an effect of nitroglycerin.
When teaching a client how to take a sublingual tablet, the nurse should instruct the client to place the tablet: a) on the floor of the mouth. b) on the top of the tongue. c) on the roof of the mouth. d) inside the cheek.
A. The nurse should instruct the client to touch the tip of the tongue to the roof of the mouth, then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream from the oral mucosa, bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth. With the buccal route, the client places the tablet between the gum and the cheek.
The nurse-manager on the oncology unit wants to address the issue of correct documentation of the effectiveness of analgesia medication within 30 minutes after administration. What should the nurse-manager do first? a) Complete a brief quality improvement study and chart audit to document the rate of adherence to the policy and the pattern of documentation over shifts. b) Consult the pharmacist. c) Change the policy of documentation to 45 minutes. d) Consult the nurses on the evening shift where documentation of analgesia is the greatest problem.
A. To determine the cause of this problem, a quality improvement study should be conducted. Before implementing solutions to a problem, the precise issues in the hospital system must be observed and documented. It is not the pharmacist's role to provide consultation about documentation of drugs administered by nurses. Consulting the evening nurses may be helpful, but this is a systems issue of the entire unit and involves every registered nurse administering analgesia.
A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention helps meet this goal? a) Administering oxygen by nasal cannula as ordered b) Repositioning the client every 2 hours c) Keeping the head of the bed at a 30-degree angle d) Restricting fluids to 1,000 ml/24 hours
B) Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, thereby hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle might ease respirations and make them more effective but wouldn't help mobilize secretions
A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client? a) Don't ambulate for 2 hours prior to the procedure. b) Don't eat for 6 hours prior to the procedure. c) Don't talk for 4 hours prior or 4 hours following the procedure. d) Don't the day of the procedure.
B) Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure. It isn't necessary for the client to avoid walking, talking, or coughing.
The nurse empties a Jackson-Pratt drainage bulb. Which of the following nursing actions ensures correct functioning of the drain? a) Irrigating it with normal saline. b) Compressing it and then plugging it to establish suction. c) Connecting it to low intermittent suction. d) Connecting it to a drainage bag and clamping it off.
B. After emptying a Jackson-Pratt drainage bulb, the nurse should compress the bulb, plug it to establish suction, and then document the amount and type of drainage emptied. Irrigating a Jackson-Pratt drain is inappropriate because it could contaminate the wound. The Jackson-Pratt drain is not usually connected to wall suction. The purpose of the Jackson-Pratt drain is to remove bloody drainage from the deep tissues of the incision; clamping the drain would be counterproductive.
A nursing instructor is instructing group of new nursing students. The instructor reviews that surgical asepsis will be used for which of the following procedures? a) Instilling eye drops b) I.V. catheter insertion c) Nasogastric tube irrigation d) Colostomy irrigation
B. Caregivers must use surgical asepsis when performing wound care or any procedure that involves entering a sterile body cavity or breaking skin integrity. To achieve surgical asepsis, objects must be sterilized or kept free of all pathogens. Because inserting an I.V. catheter disrupts skin integrity and involves entry into a sterile cavity (a vein), surgical asepsis is required. Medical asepsis is used when instilling eye drops. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.
The nurse assesses a client who has just received morphine sulfate. The client's blood pressure is 90/50 mm Hg; pulse rate, 58 bpm; respiration rate, 4 breaths/minute. The nurse should check the client's chart for an order to administer? a) Doxacurium. b) Naloxone hydrochloride. c) Remifentanil. d) Flumazenil.
B. Naloxone hydrochloride is the antidote for morphine sulfate. The signs of overdose on morphine sulfate are a respiration rate of 2 to 4 breaths/minute, bradycardia, and hypotension. Flumazenil is the antidote for midazolam. Doxacurium is a nondepolarizing muscle relaxant. Remifentanil is an opioid used as an anesthetic adjunct.
Which of the following physician prescriptions is written correctly? a) Give 4 U regular insulin IV now b) Fentanyl 50 micrograms given IV every 2 hours as needed for pain > 6/10 c) 60.0 mg toradol given IM for c/o pain d) .5 mg MS given IM for c/o pain
B. Prescriptions should be written clearly to avoid confusion or misinterpretation. Clearly written prescriptions do not use a "trailing" zero (a zero following a decimal point) and do use a "leading" zero (a zero preceding a decimal point). Additionally, the prescribed medication should be written in full and avoid abbreviations of the drug and the dosage, for example "morphine sulfate" (avoiding use of "MS"), "ml" instead of "cc," and "micrograms" instead of "mcg."
Which of the following medications should the nurse anticipate administering in the event of a heparin overdose? a) Acetylsalicylic acid (ASA). b) Protamine sulfate. c) Warfarin sodium (Coumadin). d) Atropine sulfate.
B. Protamine sulfate is a heparin antagonist. It is administered intravenously very slowly (over at least 10 minutes). Warfarin sodium and ASA have anticoagulant properties and would be contraindicated. Atropine sulfate is an anticholinergic drug and would not be effective in treating a heparin overdose.
Which of the following is a serious adverse effect of ibuprofen (Advil, Motrin) in the elderly? a) Neuropathy. b) Impaired renal function. c) Hypoglycemia. d) Rebound headaches.
B. Renal function may already be compromised in the elderly, and ibuprofen can further impair renal or liver function. Nonsteroidal anti-inflammatory drugs can also cause nephrosis, cirrhosis, and heart failure in elderly persons. Rebound headaches are not a serious adverse effect of ibuprofen. Neuropathy is not an adverse effect of ibuprofen. Hypoglycemia is not an adverse effect of ibuprofen.
A priority for nursing care for an adult female who has pruritus and is continuously scratching the affected areas and demonstrates agitation and anxiety regarding the itching sensation would be: a) Avoiding soical isolation b) Preventing infection c) Instructing the client not to scratch d) Increasing fluid intake
B. The client is at risk for infection because of the pruritus, and the nurse should institute measures to help the client control the scratching, such as cutting fingernails, using protective gloves or mitts, and if necessary administering anti-anxiety medications. More information is required regarding the knowledge level of the client, but learning cannot take place when an individual's attention is distracted with pruritus. Increasing fluid intake is not a priority at this time. There is no data to indicate the client is experiencing social isolation.
A loading dose of digoxin (Lanoxin) is given to a client newly diagnosed with atrial fibrillation. The nurse begins instructing the client about the medication and the importance of monitoring his heart rate. An expected outcome of the education program will be: a) Verbalization of the need for the medication. b) A return demonstration of how to take the medication. c) A return demonstration of palpating the radial pulse. d) Verbalization of why the client has atrial fibrillation.
B. The goal of the education program is to instruct the client to take his pulse; therefore, the expected outcome would be the ability to give a return demonstration of how to palpate the heart rate.
A client is admitted to the hospital. The graduate nurse is completing a nursing assessment and asks the client if he has an advanced directive. The client responds that he doesn't know what an advanced directive is. The registered nurse preceptor would intervene if she heard the graduate nurse inform the client that an advance directive is: a) A legal document completed by the physician to withhold food and fluids in clients with severe brain injuries b) A legal document, made by the client when he is healthy, that directs others to follow the client's wishes if he is incapacitated c) A legal opinion, instituted by the physician alone, to give the client "do not resuscitate" (DNR) status. d) A legal document that is commonly referred to as a living will and recognized in all North America.
C) A facility refers to an advance directive, a document the client writes or completes, to provide care at a time when the client can't make his own choices. The living will and health care power of attorney are both examples of advance directives. A living will is a document which a competent adult prepares and which provides direction regarding medical care if the client becomes incapacitated. health care power of attorney is an authorization enabling any competent individual to designate someone else to exercise decision-making authority on the individual's behalf under specific circumstances. The Patient Self-Determination Act of 1990 allows clients to write advance directives.
A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration? a) Nasal cannula b) Simple mask c) Nonrebreather mask d) Venturi mask
C) A nonrebreather mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A simple mask delivers 2 to 10 L/minute of oxygen in uncontrollable concentrations.
A nurse is to collect a sputum specimen from a client. The best time to collect this specimen is: a) before bedtime. b) any time during the day. c) in the morning, as soon as the client awakens. d) early in the evening when secretions settle in the lungs.
C) Because sputum accumulates in the lungs during sleep, the nurse should collect a sputum specimen in the morning, as soon as the client awakens. This specimen will be concentrated, increasing the likelihood of an accurate culture. Sputum specimens collected at other times during the day aren't concentrated and may not provide an accurate culture.
A client is admitted to the post-anesthesia care unit (PACU) following a left hip replacement. The initial nursing assessment findings are T 96.6 degrees F (35.9 degrees C), pulse 90, RR 14, and BP 128/80. The client only responds with moaning when spoken to. The nurse should first: a) Administer sedation reversal agent such as flumazenil. b) Observe the surgical dressing. c) Position the client on the right side. d) Remove the oral airway remaining from surgery.
C) During the immediate post-anesthesia period, the unconscious client should be positioned on the side to maintain an open airway and promote drainage of secretions; because of the type of surgery, the client should be positioned on the right side. Removing the oral airway and observing the surgical dressing is appropriate, but other actions should be implemented before these. Respiratory depression can occur in a client after a procedure requiring sedation. If the client cannot be aroused, the sedation drugs can be reversed by administering a sedation reversal agent, but this client's respiratory rate is 14 and the client is moaning, indicating expected recovery from anesthetics
A client has a nursing diagnosis of Ineffective airway clearance related to retained secretions. When planning this client's care, the nurse should include which intervention? a) Suctioning the client every 2 hours b) Increasing fluids to 1,500 ml/day c) Teaching the client how to deep-breathe and cough d) Improving airway clearance
C) Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client's condition, but this intervention doesn't address poor coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning isn't indicated unless other measures fail to clear the airway.
A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important? a) A history of diabetes mellitus b) An active daily walking program c) Recent pelvic surgery d) History of increased aspirin use
C) The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.
A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which of the following should the nurse keep in mind? a) The current reimbursement system recognizes the family's nontechnical value priorities. b) Family caregivers are always perceived to be supportive of good care. c) The nurse needs to be creative in integrating the technical and relational aspects of care. d) Nurses should avoid asking the family caregivers to conduct the skilled task.
C) The nurse needs to be creative in integrating the technical and relational aspects of care. The current reimbursement system does not recognize the family's nontechnical value priorities. Nurses are expected to educate the family caregivers to conduct the skilled task where possible. In this case, the nurse can teach the family caregivers to inject insulin. Family caregivers can be perceived to be nonsupportive of good care if the families do not follow through.
A nurse is caring for another nurse's clients while that nurse is on break. While was making rounds of the other nurse's clients, the nurse found medications left a client's bedside stand. How should the nurse best address this problem? a) Correct the problems and submit a written report. b) Inform the nurse-supervisor right away. c) Speak to the coworker when she returns to the unit. d) Ask for a meeting with the coworker and a manager.
C) When a nurse discovers substandard practice by another nurse, it's always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse-supervisor first doesn't promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issues can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed only by those directly involved. (l
A laissez-faire nurse-manager takes which action? a) Identifies possible solutions to staffing problems and asks staff members for their opinions about each one b) Completes the vacation schedule without staff input c) Delegates to staff responsibility for selecting a new nursing care delivery system (model) d) Delegates responsibility for evaluating the effectiveness of new equipment to the staff members who use that equipment
C) Delegating a process that will affect all aspects of a nursing area shows a lack of accountability characteristic of a laissez-faire manager. Making critical decisions without staff input is characteristic of an autocratic manager. Delegating evaluation to staff who are intimately involved in a project is appropriate and characteristic of a democratic manager. Identifying potential solutions to a problem and asking staff members for their opinions of the solutions is characteristic of a participative manager
A client is recovering from an abdominal-perineal resection. Which of the following measures would most effectively promote wound healing after the perineal drains have been removed? a) Applying a protected heating pad to the area. b) Taking daily showers. c) Taking sitz baths. d) Applying warm, moist dressings to the area.
C) Sitz baths are an effective way to clean the operative area after an abdominal-perineal resection. Sitz baths bring warmth to the area, improve circulation, and promote healing and cleanliness. Most clients find them comfortable and relaxing. Between sitz baths, the area should be kept clean and dry. A shower will not adequately clean the perineal area. Moist dressings may promote wound contamination and delay healing. A heating pad applied to the area for longer than 20 minutes may cause excessive vasodilation, leading to congestion and discomfort.
Which nursing intervention takes highest priority when caring for a client who's receiving a blood transfusion? a) Documenting blood administration in the client care record b) Assessing the client's vital signs at the conclusion of the transfusion c) Monitoring the client for itching, swelling, or dyspnea d) Informing the client that the transfusion usually takes 1½ to 2 hours
C. Because administration of blood or blood products may cause serious adverse effects such as allergic reactions, the nurse must monitor the client for these effects. Signs and symptoms of life-threatening allergic reactions include itching, swelling, and dyspnea. Although the nurse should inform the client how long the transfusion will take and should document its administration, these actions are less critical to the client's immediate health. The nurse should assess the client's vital signs at least hourly during the transfusion, not just at the conclusion of the transfusion.
The nurse should teach the client that signs of digoxin toxicity include which of the following? a) Visual disturbances such as seeing yellow spots. b) Increased appetite. c) Rash over the chest and back. d) Elevated blood pressure.
C. Colored vision and seeing yellow spots are symptoms of digoxin toxicity. Abdominal pain, anorexia, nausea, and vomiting are other common symptoms of digoxin toxicity. Additional signs of toxicity include arrhythmias, such as atrial fibrillation or bradycardia. Rash, increased appetite, and elevated blood pressure are not associated with digoxin toxicity.
When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing? a) In the middle of the wound b) At the top of the wound c) At the base of the wound d) Over the total wound
C. When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage.
The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. Which of the following actions should the nurse take next? a) Press the emergency alarm to call the resuscitation team. b) Have all visitors and family leave the room. c) Cover the abdominal organs with sterile dressings moistened with sterile normal saline. d) Call the surgeon to come to the client's room immediately.
C. When a wound eviscerates (abdominal organs protruding through the opened incision), the nurse should cover the open area with a sterile dressing moistened with sterile normal saline and then cover it with a dry dressing. The surgeon should then be notified to take the client back to the operating room to close the incision under general anesthesia. The nurse should not press the emergency alarm because this is not a cardiac or respiratory arrest. The nurse should have the visitors and family leave the room to decrease the chance of airborne contamination, but the primary focus should be on covering the wound with a moist, sterile covering.
Which of the following is the correct technique for applying an elastic bandage to a leg? a) Overlap each layer twice when wrapping. b) Secure the bandage with clips over the area of the inner thigh. c) Start at the distal end of the extremity and move toward the trunk. d) Increase tension with each successive turn of the bandage.
C. When applying an elastic bandage to a leg, start at the distal end and move toward the trunk in order to support venous return. Tension should be kept even and not increased with each turn to prevent circulatory impairment. Overlapping each layer twice when wrapping can also impair circulation. The clips securing the bandage should be placed on the outer aspect of the leg to avoid creating a pressure point on the other leg.
A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin (Coumadin). The expected outcome of this drug is to: a) Prevent thrombus formation. b) Regulate cardiac rhythm. c) Decrease circulatory overload. d) Improve the myocardial workload.
Coumadin is an anticoagulant, which is used in the treatment of atrial fibrillation and decreased left ventricular ejection fraction (less than 20%) to prevent thrombus formation and release of emboli into the circulation. The client may also take other medication as needed to manage the heart failure. Coumadin does not reduce circulatory load or improve myocardial workload. Coumadin does not affect cardiac rhythm
A client has an open cholecystectomy with bile duct exploration. Following surgery, the client has a T-tube. To evaluate the effectiveness of the T-tube, the nurse should: a) Unclamp the T-tube and empty the contents every day. b) Irrigate the tube with 20 ml of normal saline every 4 hours. c) Monitor the multiple incision sites for bile drainage. d) Assess the color and amount of drainage every shift.
D. A T-tube is inserted in the common bile duct to maintain patency until edema from the duct exploration subsides. The bile color should be gold to dark green and the amount of drainage should be closely monitored to ensure tube patency. Irrigation is not routinely done, unless ordered using a smaller volume of fluid. The T-tube is not clamped in the early post-op period to allow for continuous drainage. An open cholecystectomy has one right subcostal incision, whereas a laparoscopic cholecystectomy has multiple small incisions
A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority? a) Imbalanced nutrition: Less than body requirements b) Impaired oral mucous membranes c) Activity intolerance d) Impaired gas exchange
D. Although all of these nursing diagnoses are appropriate for a client with AIDS, Impaired gas exchange is the priority nursing diagnosis for a client with P. carinii pneumonia. Airway, breathing, and circulation take top priority for any client.
A client will receive I.V. midazolam hydrochloride (Versed) during surgery. Which of the following should the nurse determine as a therapeutic effect? a) Nausea. b) Mild agitation. c) Blurred vision. d) Amnesia.
D. Midazolam hydrochloride causes antegrade amnesia or decreased ability to remember events that occurred around the time of sedation. Nausea, mild agitation, and blurred vision are adverse effects of Versed.
When assessing a client's I.V. insertion site, a nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first? a) Discontinue the I.V. infusion at that site and restart it in the other arm. b) Irrigate the I.V. tubing with 1 ml of normal saline solution. c) Elevate the I.V. fluid bag. d) Check the tubing for kinks and reposition the client's wrist and elbow.
D. The nurse should check for common causes of a decreased I.V. flow rate, such as kinks in the tubing and poor positioning of the affected arm. The nurse should discontinue the I.V. infusion only if other measures fail to solve the problem. Irrigating I.V. tubing may dislodge any clots that are present. Elevating the I.V. fluid bag may help if the nurse finds no kinks and if repositioning doesn't resolve the problem.
A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client? a) The client should be encouraged to take food and fluids to prevent dehydration and malnutrition. b) The client's skin should be assessed hourly. c) Surgical wound infection is most likely to occur during the first postoperative day. d) The client should begin coughing and deep-breathing exercises as soon as he's able to follow instructions.
D. The nurse should encourage the client to cough and breathe deeply as soon as possible after surgery to help prevent atelectasis and pneumonia. She shouldn't encourage the client to take food or fluids until bowel sounds are present (usually 24 hours postoperatively). Wound infection is a concern, but usually not during the first postoperative day. The nurse should assess the client's skin every 2 hours when he is made to either change position or get out of bed
Which of the following should the nurse include when teaching the family and a client who was prescribed benztropine (Cogentin), 1 mg P.O. twice daily, about the drug therapy? a) Antacids can be used freely when taking this drug. b) Alcohol consumption with benztropine therapy need not be restricted. c) The drug can be used with over-the-counter cough and cold preparations. d) The client should not discontinue taking the drug abruptly.
D. The nurse should teach the client and family the importance of not discontinuing benztropine abruptly. Rather, the drug should be tapered slowly over a 1-week period. Benztropine should not be used with over-the-counter cough and cold preparations because of the risk of an additive anticholinergic effect. Antacids delay the absorption of benztropine, and alcohol in combination with benztropine causes an increase in central nervous system depression; concomitant use should be avoided
Diuretic therapy with furosemide is started for a client with heart failure. Two days after the drug therapy is started, the nurse evaluates the furosemide as effective when the client has experienced which of the following outcomes? a) Has an improved appetite and is eating better. b) Is less thirsty than she was before the drug therapy. c) Has clearer urine since starting furosemide. d) Weighs 6 lbs (3 kg) less than she did 2 days ago.
D. The primary reason to give a diuretic to a client with heart failure is to promote sodium and water excretion through the kidneys. As a result, the excessive body water that tends to accumulate in a client with heart failure is eliminated, which causes the client to lose weight. Monitoring the client's weight daily helps evaluate the effectiveness of diuretic therapy. The client should be advised to weigh herself daily. An increased appetite or decreased thirst does not establish the effectiveness of the diuretic therapy, nor does having clearer urine after starting furosemide.
Which of the following is an adverse effect of vancomycin (Vancocin) and needs to be reported promptly? a) Muscle stiffness. b) Vertigo. c) Tinnitus. d) Ataxia.
Tinnitus. Explanation: The client should report tinnitus because vancomycin can affect the acoustic branch of the eighth cranial nerve. Vancomycin does not affect the vestibular branch of the acoustic nerve; vertigo and ataxia would occur if the vestibular branch were involved. Muscle stiffness is not associated with vancomycin.
A nurse is preparing to administer digoxin (Lanoxin) elixir to a client. Which principle regarding this medication is correct? a) Liquid digoxin should be measured with a calibrated dropper or syringe. b) The adult therapeutic level for digoxin is 2 to 3 mg/ml. c) Digoxin shouldn't be administered if the client's heart rate is below 100 beats/minute or lower. d) Although serious, digoxin toxicity isn't life-threatening.
a. The adult therapeutic level for digoxin is 0.5 to 2 ng/ml (1.0 - 2.6 nmol/L). This narrow therapeutic range makes digoxin toxicity likely, so the nurse must measure liquid preparations with calibrated droppers or syringes. Digoxin toxicity commonly causes life-threatening cardiac arrhythmias. The nurse should hold and notify the physician about digoxin for heart rates below 60 beats/minute.
At what time should the blood be drawn in relation to the administration of the I.V. dose of gentamicin sulfate (Garamycin)? a) 2 hours before the administration of the next I.V. dose. b) 4 hours before the administration of the next I.V. dose. c) 3 hours before the administration of the next I.V. dose. d) Just before the administration of the next I.V. dose.
a. To determine how low the gentamicin serum level drops between doses, the trough serum level should be drawn just before the administration of the next I.V. dose of gentamicin sulfate.
The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a corticosteroid. Which of the following indicates that the client is using the MDI correctly? Select all that apply. a) The client rinses the mouth with water following administration. b) The inhaler is held upright. c) The head is tilted down while inhaling the medicine. d) The client waits 5 minutes between puffs. e) The client lies supine for 15 minutes following administration.
a. b. The client should shake the inhaler and hold it upright when administering the drug. The head should be tilted back slightly. The client should wait about 1 to 2 minutes between puffs. The mouth should be rinsed following the use of a corticosteroid MDI to decrease the likelihood of developing an oral infection. The client does not need to lie supine; instead, the client will likely to be able to breathe more freely if sitting upright.
The nurse is preparing to administer 4 units of regular insulin to a client with type 1 diabetes mellitus. Which of the following equipment does the nurse need to perform the injection? Select all that apply. a) 27-gauge, ½" needle b) Nursing assessment sheet c) 27-gauge, 1" needle d) 22-gauge, ½" needle e) 22-gauge 1" needle f) Medication administration record
a. f.
Which of the following demonstrates that the client needs further instruction after being taught about ciprofloxacin (Cipro)? a) "I may get light-headed from the Cipro." b) "I should let the doctor know if I start vomiting from the Cipro." c) "I shouldn't take an antacid before taking the Cipro." d) "I must drink 1,000 to 1,500 ml of water a day."
a. To reduce the risk of crystalluria, the client should drink 2,000 to 3,000 ml of water a day, not 1,000 to 1,500 ml. The client should not take an antacid before taking Cipro. An antacid decreases the absorption of the Cipro. The client should let the doctor know if vomiting occurs from the medication. The client may get light-headed from the Cipro. If so, the client should not drive a motor vehicle and should contact the physician
The nurse should monitor the surgical client closely for which clinical manifestation with the administration of naloxone (Narcan)? a) Urine retention. b) Bleeding. c) Biliary colic. d) Dizziness.
b.
A nurse is administering I.V. fluids to a dehydrated client. When administering an I.V. solution of 3% sodium chloride, what should the nurse do? Select all that apply. a) Force fluids, especially water. b) Measure the intake and output. c) Evaluate the client for neurologic changes. d) Inspect the jugular veins for distention. e) Insert an indwelling urinary catheter.
b. d. c.
When administering an I.M. injection, the nurse should use the Z-track technique when the medication: a) Is viscous in consistency. b) Is irritating to tissues. c) Takes a long time to absorb. d) Takes effect very quickly.
b. The Z-track technique is used with medications that are irritating to tissues. It allows the medication to be trapped in the muscle and prevents it from leaking back through the tissues
A 14-year-old with rheumatic fever who is on bed rest is receiving an I.V. infusion of dextrose 5% in water administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which of the following times? Select all that apply. a) When the child is sleeping. b) When the child moves in the bed. c) At the beginning of each shift. d) When the child returns from X-ray. e) When the infusion is started.
c, d, e
A nurse inadvertently gives a client a double dose of an ordered medication. After discovering the error, whom should the nurse notify first? a) The pharmacist b) The client c) The prescriber d) The risk manager
c.
After reconstituting a multidose vial of medication, a nurse writes the date and time of reconstitution on the vial label. What else should the nurse write on the label? a) Prescriber's name b) Expiration date of the order c) Strength of the medication d) Route of administration
c.
A client with peripheral vascular disease and chronic obstructive pulmonary disease takes theophylline 200 mg twice daily every day. The physician now prescribes pentoxifylline. To prevent problematic adverse effects, the nurse should monitor the client's: a) Serum cholesterol level. b) Partial thromboplastin time (PTT). c) Theophylline level. d) Digoxin level.
c. Pentoxifylline can potentiate the effects of theophylline and increase the risk of theophylline toxicity. Therefore, the nurse should monitor the client's theophylline level. Pentoxifylline does not interact with digoxin. Pentoxifylline can interact with heparin, and the client's PTT would need to be monitored closely if the client were taking heparin. It does not affect cholesterol levels.
Two days after surgery, a client continues to take hydrocodone 7.5 mg and acetaminophen 500 mg (Lortab 7.5/500). What should the nurse ask the client before administering the pain medication? a) "Have you emptied your bladder?" b) "Is your pain better than before you had surgery?" c) "Where is your pain located?" d) "How long has it been since your last dose?"
c. The nurse should ask the location of the client's pain because Lortab is an opioid, which can be constipating. By the third day, many clients become constipated and are feeling distended, with sharp, cramping pain due to gas, which is treated with ambulation, not more opioids. The client's emptying his bladder should not affect his pain level. The nurse should look at the client's chart to determine when the client's last dose of pain medication was administered, rather than asking the client. The client's statement regarding his pain level before the surgery is not relevant to whether the nurse should administer the Lortab.
A nurse is instructing a client about the use of nitroglycerin patches. The nurse should instruct the client to: a) Use the patch only when chest pain occurs. b) Apply the patch only on alternate days. c) Change the site of the patch every day. d) Remove the patch every night.
d.
A nurse discovers that an I.V. site in a client's hand has infiltrated, causing localized pain and swelling. Which intervention would relieve the client's discomfort most effectively? a) Wrapping the arm in an elastic bandage from wrist to elbow b) Placing an ice pack on the hand c) Administering an as-needed analgesic d) Elevating the hand and wrapping it in a warm towel
d. Elevating the arm promotes venous drainage and reduces edema; applying warmth increases circulation and eases pain and edema. Ice application would relieve pain but not edema. An analgesic wouldn't correct the primary cause of the discomfort. Wrapping the arm above the hand would slow venous return and is contraindicated.
When teaching the client older than age 50 who is receiving long-term prednisone therapy, the nurse should recommend? a) Eat foods that are low in potassium. b) Exercise three to four times a week. c) Take over-the-counter drugs as needed. d) Take the prednisone with food.
d. Nausea, vomiting, and peptic ulcers are gastrointestinal adverse effects of prednisone, so it is recommended that clients take the prednisone with food. In some instances, the client may be advised to take a prescribed antacid prophylactically. The client should never take over-the-counter drugs without notifying the physician who prescribed the prednisone. The client should ask the physician about the amount and kind of exercise because of the need to establish baseline physical values before starting an exercise program and because of the increased potential for comorbidity with increasing age. The client should eat foods that are high in potassium to prevent hypokalemia.
