HESI/Saunders Review
A nurse is caring for a client who has just undergone cardioversion. Which of the following interventions is the nurse's priority after this procedure? A) Administering oxygen B) Monitoring the blood pressure C) Administering antidysrhythmic medications D) Monitoring the client's level of consciousness
Answer: A Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and detection of dysrhythmias. The priority nursing intervention here is administering oxygen.
A client with skeletal traction applied to the right leg complains to the nurse of severe pain in the leg. The nurse realigns the client's position, but this intervention does not relieve the pain. Which action would the nurse take next? A) Providing pin care B) Calling the physician C) Removing some of the traction weights D) Medicating the client with the prescribed analgesic
Answer: B Rationale: A client who complains of severe pain may need realignment, or the prescribed traction weights may be too heavy. The nurse realigns the client and, if this is ineffective, calls the physician. The nurse never removes traction weights unless this is specifically prescribed by the physician. Severe leg pain, once traction has been established, indicates a problem. The client should be medicated after an attempt has been made to identify and treat the cause of the pain. Pin care is unrelated to the problem as described.
A nurse is preparing to administer an injection of vitamin K to a newborn. At which site would the nurse select to administer the medication? 1) area of greater trochanter 2) area of the femoral vein 3) lateral aspect of the middle third of the vastus lateralis 4) patellar area
Answer: 3 Rationale: The preferred injection site for the administration of vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle (the newborn's thigh). This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication. Option 1 is the area of the greater trochanter. Option 2 is the area of the femoral vein. Option 4 is the patellar area.
A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should: A) Assess the clear fluid for protein B) Check the clear fluid for the presence of glucose C) Place cotton balls or dry gauze loosely in the ears D) Use an otoscope to assess the tympanic membrane for rupture
Answer: B Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because it will separate into bloody and yellow concentric rings on dressing material, a phenomenon referred to as the halo sign. It also tests positive for glucose. CSF does not contain protein. The presence of CSF indicates a disruption in the integrity of the cranium. Therefore inserting cotton balls, gauze, or an otoscope into the ear puts the client at risk for infection.
A nurse completes an initial assessment of a client admitted to the mental health unit. Which assessment finding is the matter of greatest concern? A) Bruises on the client's neck B) The client's report of not sleeping well C) The client's report of suicidal thoughts D) The spouse's statement "I don't approve of this treatment."
Answer: C Rationale: The client's verbalized thoughts are extremely important. The verbalization of suicidal thoughts must be incorporated by the nurse into the plan of care. The nurse has the legal responsibility to protect the client from harm. The presence of bruises on the client's neck, the client's report of not sleeping well, and the spouse's statement are concerns to be addressed but are not priority concerns.
Zidovudine (AZT, Retrovir) is prescribed for a client with AIDS. The nurse tells the client that it is important to report back to the clinic as scheduled for follow-up: A) Blood glucose checks B) Blood pressure checks C) Complete blood counts (CBCs) D) Electrocardiographic (ECG) studies
Answer: C Rationale: Zidovudine is an antiviral medication. Common side effects include agranulocytopenia and anemia. The nurse carefully monitors CBC results for these changes. With early infection or in the client who is asymptomatic, a CBC is usually performed monthly for 3 months, then every 3 months thereafter. In clients with advanced disease, a CBC is usually performed every 2 weeks for the first 2 months and then once a month if the medication is tolerated well. This medication does not affect the blood glucose level, blood pressure, or cardiac status.
A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in my head say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority concern for this client? A) Ineffective coping skills B) Perceptual disturbances C) Chronic low self-esteem D) Risk for self-directed violence
Answer: D Rationale: The altered perceptions and cognitive distortions experienced by the client with schizophrenia put the client at risk for self-harm. A fundamental responsibility of the nurse is to provide a safe environment for this client and others. Although ineffective coping skills, disturbed perceptual ability, and low self-esteem may be appropriate concerns, the risk for self-directed violence is the priority.
A nurse caring for a client with AIDS is monitoring the client for signs of complications. Which of the following findings would cause the nurse to suspect infection with Pneumocystis jiroveci? Select all that apply. A) Diarrhea B) Tachypnea C) Pedal edema D) Intermittent fever E) Dyspnea when ambulating F) Expectoration of frothy mucus
Answer(s): B, D, E Rationale: Pneumocystis jiroveci pneumonia is a very common and severe opportunistic infection affecting the client with AIDS. Clinical manifestations include dyspnea, nonproductive cough, intermittent fever, fatigue, anorexia, weight loss, and tachypnea. Persons with advanced disease may exhibit crackles, decreased breath sounds, and cyanosis. Diarrhea and pedal edema are not associated with this infection.
A nurse provides dietary instructions to the mother of a child with iron-deficiency anemia. The nurse should tell the mother that the food highest in iron is: A) Milk B) Cheese C) Orange juice D) Cream of Wheat
Answer: D Rationale: Foods high in iron include liver, dried beans, Cream of Wheat, iron-fortified cereal, apricots and prunes (and other dried fruits), egg yolks, and dark-green leafy vegetables. Milk and cheese are high in calcium. Orange juice is high in vitamin C.
A nurse provides instructions to a pregnant woman about foods that contain calcium. Which of the following foods does the nurse recommend? Select all that apply. A) Cheese B) Yogurt C) Spinach D) Sardines E) Shellfish
Answer: A, B, D Rationale: Calcium is essential for fetal skeleton and tooth formation. The body also uses calcium to maintain maternal bone and tooth mineralization during pregnancy. Therefore adequate intake of calcium is of utmost importance for the bone health of both mother and fetus. Cheese, sardines (and other fish eaten with bones left in), and yogurt are good sources of calcium. Shellfish are a good source of zinc and green leafy vegetables (except spinach and Swiss chard) are good sources of calcium. Spinach is a good source of iron and many vitamins.
A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at the nursing unit, the nurse should first: A) Ask the client to sign a no-harm contract B) Ask the client to report any suicidal thoughts immediately C) Place the client under suicide precautions with 15-minute checks D) Check the dressings that were placed over the client's wrists in the emergency department
Answer: D Rationale: The nurse would first assess the physical status of the client. Therefore, the first nursing intervention is to check the dressings that have been placed over the client's wrists. The nurse would also immediately implement one-to-one suicide precautions (not 15-minute checks) for the client who has attempted suicide. The client would be asked to sign a no-harm contract, but this would not be the first action. Asking the client to report any suicidal thoughts immediately is a component of a no-harm contract.
A physician prescribes morphine sulfate, gr 1/8 intramuscular stat, for a client with cancer. The medication ampule reads, "Morphine sulfate 10 mg/mL." How many milliliters of medication does the nurse prepare to administer the correct dose?
Correct Responses 0.75 .75 Rationale: It is necessary to convert gr 1/8 to mg. After converting grains to milligrams, use the formula to calculate the correct dose. Formula: Desired/Available X Tablet = Tablets per dose 75mg/10mg X 1ml= 7.5/10= 0.75 or .75
A nurse is providing dietary instructions to a pregnant client with diabetes mellitus. The nurse tells the client that: A) Fat intake must be increased to ensure that the baby gains weight B) A high-protein, high-fat diet is necessary to help control the blood glucose level C) Glucose must be increased in the diet because additional calories are needed during pregnancy D) It is important to increase fiber in the diet to help control the blood glucose level and prevent constipation
Answer: D Rationale: An increase in calories is needed with pregnancy, but additional glucose should be avoided because it may cause hyperglycemia. Approximately 50% to 60% of the total calories should be carbohydrate, at least 250 g/day. Protein intake should constitute 12% to 20% of the total kilocalories. Twenty percent to 30% of the daily caloric intake should come from fat, with no more than 10% saturated fats. High-fiber foods will cause the blood glucose level to rise more slowly by delaying gastrointestinal absorption. High-fiber foods also aid in the prevention of constipation.
A client is receiving parenteral nutrition (PN) solution at 60 mL/hr by means of infusion pump through a subclavian central line. The client calls the nurse and complains of difficulty breathing and chest pain. The nurse notes that the client's pulse rate is increased, the blood pressure has dropped, and oxygen saturation is 89%. Use the number 1 to denote the first action and the number 4 the last. ~ Placing the client in lateral Trendelenburg position on the left side ~ Clamping the PN infusion catheter ~ Obtaining an electrocardiogram (ECG) ~ Notifying the physician
The correct order is: 1) Clamping the PN infusion catheter 2) Placing the client in lateral Trendelenburg position on the left side 3) Notifying the physician 4) Obtaining an electrocardiogram (ECG)Rationale: One complication of subclavian central line insertion is embolism, air or thrombus. Signs and symptoms include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. On auscultation, the nurse would hear a loud churning sound over the pericardium. If this sign is detected, the PN infusion catheter is immediately clamped and the client placed in a lateral Trendelenburg position on the left side, which helps trap the air in the apex of the ventricle and prevents its ejection into the pulmonary arterial system. The physician would be notified. An ECG may be obtained, but this would not be the immediate action.
A client who was recently sexually assaulted is self-contained and calm. The client says to the nurse, "It doesn't seem real." Which defense mechanism is the client using? A) Denial B) Projection C) Rationalization D) Intellectualization
Answer: A Rationale: Denial is a common reaction by a victim of sexual assault. This defense mechanism is an adaptive and protective reaction. Projection is blaming or scapegoating. Rationalization is justifying unacceptable attributes. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking.
A nurse provides information to a pregnant client about foods that are high in iron. Which food, suggested by the client after this discussion, indicates that the client requires further instruction? A) Spinach B) Tomatoes C) Lima beans D) Whole-grain bread
Answer: B Rationale: Foods that are high in iron include red meat, whole-grain bread and cereals, lima beans, raisins, spinach, and broccoli. Tomatoes are high in vitamin C.
A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through an internal arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse implement in caring for the client? Select all that apply. A) Assessing the radial pulse in the right extremity B) Using the left arm to take blood pressure readings C) Drawing predialysis blood specimens from the left arm D) Assessing the area over the AV fistula for a bruit and thrill each shift E) Placing a pressure dressing over the site after each dialysis treatment F) Administering intravenous (IV) fluids through the venous site of the AV fistula as needed
Answer(s): A,B,C,D Rationale: Several precautions must be observed to ensure the function of an internal AV fistula. The nurse assesses the fistula, and the distal portion of the extremity, for adequate circulation; checks for a bruit and a thrill by means of auscultation or palpation over the access site; monitors the radial pulse in the extremity; and avoids taking blood pressure readings or drawing blood from the arm with the AV fistula. Venipuncture is avoided in the extremity bearing the AV fistula. Blood is never drawn from the AV fistula, and the AV fistula is not used for the administration of IV fluids. The AV fistula site is not covered with a pressure dressing after dialysis.
A client with a manic disorder monopolizes group therapy. What should the nurse leading the group say to the client? A) "Leave the room." B) "Go to the nurses' station until our group therapy session is finished." C) "I will recommend that group therapy be eliminated from your treatment plan." D) "Thank you for your comments. Now, try to stop talking and listen to the others."
Answer: D Rationale: When a client is monopolizing the group, it is important for the nurse to be direct and decisive and set constructive limits. The best action is to acknowledge the client's input and then suggest that the client stop talking and try listening to others. Having the client leave the room, sending the client to the nurses' station until the group therapy session is finished, and eliminating group therapy from the client's treatment plan are all inappropriate interventions.
A nurse is caring for a client with preeclampsia who suddenly progresses to an eclamptic state. In which order should the nurse perform the following actions? Use the number 1 to denote the first action and the number 5 the last. ~Administering oxygen by way of face mask ~Turning the woman on her side ~Beginning an intravenous (IV) infusion of magnesium sulfate solution ~Assessing the maternal blood pressure ~Contacting the physician
The correct order is: Turning the woman on her side Administering oxygen by way of face mask Contacting the physician Assessing the maternal blood pressure Beginning an intravenous (IV) infusion of magnesium sulfate solution Rationale: If a client has a seizure (eclampsia), the initial nursing action is ensuring a patent airway. This is done by turning the woman on her side, because a side-lying position permits greater circulation through the placenta and helps prevent aspiration. The nurse must remain with the woman and press the emergency bell for assistance. Applying oxygen is not useful if the client's airway is blocked, so this would be done after the client has been turned. The physician would be notified, vital signs assessed, and a magnesium sulfate infusion started per the physician's prescription.
A nurse is providing care to a client with a closed chest tube drainage system. When the nurse assists the client in turning onto his side, the chest tube is accidentally dislodged from the insertion site. The nurse must immediately: A) Contact the physician B) Reinsert the chest tube C) Turn the client onto his back D) Apply pressure over the chest tube insertion site
Answer: D Rationale: If a chest tube is dislodged from the insertion site, the nurse immediately applies pressure over the insertion site and covers the site with sterile gauze. The nurse then performs a respiratory assessment and contacts the physician. The nurse does not reinsert a chest tube, because this is outside the nurse's scope of practice. The physician will reinsert the chest tube if this is necessary. The head of the client's bed should be elevated to facilitate breathing.
A nurse provides instruction to a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which statement by the client indicates a need for further instruction? Select all that apply. A) "I should limit activity as much as I possibly can." B) "If I have trouble breathing, I need to call the doctor." C) "I need to drink lots of fluids to keep my mucus thin." D) "I can apply Vaseline to my nose if the oxygen dries it out." E) "I should wear a scarf over my nose and mouth in cold weather." F) "If I get a flu shot, I don't have to worry about being around people with colds."
Answer(s): A, D, F Rationale: Clients with COPD should be encouraged to keep up their daily activities as much as possible to help prevent muscle wasting and maintain activity tolerance. An occupational therapy consult may be useful in helping the client learn how to perform activities in ways that conserve energy. Oxygen is drying to the membranes of the nose, but the client should apply a water-soluble lubricant (K-Y Jelly) to the inside of the nose to reduce dryness and cracking rather than petroleum jelly (Vaseline), which could be inhaled. Every client with COPD should be encouraged to get a yearly flu vaccination, but because of the increased risk of infection, the client must still avoid crowds and people with infections. The remaining options are appropriate home care measures.
A nurse is evaluating outcomes for a client with Guillain-Barré syndrome. Which of the following outcomes does the nurse recognize as optimal respiratory outcomes for the client? Select all that apply. A) Normal deep tendon reflexes B) Improved skeletal muscle tone C) Absence of paresthesias in the lower extremities D) Clear sounds in the lower lung fields bilaterally E) Po2 of 85% and Pco2 of 40 mm Hg
Answer(s): D,E Rationale: Satisfactory respiratory outcomes include clear breath sounds on auscultation, clear mentation, spontaneous breathing, normal vital capacity, and normal arterial blood gases. The ABG results listed here — a Po2 of 85% and a Pco2 of 40 mm Hg — are normal. The presence of normal deep tendon reflexes, improved skeletal muscle tone, and absence of paresthesias in the lower extremities reflect improvement in the symptoms associated with Guillain-Barré but are not specific to a respiratory outcome.
A nurse assesses the chest tube drainage system of a client who has undergone surgery and notes intermittent bubbling in the water seal chamber. One hour later, the nurse notes the presence of continuous bubbling in the chamber. On the basis of this finding, the nurse would first check: A) The chest tube connection sites B) For bubbling in the suction-control chamber C) The amount of drainage in the collection chamber D) The amount of suction being applied to the chest tube system
Answer: A Rationale: Continuous bubbling in the water seal chamber indicates that air is leaking into the drainage system or pleural cavity. The nurse must locate the source of the air leak and would first check all of the chest tube connection sites. If a break in the tubing or a loose connection is found, the nurse tightens the connection or seals the break with tape. The remaining options are unrelated to continuous bubbling in the water seal chamber.
A child with osteosarcoma who required amputation of a lower limb is experiencing phantom limb pain. The nurse attempts to comfort the child by explaining that: A) The pain is a normal, temporary condition Correct B) The pain occurs because nerves have been cut C) This pain will go away once a prosthesis is used D) Pain medication may be needed for life to alleviate the discomfort
Answer: A Rationale: Phantom limb pain is a temporary condition that some people who undergo amputation experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the client. The child should be reassured that the condition is normal. Numerous pharmacological agents are available to help ease postoperative neurogenic pain. Pain medication is not needed for life. The incorrect options will not provide comfort to the child.
A client has just been found to have deep vein thrombosis (DVT) of the right leg. Which of the following interventions does the nurse immediately implement? A) Elevating the foot of the bed 6 inches B) Placing ice packs on and under the right leg C) Documenting the need for hourly calf measurements D) Performing passive range-of-motion exercises of the right leg
Answer: A Rationale: Standard therapy for DVT consists of bed rest, leg elevation, and application of warm, moist heat to the affected leg. Elevation of the legs decreases venous pressure, which in turn relieves edema and pain. The client may have calf measurements prescribed once per shift or once per day, but they would not be obtained hourly. Placing ice packs on and under the right leg is incorrect, because heat, not cold, is usually prescribed. Passive range-of-motion exercises of the right leg would be dangerous to the client because activity after clot formation can cause pulmonary embolus.
A nurse performing an otoscopic examination of an adult client: A) Uses a small speculum to decrease the discomfort B) Pulls the pinna up and back before inserting the speculum C) Tilts the client's head forward before inserting the speculum D) Pulls the earlobe down and back before inserting the speculum
Answer: B Rationale: The correct procedure for performing an otoscopic examination is to pull the pinna up and back and to visualize the external canal while slowly inserting the speculum. The nurse tilts the client's head slightly away and holds the otoscope upside down as if it were a large pen. A small speculum may not provide adequate visualization of the ear canal and is more appropriate for use in a pediatric setting.
A nurse is performing an initial assessment of a pregnant adolescent client with diabetes mellitus. The client says to the nurse, "I've stopped my insulin and cut back on my food." Which client concern does the nurse recognize as the priority? A) Concern about gaining weight B) Concern about getting stretch marks C) Concern about being able to care for the infant D) Concern about what her friends might think about her wearing maternity clothes
Answer: A Rationale: The decrease in nutritional intake during the pregnancy will place the mother and fetus at risk. Because she is diabetic, the mother is at risk for ketoacidosis, which can be harmful to the fetus. Also, deficiencies of specific nutrients, such as folic acid, may produce fetal anomalies. Body image disturbance is a problem for this client; however, nutrition is a higher priority. Most adolescent mothers are not developmentally, emotionally, psychologically, or financially prepared for the responsibilities of parenthood, but this is a concern that may be addressed as a later time, for it does not put the fetus or the mother at immediate risk.
A nurse is assessing a client during her first prenatal visit to the clinic. The nurse takes the client's temperature: 100.8° F. Which of the following actions on the part of the nurse is appropriate? A) Notifying the physician B) Documenting the temperature C) Retaking the temperature rectally D) Informing the client that a temperature of 100.8 °F is normal during pregnancy
Answer: A Rationale: The normal temperature during pregnancy is 98° to 99.6° F (36.2° to 37.6° C). A higher temperature requires physician notification, because it may indicate an infection that requires medical management. The temperature would be documented, but this is not the most appropriate action, because the temperature is abnormal. Taking the temperature rectally is an unnecessarily invasive way of reassessing the client's temperature. The nurse could retake the temperature again orally to make sure that the original reading was correct. A temperature of 100.8° F is not normal during pregnancy. Therefore the most appropriate nursing action is notification of the physician.
A nurse stops at the scene of an automobile accident. One of the victims is sitting in the driver's seat, complaining of severe muscle spasms in the neck area. The nurse must first: A) Stabilize the neck area B) Firmly massage the neck area C) Assist the victim out of the automobile and lay the victim on the ground D) Tell the victim that she is leaving to call an ambulance but will be right back
Answer: A Rationale: The presence of muscle spasms after a spinal or head injury may indicate cervical fracture or dislocation. The rescuer must stabilize the affected area and help the client remain still. The client should not be moved. The nurse should remain with the victim and have someone else call for emergency help.
A nurse is assessing a client who has undergone radical neck dissection for the treatment of cancer. The nurse hears this sound when auscultating over the trachea. On the basis of this finding, the priority nursing action is to: A) Contact the physician B) Assess the client's pulse oximetry C) Place the client in a supine position D) Administer a nebulizer treatment with the use of a bronchodilator
Answer: A Rationale: The sound that the nurse hears is stridor. In the immediate postoperative period, the nurse assesses the client for stridor, a high-pitched musical sound heard on inspiration during auscultation over the trachea. This finding is reported immediately because it indicates airway obstruction. The client is placed in the Fowler position to facilitate breathing and promote comfort. Suctioning is performed to remove secretions that cannot be expectorated by the client. Pulse oximetry may be performed, but this is not the priority of the options provided. Administering a nebulizer treatment with a bronchodilator is not indicated at this time.
The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think that the twins should come to the funeral service for their grandfather. What do you advise?" Which response by the nurse would be therapeutic? A) "What do you and your husband believe is the right thing for your children?" B) "By all means have them attend. Keeping them home will only prolong their grief. " C) "I agree with your mother-in-law. Just tell your children that their grandfather is in heaven." D) "It's a difficult decision, but given their young age, maybe it would be best to keep them home from the wake and just let them attend the funeral."
Answer: A Rationale: The therapeutic response is the one that encourages open expression of feelings and empowers the grieving relative. Values, beliefs, and practices will differ with the client's ethnic and spiritual background, and the nurse should not push a decision based on his or her own belief system. The remaining options are nontherapeutic responses because the nurse is agreeing with or advising the mother.
A nurse on the telemetry unit is caring for a client who has had a myocardial infarction and is now attached to a cardiac monitor. The nurse, monitoring the client's cardiac rhythm, notes the rhythm depicted in the image. Which of the following nursing actions should the nurse take? (Rhythm is continuous up and down in pic) A) Calling the rapid response team B) Preparing the client for cardioversion C) Asking the client to bear down and cough D) Preparing to administer diltiazem (Cardiazem)
Answer: A Rationale: This pattern indicates ventricular fibrillation (VF). Clients who have sustained a myocardial infarction are at great risk for VF. With the onset of VF the client feels faint, then immediately loses consciousness and becomes pulseless and apneic. There is no blood pressure, and heart sounds are absent. The goals of treatment are to terminate VF promptly and convert it to an organized rhythm. Because defibrillation is the immediate treatment, the nurse must call the rapid response team and initiate cardiopulmonary resuscitation. The client would not be able to bear down or cough. Cardioversion is a synchronized countershock that may be performed in emergencies for unstable ventricular or supraventricular tachydysrhythmias or electively for stable tachydysrhythmias that are resistant to medical therapies such as the administration of diltiazem (Cardiazem).
A man calls the emergency department and tells the nurse that he sustained a bee sting on his leg while working in his yard. The client states that he is not allergic to bees and wants to know how to treat the sting. The nurse tells the client to first: A) Place a cool compress on the sting site B) Apply an antipruritic lotion to the sting site C) Apply a topical corticosteroid to the sting site D) Take an oral antihistamine such as diphenhydramine (Benadryl)
Answer: A Rationale: Treatment for a bee sting depends on the severity of the reaction. Mild reactions are treated with elevation, cool compresses, antipruritic lotions, and oral antihistamines. Rings, watches, and restrictive clothing are removed. In this situation, there is no information to indicate that the client is experiencing a severe reaction, so the nurse would first tell the client to apply a cool compress to the sting site. More severe reactions are treated with intravenous antihistamines such as diphenhydramine, subcutaneous epinephrine, and corticosteroids.
A nurse is caring for the client who begins to exhibit seizure activity while in bed. Which of the following actions does the nurse implement to care for the client? Select all that apply. A) Observing and timing the seizure B) Loosening any restrictive clothing C) Turning the client's head to the side D) Removing the pads on the side rails E) Inserting an airway into the client's mouth F) Removing objects that might injure the client from the vicinity
Answer: A, B, C, F Rationale: Client safety is a priority for the client experiencing a seizure. Nursing actions during a seizure include providing privacy, loosening restrictive clothing, removing the pillow, raising the padded side rails on the bed, removing objects that might cause injury to the client, and placing the client on the side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. (The nurse should not insert anything into the client's mouth.) The nurse also observes, documents, and times the seizure. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head against injury; and moves furniture that may injure the client if he or she were to come in contact with it during the seizure.
A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that she felt a large gush of fluid from her vagina on the way to the hospital. The nurse detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that the umbilical cord is protruding from the vagina. Which of the following actions should the nurse perform? Select all that apply. A) Placing the woman in knee-chest position B) Administering oxygen at 2 to 4 L/min by nasal cannula C) Administering terbutaline (Brethine) to stop contractions D) With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part E) Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline solution
Answer: A, D, E Rationale: When the umbilical cord is protruding, one of the first interventions the nurse should perform is to relieve compression of the cord by exerting upward pressure on the presenting part with two gloved fingers inserted vaginally. The cord must be protected from drying out and from becoming compressed. Therefore it should be wrapped with towels soaked in warm, sterile normal saline solution. The client is placed in an extreme Trendelenburg or modified Sims position or knee-chest position to ease compression. Oxygen should be administered by way of face mask at a rate of 8 to 10 L/min. A physician's prescription is needed for terbutaline, but this medication is usually not given in these circumstances.
A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my coffin." Which response by the nurse is therapeutic? A) "Do you think that having asthma will kill you?" B) "You seem very distressed at learning that you have asthma." C) "I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'" D) "Asthma is a very treatable condition, but it's important to learn how to properly administer your medications. Let's practice with your inhalant."
Answer: B Rationale: A clients who has learned that he or she has a chronic illness may exhibit denial, anger, or sarcasm because of the fear associated with such illnesses. It is important for the nurse to convey an accepting attitude as a means of enhancing mutual respect and trust. Stating, "You seem very distressed at learning that you have asthma" paraphrases the client's words and focuses on the client's feelings. "Do you think that having asthma will kill you?" reflects and paraphrases the client's words but is somewhat sarcastic. "Asthma is a very treatable condition, but it's important to learn how to properly administer your medications. Let's practice with your inhalant" lectures the client and does not deal directly with expressed concerns. "I'm not going to work with you if you can't view this as a challenge rather than as a 'nail in your coffin'" is punitive, threatens the client, and sarcastically quotes the client's words.
A nurse performing a fundal assessment after a vaginal birth notes that the fundus is above the umbilicus and displaced from the midline. What should the nurse do first? A) Massage the fundus B) Help the client void C) Document the findings D) Help the client ambulate
Answer: B Rationale: After a vaginal birth, the fundus should be firmly contracted and at or near the level of the umbilicus. If the uterus is above the expected level or displaced from the midline position (usually to the right), the bladder may be distended. The nurse would help the client void and then reassess the location of the fundus. Fundal massage is indicated if the fundus is difficult to locate or is soft or boggy. Ambulation is not appropriate. Although the nurse would document the findings, the most appropriate initial action would be to help the client void.
After a nonimmunocompromised client undergoes a Mantoux test for tuberculosis (TB) infection, an area of induration 6 mm wide develops. The client asks the nurse what this result means. The nurse's best response is: A) "We'll have to repeat the test, because the result is inconclusive." B) "The swollen area is small, so that means your test result is negative." C) "You've been exposed to tuberculosis, so you'll need to have a chest x-ray." D) "You need to get started on medication right away, because you've got tuberculosis."
Answer: B Rationale: An area of induration of less than 10 mm is considered a negative result. An area of induration (not redness) measuring 10 mm or more in diameter 48 to 72 hours after injection in a client without immunosuppressive disease indicates exposure to and possible infection with TB. A reaction of 5 mm or greater is considered positive in immunocompromised individuals. A positive reaction does not mean that active disease is present but instead indicates exposure to TB or the presence of inactive (dormant) TB. Further testing, including a chest x-ray and sputum culture, would be required if the reaction were positive.
A nurse is caring for a hospitalized child with newly diagnosed type 1 diabetes mellitus who received NPH and regular humulin insulin at 7:30 am. At 11 am the child suddenly complains of dizziness, headache, and a shaky feeling. The nurse immediately: A) Contacts the physician B) Gives the child milk to drink C) Arranges to have the child's lunch tray delivered early D) Prepares to administer intravenous 5% dextrose solution
Answer: B Rationale: Dizziness, headache, and a shaky feeling are signs of hypoglycemia. A blood glucose reading will confirm the diagnosis and would be the initial action. However, because this is not one of the options, the nurse would give the child milk to drink because of the child's history and current symptoms indicating hypoglycemia. Other items used to treat hypoglycemia include orange juice and hard candy. The nurse would prepare to administer intravenous 5% dextrose solution if the child were not responsive enough to safely take oral fluids, but this is not indicated in the question. Arranging to have the child's lunch tray delivered early is inappropriate because the child should eat meals at basically the same time each day to achieve the best control of the diabetes. Contacting the physician would not be the immediate action.
A female client is examined in the clinic, and gonorrhea is diagnosed. The nurse provides information to the client about the disease and tells the client that: A) Condoms will not help prevent transmission of the infection B) Healthcare providers are legally responsible for reporting all cases of gonorrhea to the health authorities C) It is not necessary for sexual partners to be examined, because the disease is not highly communicable D) Treatment includes the administration of an antibiotic, but it is not necessary for sexual partners to be treated
Answer: B Rationale: Gonorrhea is caused by the aerobic Gram-negative diplococcus Neisseria gonorrheae. It is almost exclusively transmitted by way of sexual contact. Gonorrhea is a reportable communicable disease; healthcare providers are legally responsible for reporting all cases of gonorrhea to the health authorities, usually the local health department of the woman's county of residence. Gonorrhea is highly communicable. Recent sexual partners (past 30 days) should be examined, cultures performed, and treatment with the appropriate regimen provided. Women are counseled to have their partners use condoms.
A nurse is caring for a client in labor who is receiving an oxytocin (Pitocin) infusion. The nurse notes that the client is experiencing uterine hypertonicity. The nurse should immediately: Contact the physician Stop the oxytocin infusion Correct Check the client's blood pressure Place the client in a side-lying position
Answer: B Rationale: If uterine hypertonicity or a nonreassuring fetal heart pattern occurs, the nurse must intervene to increase fetal oxygenation. The oxytocin infusion is stopped immediately and the infusion rate of the nonadditive IV solution is increased. The client is placed in a side-lying position, and oxygen is administered with the use of a snug face mask at 8 to 10 L/min. The physician is notified of the adverse reactions, the nursing interventions implemented, and the client's response to the interventions. The client's blood pressure is monitored closely.
During a preoperative assessment, a nurse notices the client is crying. In light of this observation, which statement by the nurse is appropriate? A) "You seem upset. Would you rather be alone?" B) "You're crying. Tell me more about how you are feeling." C) "Your surgeon is the best and has done many of these operations." D) "Crying before a serious operation is common, but everything will be okay."
Answer: B Rationale: Taking time to discuss the client's concerns is as important a nursing action in many instances as any intervention for physical care. Therapeutic communication in this situation involves focusing on the client's nonverbal cues and encouraging the client to express feelings or concerns about surgery. Changing the subject and avoiding the client are techniques that also block communication with the client. False reassurance also blocks communication with the client.
A client with diabetes mellitus who is scheduled to have blood drawn for determination of the glycosylated hemoglobin (HbA1C) level asks the nurse why the test is necessary if he is performing blood glucose monitoring at home. The nurse tells the client that this test is used specifically to: A) Detect diabetic complications B) Assess long-term glycemic control C) Determine whether the client is at risk for hypoglycemia D) Determine whether the prescribed insulin dosage is adequate
Answer: B Rationale: The HbA1C reading provides an indication of glycemic control over the preceding 3 months. An HbA1C value of less than 7% indicates good glycemic control. When increases in the blood glucose occur, some glucose molecules attach themselves to red blood cells (RBCs) and remain there for the life of the RBCs. Therefore a high value on this test is correlated with a high blood glucose level, indicating poor long-term control of blood glucose, which often leads to the development of complications in the client with diabetes mellitus. The other options are not purposes for this test.
A nurse provides home care instructions to an adolescent with sickle cell disease about measures to prevent vaso-occlusive crisis. The nurse should tell the adolescent to: A) Restrict fluid intake B) Take ibuprofen (Motrin) for discomfort C) Take acetylsalicylic acid (aspirin) immediately if a fever develops D) Be sure to spend plenty of time in the fresh air and sun each day
Answer: B Rationale: The adolescent with sickle cell disease is advised to take acetaminophen (Tylenol) or ibuprofen (Motrin) if discomfort occurs. The use of aspirin is avoided. The adolescent is instructed to contact the physician if a fever develops. Dehydration is avoided, and the adolescent is instructed to consume adequate fluids. Cold and heat stress and prolonged exposure to the sun are avoided because they can cause dehydration, which may precipitate a crisis.
A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent autonomic dysreflexia (hyperreflexia). Which of the following interventions does the nurse incorporate into the plan to prevent this complication? A) Keeping a fan running in the client's room B) Keeping the linens wrinkle-free under the client C) Limiting bladder catheterization to once every 12 hours D) Avoiding the administration of enemas and rectal suppositories
Answer: B Rationale: The most frequent causes of autonomic dysreflexia are a distended bladder and impacted feces in the rectum. Straight catheterization should be performed every 4 to 6 hours, and the Foley catheter should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize risk in these areas.
An HIV-positive child is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The laboratory results show the CD4+ as 1000 cells/mm3. Which of the following nursing actions is appropriate? A) Contacting the physician B) Administering the vaccine C) Asking the laboratory to repeat the CD4+ test D) Informing the child's mother that the vaccine must not be administered at this time
Answer: B Rationale: The normal CD4+ count is 500 to 1600 cells/mm3. Because this child's CD4+ count is 1000 cells/mm3, the nurse would administer the vaccine. Contacting the physician, asking the laboratory to repeat the CD4+ test, and telling the mother that the vaccine should not be administered at this time are all incorrect in light of the results of the CD4+ count.
A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his belongings from where he always kept them. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic? A) "I know just how you feel, because I lost my husband last summer." B) "It's OK to grieve and be angry with your daughter and anyone else for a time." C) "You need to focus on the many good years you enjoyed together and move on." D) "I know it's a troubling time for you, but try to focus on your children and grandchildren."
Answer: B Rationale: The therapeutic statement is the one that gives the client permission to grieve and acknowledges that anger is part of loss and that it may be aimed at the people who are trying most to help and are closest. "I know just how you feel, because I lost my husband last summer," "I know it's a troubling time for you, but try to focus on your children and grandchildren," and "You need to focus on the many good years you enjoyed together and move on" are all nontherapeutic and do not encourage the client to express her feelings.
As a nurse is providing care, the client suddenly experiences a tonic-clonic seizure. The nurse would immediately: A) Call the physician B) Turn the client to the side C) Restrain the client's limbs D) Insert an airway in the client's mouth
Answer: B Rationale: When a client experiences a seizure, the nurse must immediately turn the client to the side and protect the client from injury. The nurse would maintain the client's airway and suction the client as needed but would not place an airway in the client's mouth. The physician is also notified, but turning the client to the side is the immediate action. Restrictive clothing is loosened, but restraints are not applied, because this could result in injury to the client.
A primigravida is admitted to the labor unit. During assessment, the client's membranes rupture spontaneously. What is the priority nursing action? A) Checking the amniotic fluid B) Checking the fetal heart rate C) Assessing the contraction pattern D) Preparing for immediate delivery
Answer: B Rationale: When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Assessing the contraction pattern and amniotic fluid may also be a part of the assessment, but neither is the priority action. There is no information to indicate that immediate delivery is necessary at this time.
Which of the following infection-control measures would the nurse implement for a client in whom smallpox is diagnosed? Select all that apply. A) Enteric B) Droplet C) Contact D) Standard E) Protective isolation
Answer: B, C, E Rationale: Smallpox is transmitted from person to person in infected aerosols and air droplets spread by way of face-to-face contact with an infected person after fever has begun, especially if the infected person is also coughing. The disease can also be transmitted in contaminated clothes and bedding, although the risk of infection from this source is much lower. Therefore droplet and contact precautions are necessary. Standard precautions are implemented for the care of all clients. Enteric precautions are implemented if the infectious agent is transmitted by way of contact with feces. Protective isolation is implemented when the client is neutropenic and needs to be protected from infection.
A nurse is preparing client assignments for the day. Which assignments would be appropriate for a registered nurse who is pregnant? Select all that apply. A) A client with active herpes virus lesions in the perianal area B) A client who requires frequent abdominal wound irrigations C) A client with a solid sealed implanted radiation source who is restricted to bed rest D) A client with methicillin-resistant Staphylococcus aureus (MRSA) under contact precautions E) A client undergoing mechanical ventilation through a tracheostomy who requires frequent suctioning
Answer: B, D, E Rationale: Pregnant nurses should not care for clients with solid sealed implanted radiation sources. The client emits radiation while the implant is in place, and the ionizing radiation could have a damaging effect on the fetus. Likewise, pregnant nurses should not care for any client with herpes lesions, because the virus may damage the fetus. There are no contraindications to assigning the other clients to a pregnant nurse.
A rubella titer is performed on a woman who has just been told that she is pregnant. The results of the titer indicate that the mother is not immune to rubella. The nurse tells the client that: A) A therapeutic abortion should be considered B) Immunization against rubella is required immediately C) Immunization against rubella is required after delivery D) Antibiotics will be prescribed to prevent the infection
Answer: C Rationale: A rubella titer is performed to determine the pregnant client's immunity to rubella. If the titer is less than 1:8, the woman is not immune. The client is then immunized after delivery. Because the vaccine contains live virus, the client should not be immunized during pregnancy. Antibiotics are not prescribed. Counseling the client on therapeutic abortion is incorrect.
A nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. On assessing of the client, the nurse notes an apical pulse rate of 58 beats/min and the client complains of anorexia and nausea. Which action should the nurse take first on the basis of these assessment findings? A) Contacting the physician B) Administering an as-needed antiemetic C) Checking the most recent digoxin level D) Administering the digoxin with an antacid
Answer: C Rationale: Anorexia and nausea are two of the symptoms most commonly associated with digoxin toxicity. The nurse should withhold the digoxin until the physician has been consulted if the pulse rate is slower than 60 beats/min, because bradycardia is also an indication of digoxin toxicity. The nurse then checks the most recent digoxin level, which will provide additional data to report to the physician — a key follow-up nursing action. The nurse would not administer an antiemetic without further investigating the client's problem.
A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would expect to note documentation of: A) Refusal to suck Incorrect B) Frequent diarrhea C) Recurrent otitis media D) Inability to pass stools
Answer: C Rationale: GER is regurgitation of gastric contents back into the esophagus. The three types of GER are physiologic, functional, and pathologic. Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of GER. Refusal to suck, diarrhea, and inability to pass stools are not associated with GER.
An emergency department nurse is caring for an older client who may have been physically abused by her caregiver. In planning care for the client, the nurse makes a priority of: A) Notifying the police department B) Obtaining psychiatric help for the caregiver C) Contacting adult protective services to investigate the situation D) Telling the caregiver that he or she is not allowed to care for the client
Answer: C Rationale: If physical abuse or neglect is suspected, the priority nursing actions are to assess the client, treat any physical injuries, and ensure that the client is safe. Once these measures have been taken, referral to adult protective services is appropriate. The nurse also notifies the physician. Although there are laws requiring healthcare professionals to report suspected elder abuse to local authorities, calling the police at this point is premature. Telling the caregiver that he or she is no longer allowed to care for the client could trigger aggressive behavior on the part of the caregiver. Although the nurse may be involved in obtaining psychiatric assistance for the caregiver, this is not the priority action.
A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. The first action on the part of the nurse is: A) Calling the physician B) Inserting an oral airway C) Turning the client on her side D) Noting the time of the seizure
Answer: C Rationale: If seizure activity occurs, the nurse remains with the client and presses the emergency bell for assistance. The client is turned on her side because a side-lying position permits greater circulation through the placenta and helps prevent aspiration. The nurse then notes the time and sequence of the seizure. The physician is notified that a seizure has occurred, because this is an obstetric emergency associated with cerebral hemorrhage, abruptio placentae, severe fetal hypoxia, and death. No object should be placed in the client's mouth during a seizure. An airway may be inserted after the seizure, and the client's mouth and nose are suctioned to prevent aspiration. Oxygen may be administered by way of face mask during the seizure to increase oxygenation of the placenta and all maternal organs.
A nurse reviewing the record of a child with suspected acute poststreptococcal glomerulonephritis notes that the child recently had a streptococcal throat infection that was treated with antibiotics. Which of the following physician prescriptions that will confirm the presence of acute poststreptococcal glomerulonephritis does the nurse expect to find? A) Throat culture B) Blood urea nitrogen (BUN) C) Antistreptolysin (ASO) titer D) White blood cell (WBC) count
Answer: C Rationale: Immunologic studies are important in diagnosing acute poststreptococcal glomerulonephritis. The ASO titer, which indicates the presence of antibodies to streptococcal bacteria, may be increased. Culture of the throat may be helpful in isolating the bacterium, but this test is only useful if the infection is recent and the child has not received antibiotics. The BUN level would be increased if renal insufficiency was present. The WBC count is usually normal. Throat culture, BUN and WBC count would not confirm the presence of acute poststreptococcal glomerulonephritis.
A client who is delusional says to the nurse, "Terrorists have been sent here to kill me." How should the nurse respond to the client? A) "No one is going to kill you." B) "Your medication is making you feel like this." C) "Are you worried that people are trying to hurt you?" D) "What makes you think that terrorists were sent to hurt you?"
Answer: C Rationale: It is most therapeutic for the nurse to empathize with the client's experience. Disagreeing with delusions may make the client more defensive and cause the client to cling to the delusions even more strongly. Medication may be prescribed to reduce the occurrence of delusions, but it does not cause the delusions. Encouraging discussion regarding the delusion is inappropriate.
In caring for a child admitted to the hospital with Kawasaki disease, the nurse should monitor the child most closely for signs of: A) Anemia B) Renal failure C) Thrombus formation D) Gastrointestinal disturbances
Answer: C Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is an acute febrile exanthematous illness of children with a generalized vasculitis of unknown origin. A generalized immune response affects the smooth muscle cells of the vascular walls. These vascular changes, along with the increase in platelets that occurs as part of the disease, can cause thrombus formation, myocardial infarction, and death in some children. Anemia, renal failure, and gastrointestinal disturbances are not specifically associated with this disorder.
A nurse provides information to the mother of a child with diarrhea about signs and symptoms that indicate the need to call the physician. Which statement by the mother indicates the need for further instruction? A) "I'll call the doctor if she gets dizzy and acts sick." B) "I'll call the doctor if she has severe stomach cramps." C) "I'll call the doctor if her temperature is 102° or higher." D) "I'll call the physician if she goes longer than 6 hours without urinating."
Answer: C Rationale: The mother should call the physician if a fever higher than 100° F, especially one that persists for more than 72 hours, develops. The mother should not wait until the temperature reaches 102° F. The remaining statements are all accurate because the findings indicate possible dehydration and hypovolemia. Additionally, severe abdominal cramps could indicate the presence of an acute problem.
A clinic nurse reviews the record of a pregnant client and notes that the physician has documented that the client exhibits the Hegar sign. The nurse understands that: A) Fetal movement is being felt by the mother B) A soft blowing sound can be heard when the uterus is auscultated C) Softening and compressibility of the lower uterine segment has been detected D) The client is experiencing irregular painless contractions during the pregnancy
Answer: C Rationale: Softening and compressibility of the lower uterine segment, occurring around the sixth week of pregnancy, is called the Hegar sign. Quickening, or fetal movement, is not perceived until the second trimester. Braxton Hicks contractions are irregular painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. A soft blowing sound, corresponding to the maternal pulse, that is auscultated over the uterus is known as uterine souffle. This sound is the result of blood circulation to the placenta and corresponds to the maternal pulse.
A nurse provides home care instructions to a client who has been fitted with a halo device to treat a cervical fracture. Which statement by the client indicates the need for further instruction? A) "I need to get more fluids and fiber into my diet." B) "I should cut my food into small pieces before I eat." C) "I need to put powder under the vest twice a day to prevent sweating." D) "I have to check the pin sites every day and watch for signs of infection."
Answer: C Rationale: The client should cleanse the skin under the lambs-wool liner each day to prevent rashes or sores. Powder or lotions should be used only sparingly or not at all because they may cake, resulting in skin irritation. The client should increase intake of fluid and fiber to help prevent constipation. Food should be cut into small pieces to facilitate chewing and swallowing. The client should also use a straw for drinking. The pin sites should be checked daily for signs of infection.
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes an audible wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. After immediately disconnecting the suction source from the catheter, which intervention does the nurse implement next? A) Calling a code B) Administering an inhaled bronchodilator C) Connecting oxygen to the suction catheter D) Encouraging the client to take deep breaths
Answer: C Rationale: The inability to remove a suction catheter is a critical situation. This finding, along with the client's symptoms presented in the question, indicates bronchospasm and bronchoconstriction. The nurse must immediately disconnect the suction source from the catheter but leave the catheter in the trachea. The nurse then connects the oxygen source to the catheter, because the client is at risk for hypoxia. The physician is notified and will most likely prescribe an inhaled bronchodilator. The nurse also prepares for emergency resuscitation if this situation occurs during suctioning. The client will be unable to take deep breaths. There is no information in the question indicating the need to call a code.
A nurse responds to an external disaster in a large city involving an explosion at a shopping mall. Numerous victims require treatment. Which victim will the nurse attend to first? A) A victim with multiple bruises who is alert and oriented B) A victim who has sustained multiple lacerations with minor bleeding Incorrect C) A victim who is alert and wandering around yelling that he cannot see D) A victim with a crush injury to the abdomen who has no pulse or blood pressure
Answer: C Rationale: The nurse determines which victim will be attended to first on the basis of the acuity level of the victims involved in the disaster. The victim who must be treated immediately because of the threat to life, limb, or vision is categorized as emergent and is the priority. The victim who requires treatment but whose life, limb, or vision is not threatened if care can be provided within 1 to 2 hours is considered urgent and is the second priority. Victims who require evaluation and possible treatment but for whom time is not a critical factor are categorized as nonurgent and are the third priority. A victim who is deceased after sustaining multiple serious injuries is not the priority.
A nurse on the day shift receives the client assignment for the day. Which assigned client will the nurse assess first? A) A client who has been fitted with a closed chest tube drainage system B) A client with a nasogastric tube who underwent bowel resection 2 days ago C) A client who was admitted during the night because of congestive heart failure Correct D) A client on nothing-by-mouth (NPO) status who is scheduled for a barium enema at 10 a.m.
Answer: C Rationale: The nurse would first assess the client who was admitted during the night because of congestive heart failure. This client's problem is directly related to airway, breathing, and circulation, and the nurse would need to determine that the interventions administered on admission and during the night were effective. The nurse would next assess the client who has been fitted with a closed chest tube drainage system. This client's problem also involves airway; however, there is no indication that this client is experiencing any acute problems. The nurse would next assess the client with a nasogastric tube who underwent bowel resection 2 days ago to ensure that the client is comfortable and that the nasogastric tube is functioning. The nurse would then assess the client scheduled for a barium enema to ensure that this client understands the reason for the diagnostic test.
A postpartum nurse is caring for a client who had a placenta previa. Which nursing intervention does the nurse, reviewing the plan of care, identify as the priority for this client? A) Fundal assessment B) Monitoring of urine output C) Frequent assessment of lochia D) Inclusion of iron in every meal
Answer: C Rationale: The placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding even when the fundus is firm. The nurse may first see an increase in lochia as a sign of hemorrhage. The nurse then must assess the client carefully for signs of deficient fluid volume as a result of postpartum hemorrhage. This assessment includes urine output and fundal assessment however these are not the priority. Dietary intake of iron is not related specifically to placenta previa.
A contraction stress test is scheduled, and the nurse provides instructions to the client regarding the test. Which of the following pieces of information should the nurse give to the client? Select all that apply. A) An internal fetal monitor is attached. B) The client will walk on a treadmill until contractions begin. C) A positive test result indicates a need for further evaluation. D) Special body movements will be performed to stimulate contractions. E) The client may be asked to massage one or both nipples to stimulate uterine contractions.
Answer: C, E Rationale: A contraction stress test is used to assess placental oxygenation and function, determine the fetus' capacity to tolerate labor, and determine fetal well-being; it is performed if the nonstress test result is abnormal. The fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract either with the administration of a dilute dose of oxytocin (Pitocin) or by having the mother stimulate the nipples until three palpable contractions with a duration of 40 seconds or more in a 10-minute period have been achieved. Frequent maternal blood pressure readings are taken, and the client is monitored closely if increasing doses of oxytocin are given. A positive contraction stress test result indicates that the fetus may be compromised and requires continued monitoring and further evaluation. A negative result indicates fetal well-being.
A client in a manic state emerges from her room and quickly enters the dayroom. She announces to the group that she is the star of a burlesque show and will begin her performance shortly. The priority nursing action is to: A) Ask the client to go to her room and to change her clothes B) Tell the client firmly that burlesque shows are not allowed in the nursing unit C) Tell the client that her bathroom privileges are being suspended because of her behavior D) Quietly and firmly assist the client to her room and help her dress in appropriate clothes
Answer: D Rationale: A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety in the client. Taking a quiet, firm approach while distracting the client (i.e., walking her to her room and helping her dress appropriately) achieves the goal of preserving her psychosocial integrity. Suspending the client's bathroom privileges because of behavior, having the client change her clothes and telling the client that burlesque shows are not allowed in the nursing unit will all increase the client's anxiety.
A client's arterial blood gases (ABGs) are analyzed: pH 7.49, Paco2 31 mm Hg, Pao2 97 mm Hg, HCO3- 22 mEq/L. Which of the following acid-base disturbances does the nurse identify from these results? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis
Answer: D Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH greater than 7.45. Respiratory acidosis is present when the Paco2 is greater than 45 mm Hg; respiratory alkalosis is present when the Paco2 is less than 35 mm Hg. Metabolic acidosis is present when the HCO3- is less than 22 mEq/L; metabolic alkalosis is present when the HCO3- is greater than 26 mEq/L. This client's ABG results are consistent with respiratory alkalosis.
A nurse on the day shift is assigned to care for four clients. Which client will the nurse assess first after receiving report from the night shift? A) A client scheduled for an electrocardiogram (ECG) at 11 am B) A client on nothing-by-mouth (NPO) status who is for bronchoscopy at 9 am C) A client who has undergone above-the-knee amputation who is scheduled for discharge home D) A client who had a seizure at 2 a.m. and was treated with intravenous (IV) diazepam (Valium) and phenytoin (Dilantin)
Answer: D Rationale: Airway is always a high priority, and the nurse must first assess the client who had a seizure during the night and was treated with IV diazepam (Valium) and phenytoin (Dilantin). The nurse would next assess the client scheduled for bronchoscopy to ensure that the client understands the test. The client scheduled for discharge would be assessed third for discharge needs, followed by the client scheduled for an ECG.
A pregnant client complains of heartburn, and the nurse provides instruction regarding measures to alleviate the problem. The nurse tells the client to: A) Lie down right after meals B) Take antacids as often as necessary C) Eat three meals a day and avoid eating between meals D) Sleep with an extra pillow under the head and shoulders
Answer: D Rationale: Heartburn is caused by the regurgitation of gastric acid into the esophagus. Self-care for heartburn includes eating small frequent meals, avoiding fatty or spicy foods, remaining upright for 30 minutes after eating, sleeping with an extra pillow under the head and shoulders, and drinking approximately 2000 mL of fluid per day. The client should not be advised to take antacids as often as necessary; some antacids are high in sodium and may cause fluid retention and electrolyte imbalances. Some antacids are high in calcium and may provide relief, but they may also cause rebound hyperacidity. The physician should be consulted if heartburn is not relieved with nonpharmacological measures.
A nurse is monitoring the neurological status of a client who underwent craniotomy 3 days ago. Which of the following signs or symptoms would prompt the nurse to notify the surgeon immediately? A) Disorientation to date B) Pupils equal and reactive at 4 mm C) Mild headache relieved by codeine sulfate Incorrect D) Pain with forward flexion of the neck onto the chest
Answer: D Rationale: One of the complications of cranial surgery is meningitis. Signs of meningeal irritation include nuchal rigidity, which is characterized by a stiff neck and soreness and is especially noticeable when the neck is flexed. Pupils that are equal and reactive at 4 mm are normal. Mild headache relieved by codeine sulfate is an expected finding at this point after craniotomy. Disorientation to date is not the matter of greatest concern when the client has been hospitalized for cranial surgery.
A nurse is caring for client with increased intracranial pressure (ICP). In which position should the nurse maintain the client? A) Supine, with the head extended B) Side-lying, with the neck flexed C) Supine, with the head turned to the side D) Head midline and elevated 30 to 45 degrees
Answer: D Rationale: The client with increased ICP should be positioned with the head in a neutral midline position. It is the responsibility of the nurse to ensure that all those delivering care to the client maintain the proper positioning. The client should avoid flexing or extending the neck or turning the neck side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positioning promotes venous drainage from the cranium to keep ICP down.
A nurse performs a bedside glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 35 mg/dL. The nurse would first: A) Ask the mother to breastfeed the newborn Incorrect B) Bottle-feed the newborn with diluted glucose C) Start an intravenous line for the administration of glucose D) Ask the laboratory to perform a blood glucose test immediately
Answer: D Rationale: The normal blood glucose level in a newborn is 40 mg/dL or higher. Glucose levels of less than 40 to 45 mg/dL measured with bedside glucose screening should be reported and verified in the laboratory. Although feeding is an intervention, the result of a bedside glucose must be verified by the laboratory. Some infants need IV glucose to maintain glucose balance and prevent damage to the brain.
A nurse is monitoring a client in precipitous labor. The nurse would contact the physician on noting: A) Fetal descent of 1 cm/hr B) A reassuring fetal monitoring pattern C) Cervical dilation of 2 to 4 cm/hr during the active phase D) Shortening periods of uterine relaxation between contractions
Answer: D Rationale: The nurse would contact the physician if inadequate relaxation were noted between contractions. This situation could interfere with the transfer of oxygen and nutrients to the fetus through the placenta. All of the other options are normal findings.
