Hurst Module 1 Q Bank Questions

A client with a diagnosis of heart failure is observed in Fowler's position states, "I can't get my breath". What is the priority intervention for this client? 1. Dangle the client's legs over the side of the bed. 2. Auscultate anterior and posterior lung fields bilaterally. 3. Call respiratory therapy to the room stat to bring an oxygen mask. 4. Administer PRN morphine sulfate 2 mg IVP via existing venous access device.

1. Correct: Since the client is already in a Fowler's position,the correct option would be to "Dangle the client's legs over the side of the bed." The reason is that by dangling the legs, blood is pooling in the periphery. This decreases the circulating blood volume so that the heart does not have to work as hard and blood will then go in a forward direction rather than going backward to the lungs. 2. Incorrect: This is assessment. The question is asking for an intervention. 3. Incorrect: This may take time. Do something to help the client immediately first. 4. Incorrect: The stem does not indicate that the client is experiencing any pain.

What should the nurse monitor when caring for a client post fasciotomy of the arm? 1. Bleeding 2. Capillary refill 3. Color 4. Distal pulses 5. Infection 6. Sensation

1., 2., 3., 4., & 6. Correct: Fasciotomy is a surgical procedure that cuts away the fascia to relieve tension or pressure. So after the procedure, the nurse wants to make certain that pressure has been relieved and circulation distally is good. The nurse will thus need to monitor skin color, capillary refill, distal pulses, and sensation. Since this is a surgical procedure, bleeding will also need to be monitored. 5. Incorrect: Infection can be a complication, however, it will not be an immediate concern.

A community health nurse is planning to discuss how to prevent pesticide ingestion at a local health fair. What should the nurse include in this teaching session? 1. Discard the outer leaves of lettuce. 2. Wash fruits and vegetables with dish soap. 3. Buy organic produce. 4. Peel fruits prior to eating. 5. Dry produce thoroughly with disposable paper towels after washing. 6. Use a scrub brush when washing fresh fruits and vegetables.

1., 3., 4., 5., & 6. Correct: The outer leaves of green, leafy vegetables, such as lettuce and cabbage, should be discarded as pesticide residue likely remains there. Another great idea to reduce overall exposure to pesticides is to buy organic or unsprayed produce. If you can't buy organic, peel fruits and vegetables prior to eating. Washing your fruits and veggies is not enough if you want to reduce the pesticide load you expose yourself to, as it is very important to thoroughly dry them with disposable paper towels as well. This will remove all the remaining pesticide residue and make the produce safer to eat. A scrub brush is very effective in cleaning the crevices and areas around the stem. 2. Incorrect: One of the most common mistakes people make in their attempt to remove all pesticide residue from their produce is that they wash their fruits and vegetables with soap or, even worse, dish soap. Never use detergents, special rinses or soaps of any kind, as this will only do more harm than good. Unless the soap is entirely made of natural and organic materials, it tends to contain harmful compounds that easily penetrate the skin of the fruits, thus doing more harm than the actual pesticides after you ingest them. Simply wash with tap water.

What should the nurse monitor for when caring for a client receiving an IV of 1/2 Normal Saline at 100 mL/hr? 1. Hypertension 2. Fluid volume deficit 3. Hypernatremia 4. Pulmonary edema

2. Correct: 1/2 Normal Saline is a hypotonic solution. Monitor for cellular edema because the fluid is moving out to the cell which could lead to fluid volume deficit and decreased blood pressure. 1. Incorrect: Hypertension can occur with isotonic and hypertonic IV solutions. Hypotension can occur with hypotonic IV solutions such as 1/2 Normal Saline. 3. Incorrect: Hypernatremia can occur with isotonic and hypertonic sodium solutions. 4. Incorrect: This is a nursing alert for hypertonic IV solutions. You must identify 1/2 normal saline as a hypotonic solution. Hypotonic solutions go into the vascular space, hang out for a while to rehydrate the client, then moves into the cell. The cell uses it up for energy. So fluid is then leaving the vascular space, going to the cell. This means the nurse should monitor for cellular edema because the fluid is moving out to the cell which could lead to fluid volume deficit and decreased blood pressure.​

An elderly, confused client with dehydration is admitted to the medical unit. Which intervention would be appropriate for the RN to delegate to the LPN? 1. Encourage client contribution in care decision making. 2. Reinforce the teaching plan with the client's family. 3. Maintain fresh fluids at bedside. 4. Evaluate I & O for adequate fluid replacement.

2. Correct: The LPN can reinforce teaching. 1. Incorrect: The LPN can encourage the client to participate in care decision making. However, the client is confused and is not capable at this time to be involved in their plan of care. 3. Incorrect: This can best be accomplished by the unlicensed assistive personnel (UAP), it can be done by LPN but not best use of resources. 4. Incorrect: Evaluation is a role of the RN, not LPN. LPN can observe and data collect but not assess and evaluate on the NCLEX.

The client presents to the emergency department with nausea, vomiting and anorexia for the last few days. Based on the EKG obtained, what action should the nurse take first? 1. Defibrillate at 200 joules x 2 2. Administer amiodarone IV 150 mg over 10 minutes 3. Infuse 500 mL NS with 40 mEq KCL (40 mmol/L) at 100 mL/hour 4. Begin 2 person cardiopulmonary resuscitation

2. Correct: The one electrolyte we worry about with arrhythmias is potassium. The first line medication is amiodarone. 1. Incorrect: Pulseless v-tach and v-fib require defibrillation. 3. Incorrect: KCL is needed but we need to treat the short run of v-tach first. 4. Incorrect: Not indicated. Treat short run of v-tach and increase potassium. First, note the word FIRST in the question. So all option could be correct, but one takes priority. Next, identify the clues in the question, such as "nausea", "vomiting", and "anorexia". What electrolyte should the nurse worry about when these clues are seen? Low potassium. The client has been vomiting, so the electrolytes losses are potassium, hydrogen, and chloride. The anorexia further complicates the condition because we get potassium from the foods we eat. Knowing this, you would be concerned that ventricular tachycardia or ventricular fibrillation could occur. So, look at the strip. You should have a basic knowledge of interpreting rhythm strips to identify the rhythm shown in the exhibit. This EKG shows short runs of ventricular tachycardia. So what is the first thing the nurse should do for v-tach. Give amiodarone, an antiarrhythmic medication. The question does not say that the client is pulseless, so do not read into the question. Pulseless v-tach would indicate the need for defibrillation. The client probably needs potassium, but correcting the v-tach takes priority. CPR is initiated with pulseless v-tach.

The nurse is reviewing morning laboratory results for multiple clients. Which client laboratory results should the nurse immediately report to the Healthcare provider? 1. Client with chronic obstructive pulmonary disease (COPD) and a PCO2 of 50 mm Hg. 2. Diabetic client with fasting blood sugar of 145 mg/dL (8.0 mmol/L). 3. Cardiac client on furosemide with potassium of 3.1mEq/L (3.1 mmol/L). 4. Client with sepsis and total white blood cell count of 16,000 mm3. 5. Client following a thyroidectomy with calcium level of 8.0 mg/dL (2 mmol/L).

In this case, multiple clients have had morning laboratory tests, the results of which are ALL abnormal! However, because all these clients are hospitalized for various health issues, the nurse would definitely expect some irregularities! But, ask yourself this: are there any results the nurse would NOT expect, or that could be life-threatening to the client? Knowing all these labs are outside of a normal range, you must decide which are worrisome enough to contact the primary healthcare provider. Option 1: Not this one. The client has COPD, which means the arterial blood gas results will always be abnormal! A PCO2 of 50 mm Hg would not be unexpected in this client, even though normal levels are 35-45 mm Hg. The nurse would continue to monitor the respiratory status of this client, so no need to page the primary healthcare provider with this one. Option 2: Not this one either! The big issue with diabetic clients is the on-going battle to control blood glucose levels. You are also aware that since this client is hospitalized, there must be some type of illness, and that will most likely increase blood sugar readings. The nurse will refer to a sliding scale for possible insulin coverage and should compare these results to previous glucose levels. However, because you would expect somewhat elevated blood sugar readings, there is no need for immediate primary healthcare provider intervention. Option 3: Yes, now you should be worried! The information presented indicates this client has a history of cardiac problems and is taking furosemide. You remember that this particular loop diuretic causes the body to excrete potassium in urine; therefore, the potassium levels should be monitored. Also, recall that potassium has a very small normal range of 3.5-5.0 mEq/L, indicating that this client's levels are too low. Potassium can cause big problems for the body, regardless of whether it's too high or too low. In this case, low potassium levels can cause muscle cramps or twitching, leading to muscle paralysis, or worse yet, life-threatening arrhythmias. This is very dangerous for this cardiac client, and the nurse should definitely report this immediately to the primary healthcare provider. Option 4: Let's think about this - the client is septic! You would expect the white blood count to be elevated, even dramatically high, correct? This should not surprise anyone! Even with a lab result nearly double the normal levels, the nurse would not be overly concerned enough to track down the primary healthcare provider. Try again! Option 5: Excellent thinking! Start with what you know and what you expect. We know this client had a thyroidectomy and so you quickly recall what you know: it is a surgical intervention in which the client will have a frontal neck incision, and you also know that initial concerns include airway and bleeding. But what else do we worry about? How about the possibility that a couple parathyroid glands might accidently be removed? So now think what that means: possible hypocalcemia. What do we worry about? Seizure, laryngospasms, aspiration and even arrhythmias as the muscles become tight and rigid. Do you think the primary healthcare provider might worry that this client's calcium level is 8.0.mg/dl, when it should be between 9.0 -10.5 mg/dl? Grab the phone on this one!

A nurse is caring for a client who is on bed rest following admission to the hospital two days ago with a diagnosis of new onset heart failure. While evaluating the client's progress, what assessment findings would indicate to the nurse that further treatment is required? 1. Sacral edema 2. Orthopnea 3. Shiny skin 4. S3 heart sound 5. Heart rate 88/min 6. CVP 8mmHg

1., 2., 3., 4., & 6. Correct: These are all signs of fluid volume excess seen with heart failure. 5. Incorrect: This is a normal heart rate which would indicate the client is improving. Look at the clues in this question: bedrest, new onset heart failure, assessment findings, further treatment needed. So, you are looking for signs and symptoms that indicate heart failure. Treatment has not been successful so signs and symptoms of heart failure will still be present. When a client is in heart failure, the heart muscle is weak, so cardiac output goes down, so perfusion to vital organs goes down, so urinary output goes down. If you are not putting out urine like you used to, where is all the fluid staying? In the vascular space. So which options indicate fluid volume excess? Option 1: True. When a client has been on bed rest for a while the nurse will see sacral rather than ankle edema. Edema is seen with fluid volume excess. When the client has too much fluid in the vascular space it will eventually start to leak out into the tissue causing 3rd spacing. Option 2: True. Orthopnea is an abnormal condition in which the person must sit up or stand to breathe comfortably. This would indicate FVE. When the hear is weak it cannot pump well, so fluid backs up into the lungs. Option 3: True. Edematous skin is extremely stretched to where it appears shiny. Option 4: True. A S3 heart sound is often an indication of heart failure. The third heart sound (S3), also known as the "ventricular gallop", occurs just after S2 when the mitral valve opens allowing passive filling of the left ventricle. The S3 sound is actually produced by the large amount of blood striking a very compliant left ventricle. A S3 can be an important sign of systolic heart failure. Option 5: False. A heart rate of 88/min is normal sinus rhythm. With FVE, expect to see tachycardia. option 6: True. Normal CVP is 2-6 mmHg. This client's CVP of 8 mmHg is high indicating FVE.

Which clinical manifestations would validate to the nurse that a client has developed an electrolyte imbalance due to malabsorption from celiac disease? 1. Numbness 2. Muscle cramps 3. Negative Trousseau 4. Irritable 5. Muscle spasticity 6. Hyperreactivity to sensory stimuli

1., 2., 4., 5., & 6. Correct: Low magnesium is typically due to decreased absorption of magnesium in the gut or increased excretion of magnesium in the urine. Conditions that increase the risk of magnesium deficiency include gastrointestinal (GI) diseases, such as Celiac disease, advanced age, type 2 diabetes, use of loop diuretics, and alcohol dependence. Early signs of low magnesium include nausea, vomiting, weakness, and decreased appetite. As magnesium deficiency worsens, symptoms may include numbness, tingling, muscle cramps, seizures, muscle spasticity, personality changes, dysrhythmias, tremors, hyperactive deep-tendon reflexes, hyperreactivity to sensory stimuli, positive Chvostek and Trousseau signs, tetany, and nystagmus. 3. Incorrect: The client with a low magnesium level will have a positive Trousseau sign.

What independent nursing interventions should the nurse include when planning care for a client who is in a fluid volume excess (FVE)? 1. Monitor Central venous pressure (CVP) 2. Administer diuretic 3. Monitor for orthopnea 4. Raise head of bed (HOB) to 45 degrees 5. Elevate edematous extremities

Correct: 3,4,5 What are independent nursing interventions? Independent nursing interventions are those sanctioned by professional nurse practice acts. They do not require direction or a prescription from another health care professional. Interdependent nursing interventions are actions that are implemented in a collaboration or consultation with other health care professionals. Dependent nursing interventions are those that require an order from other health care professionals. So which options can the nurse initiate without a prescription? What about option 1? Monitor Central venous pressure (CVP). False. This would be considered an interdependent nursing intervention. The primary healthcare provider would have to place the CVP line in order for CVP monitoring to be done. Option 2? Administer a diuretic? False. This is a dependent intervention as a prescription is needed. Option 3? Monitor for orthopnea? Does the nurse need a prescription to do this? No. Does the nurse need to collaborate with anyone to do this? No. So this is a True statement. Option 4? Elevate the HOB? This is true. The nurse can do this independently. A prescription is not needed. Option 5? Elevate edematous extremities? True. No prescription needed here!

What should the nurse who is educating about the most common initial visual changes associated with glaucoma inform the client? 1. Central vision is lost. 2. Progressive tunnel vision occurs. 3. Sudden flashes of light in the eyes. 4. Eye floaters begin to be noticed.

Correct 2 If glaucoma is not diagnosed and treated early, an individual starts to lose peripheral vision, or the area of vision outside the central field of sight. People who have glaucoma experience tunnel vision and cannot see objects to the side, near the head, or by their feet. Central vision can be lost later if the disease progresses. 1. Incorrect: Central vision loss is the classic visual disturbance for macular degeneration but peripheral vision is usually maintained. 3. Incorrect: Individuals experiencing retinal detachment may have sudden flashes of light in the affected eye, but this is not an initial visual change related to glaucoma. 4. Incorrect: Eye floaters are more common in eye disorders such as retinal detachment or may occur associated with the aging process.

Standard orders on the nurse's unit include an intravenous infusion of 0.45 NS 1000 mL with 20 mEq (20 mmol/L) potassium chloride to run at 100 mL per hour. This IV solution would be appropriate for which client diagnosis? 1. Addisonian crisis 2. Hypertension 3. Chronic renal failure 4. Cushing's disease 5. Hypokalemia

The clue included in this stem is potassium IV. Who can SAFELY receive IV potassium. Look at the opposites of Addison's disease and Cushing's disease. Only one causes a decrease in potassium. That is Cushing's disease. With Cushing's disease, there is too much aldosterone. Too much aldosterone causes the retention of too much sodium and water and the elimination of potassium. So option 1 can be eliminated. Option 1: false. With Addison's disease and crisis the client does not have enough aldosterone, so the client loses too much sodium and water and retains too much potassium. This client needs an isotonic solution to keep fluid in the vascular space, but potassium is not needed. Normal saline is an isotonic solution which will go into the vascular space and stay there, increasing vascular volume. More volume means more pressure. Option 2: false. The client with hypertension can be hydrated with a hypotonic solution, such as 0.45 NS. There is no indication that the client needs potassium. Option 3: false. The client will chronic renal failure will have fluid volume retention and hyperkalemia due to poor renal perfusion and low urinary output (UOP). This client does not need potassium. Option 4: true. The client with Cushing's has too much sodium and water and not enough potassium. The potassium is needed for this client. This hypotonic solution will go into the vascular space for hydration, but then will shift to the cells. Option 5: true. The client with a low potassium will need IV potassium.

Which client would the nurse monitor for the development of hypovolemic shock? 1. Admitted with acute myocardial infarction (MI) 2. Post-operative hip replacement with spinal anesthesia 3. Diagnosed with Addisonian crisis 4. A 10 year old with 40% Total body surface area (BSA) burns 5. Admitted with severe vomiting and diarrhea

There are different types of shock, but this question wants you to identify clients at risk for hypovolemic shock (Low blood volume). So, which clients are at risk for low blood volume? Option 1 is false. With MI, think cardiogenic shock. Option 2 is false. With spinal anesthesia, think neurogenic shock. Option 3 is true. With addisonian crisis, the client is losing too much sodium and water from the vascular space which can lead to hypovolemic shock. Option 4 is true. A 10 year old child with 40% burns is considered to have a major burn. With major burns, the client loses fluid from the vascular space because of increased permeability. This sends fluid to the tissues and leads to hypovolemic shock.​ Option 5 is true. The circulating blood in your body may drop with the loss of too many other body fluids. Severe vomiting and diarrhea may cause hypovolemic shock due to this loss of body fluids.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? pH - 7.49 PaCO2 - 29 HCO3 - 24

You need knowledge of ABG interpretation. There are opposites in these options. You need to first decide if the client is in acidosis or alkalosis. So look at the pH of 7.49 (normal 7.35-7.45). This pH indicates alkalosis since it is high. You can eliminate options 1 and 2 since these are acidosis. That leaves options 3 and 4. Which other chemical says alkalosis? The PaCO2 of 29 (normal 35-45) is low which indicates alkalosis. The HCO3 is normal. This means that option 4, respiratory alkalosis is correct. How did this happen? The client must have been breathing too fast, blowing off CO2, an acid. Since the HCO3 is normal, compensation has not begun, so this is uncompensated respiratory alkalosis.