HURST module 1 Quiz
Which information should the community health nurse include when explaining to a group of college students living in a dormitory about receiving an immune globulin (IG) injection for hepatitis A virus (HAV)? 1. Immune globulin contains antibodies that destroy the HAV, preventing infection. 2. Immune globulin protection is permanent, so no other injection is required. 3. Common side effects of the injection include soreness and swelling around the injection site. 4. The sooner you get a shot of IG after being exposed to HAV, the greater the likelihood of protection from the virus. 5. Crowded living environments such as dormitories place people at risk for HAV.
1., 3., 4. & 5. Correct: These are all correct statements about immune globulin for Hepatitis A. 2. Incorrect: IG protection is only temporary, lasting about 3 months. Option 1: True. The client gets the antibodies immediately. Option 2: False. Passive immunity is temporary. Option 3: True. Even if the test taker did not know this, most injections cause some discomfort and swelling at the site. Option 4: True. Antibodies are received immediately with passive immunity, so the client has what it needs to fight off this infection at once. Option 5: True. The most common method of transmission for Hepatitis A is through the fecal/oral route. People living in crowded, confined places are at a higher risk of contracting Hepatitis A. The clues in this question include "immune globulin" and "hepatitis A". You need to know that immune globulin provides passive immunity, which is temporary protection against a disease. When immune globulin is given, the client receives antibodies immediately to fight against the disease. The body does not have to do anything for this protection. This is why it is called passive immunity. In contrast, active immunity provides the client with a small dose of the antigen. The body then has to actively produce the antibodies. It takes several weeks for the client to produce these antibodies. During this time the client is not protected.
A client is admitted for treatment of fluid volume excess. The nurse reviews the admitting lab work and the primary healthcare provider's prescriptions. Which prescription would be of concern to the nurse? LABS: Sodium138 mEq/L (138 mmol/L)Potassium5.4 mEq/L (5.4 mmol/L)Calcium9.0 mg/dL (2.25 mmol/L)Glucose108 mg/dL (6 mmol/L) Doc Prescription: Bedrest 2 gram Na diet Spironolactone 25 mg by mouth once per day Potassium Chloride (KCL) 20 mEq by mouth twice a day 1. Bedrest 2. 2 gram Na diet 3. Spironolactone 4. Potassium Chloride (KCL)
4. Correct: The client has been prescribed spironolactone, a potassium sparing diuretic, so KCL supplement is not necessary. 1. Incorrect: Bed rest induces diuresis, which is good for this client. 2. Incorrect: This client needs to be on a low sodium diet to reduce fluid retention. 3. Incorrect: Spironolactone is a potassium sparing diuretic which can be prescribed for this client.
An adult client has partial and full thickness burns over the anterior trunk and anterior and posterior aspects of both legs. Utilizing the rule of nines, what percentage of the body surface area is burned? Round your answer to the nearest whole number.
The anterior trunk counts for 18% of the body; entire right leg counts 18%; entire left leg counts 18%. Body surface on this client is 54%.
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.
A client has been admitted with a diagnosis of septic shock and has been successfully intubated.The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse? 1. Lung assessment finding 2. Blood pressure reading 3. Elevated temperature 4. Urine description and output
2. Correct: The low blood pressure indicates that systemic tissue perfusion is not adequate. The blood pressure needs to be improved rapidly. 1. Incorrect: The oxygen saturation is 94%, so the adventitious lung sounds do not need immediate intervention. 3. Incorrect: The second priority is to treat the infection that is likely the cause of the temperature elevation and hypotension. 4. Incorrect: This is the likely cause of the sepsis, but the priority is to improve the blood pressure. The second priority is to treat the infection.
The client presents to the emergency department with nausea, vomiting and anorexia for the last few days. Based on 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).
3. & 5. Correct: Although all the laboratory results are outside of standard accepted levels, two particular clients are the most concerning. The cardiac client's potassium level of 3.1 is extremely concerning, since normal potassium levels should be between 3.5-5.0 mEq/L. Hypokalemia can cause muscle weakness and heart arrhythmias, such as PVC's. Secondly, after the client's thyroidectomy, their calcium level is 8.0 mg/dl (normal 9.0-10.5 mg/dl), indicating possible removal of parathyroid glands. Because hypocalcemia places the client at risk for seizures or laryngospasms as well as arrhythmias, the primary healthcare provider needs to be notified immediately so that corrective therapy can be initiated. 1. Incorrect: While this client's PCO2 of 50 is elevated (normal is 35-45 mm Hg), this is neither unexpected or unusual for an individual with COPD. This client will frequently experience elevated levels of PCO2; therefore, the nurse should just continue monitoring for any changes in respiratory status. 2. Incorrect: This diabetic client has a fasting blood sugar of 145, which is elevated above normal levels of 70-110. However, it is not uncommon for diabetics to occasionally have elevated glucose levels, even early in the morning. The nurse can address this issue by referring to the sliding scale for insulin administration. This does not need to be reported immediately to the primary healthcare provider. 4. Incorrect: It is expected that clients diagnosed with sepsis will have extremely elevated white blood cell counts. Despite the fact that this lab result is outside of normal values (4,500 - 10,000 mm3), this level is not concerning enough to immediately contact the primary healthcare provider.