Hurst Practice Questions
In what position should the nurse place a client post lumbar puncture? 1. Reverse trendelenburg 2. Prone 3. Side-lying 4. Supine HOB elevated 45 degrees
2. Correct. Post lumbar puncture, the client should lie flat or preferably prone for 4-8 hours so that a seal will form at the puncture site. 1. Incorrect. What position is reverse trendelenburg? Trendelenburg is head down and legs up. Reverse trendelenburg is HOB up and feet down. Not the position we want this client to be placed. 3. Incorrect. Not side-lying. Flat or prone so that a seal will form. 4. Incorrect. Do not elevate the HOB for 4-8 hours.
What medication, given to help mature fetal lungs, does the nurse anticipate giving after admitting a client in preterm labor? 1. Magnesium sulfate 2. Terbutaline 3. Betamethasone 4. Nifedipine
3. Correct: Betamethasone, a steroid, is given IM to help the fetal lungs mature. 1. Incorrect: Magnesium Sulfate is given IV because it relaxes the uterus in an effort to stop contractions. 2. Incorrect: Terbutaline is given SQ because it relaxes the uterus in an effort to stop contractions. 4. Incorrect: Nifedipine is given PO because it relaxes the uterus in an effort to stop contractions.
The charge nurse on a surgical unit is assigning tasks to an LPN float nurse. What client(s) would be most appropriate for the LPN? Select All That Apply 1. Client with Gardner-Wells tongs scheduled for pin care. 2. Client needing straight-cathed for a stat urine sample. 3. Client to be ambulated following open cholecystectomy. 4. Client requiring sterile dressing change to left wrist burn. 5. Client with total laryngectomy due for trach care this shift.
1, 2 and 4. CORRECT. An LPN can perform tasks on a stable client, as long as the task does not require any assessment of that client. The LPN can perform sterile pin care on stable clients with any form of long-term traction such as Gardner-Wells tongs. Obtaining a urine sample by straight-cathing a client is also within the LPN's scope of practice. Sterile dressing changes on burns can be performed by an LPN, though the RN should indicate any need to view or assess the wound before the LPN redresses the site. 3. INCORRECT. A client needing post-operative ambulation could indeed be accompanied by an LPN. However, despite the open cholecystectomy, the client could also be ambulated by a UAP so the LPN can be utilized for a more complex task. 5. INCORRECT. Tracheostomy care must be completed by an RN because of the potential for tracheal suctioning, as well as the need to assess lung sounds before and after the procedure.
An RN has delegated several tasks to be completed before end of shift. What delegation "right" was violated by the nurse? Select All That Apply 1. LPN asked to obtain stat vital signs on client reporting chest pain. 2. UAP asked to remove foley catheter prior to client discharge. 3. UAP assigned to empty and measure fluid in client urinal. 4. LPN instructed to check drainage in client's closed drainage unit (CDU) for amount. 5. UAP ordered to obtain finger-stick blood sugar on client at four pm.
1, 2 and 4. CORRECT. The rights of delegation include the right task, right circumstances, right person and the right direction followed by the right supervision or evaluation. The RN has made several errors in utilizing correct delegation principles. A client reporting chest pain is considered unstable and should not be assigned to the LPN, even for vitals. Removal of invasive lines cannot be assigned to a UAP, which includes removal of a foley catheter. Chest tube drainage should be evaluated by an RN in order to assess color, consistency and amount during the shift. 3. INCORRECT. The UAP is qualified to empty a urinal or bedpan as part of assisting clients with ADL's and can also measure the amount of fluid at that time. Both task and individual meet the correct "rights" of delegation. 5. INCORRECT. Blood glucose levels obtained by Accu-check, also referred to as finger stick, can be performed by a UAP and reported to the LPN or RN. The nurse has provided specific details on how and when the task needs accomplished, which meets the criteria for correct delegation.
What action should the nurse take when caring for a client who has a subarachnoid screw? 1. Keep connections tight. 2. Use clean technique when caring for screw. 3. Clean daily with hydrogen peroxide. 4. Maintain a wet to dry dressing around site.
1. Correct. In order to prevent infection, all connections should be tight. We do not want leaking of the CSF. 2. Incorrect. Aseptic technique should be used when cleaning the screw insertion site in order to prevent infection. 3. Incorrect. Sterile normal saline can be used to clean the area around the site. 4. Incorrect. Dressings should be dry and intact. Wet to dry dressings are used as a method of debridement.
A nurse is hired to address quality improvement at a long-term care facility. The nurse quickly notes several legal issues requiring intervention and correction. What situation noted by the nurse represents the greatest legal or ethical risk in the facility? 1. A LPN regularly leaves pills in client's room for client to take after meals. 2. The UAP refills the water pitcher for a client on fluid restrictions. 3. Staff asks family members to assist in turning an obese client. 4. The UAP loosens trach ties at bath-time to apply cream on neck.
1. CORRECT. All the situations have the potential to become problematic. However, leaving medications unattended in a client's room violates multiple protocols as well as legal issues. The nurse must witness the client actually ingesting medication to legally sign off the drug as 'given'. Also the nurse should observe the client in case of accidental choking. Unattended pills could easily be ingested by someone other than the designated individual, or the client may simply throw the medication away. 2. INCORRECT. All staff should have been clearly instructed regarding the client's fluid restrictions. However, filling the pitcher does not necessarily mean the client drank the extra fluid. The nurse is responsible to instruct staff on any type of client restrictions. A sign noting fluid restrictions could be placed above the bed without violating HIPAA regulations as long as no name appears on the sign. 3. INCORRECT. Regardless of whether a client is obese, family should never be asked to assist staff in moving or positioning an individual. Family is neither properly trained nor covered by facility insurance for personal injury. Even if family offers to assist, the staff should utilize only other staff members. 4. INCORRECT. The UAP is never permitted to untie or loosen trach ties for any reason. If the client needs, or requests, cream to the neck area, the RN can do so during trach care. If the back of the client's neck is irritated, the RN can also address that issue with proper interventions.
When giving report to the on-coming staff, the night nurse reports a chaotic shift with short-staffing. Later, the day nurse finds multiple uncompleted tasks. What task is most concerning to the charge nurse? 1. A dose of narcotic medication not signed off. 2. A prescribed wound specimen not collected. 3. Primary healthcare provider not notified of abnormal lab results. 4. A finger stick blood sugar not obtained.
1. CORRECT. There are multiple concerns when any medication is not properly recorded, and particularly a narcotic medication. Because of the legalities involved with Schedule II or III drugs, narcotics are tracked and accounted for by two nurses. In this instance, the drug was not acknowledged, making it difficult to determine when, or even if, the client received the medication. 2. INCORRECT. Not obtaining or sending a prescribed wound specimen may delay possible treatment by an extra day, based on how soon the nurse completes this task. However, it is possible the primary healthcare provider may compensate for this issue by ultimately changing the medication or dose ordered when lab results arrive. 3. INCORRECT. While this has the potential to be serious, there is not enough data provided. Abnormal results could be life-threatening or minimal enough to require no intervention. No determination can be made. 4. INCORRECT. The primary healthcare provider will be notified of the missed blood glucose level. The action determined will depend on whether a glucose level has been obtained since the missed level, or if the primary healthcare provider prescribes a stat level now. However, there is a more serious issue.
A mom two days post delivery reports abdominal pain while breast feeding her newborn. What should the nurse tell the client? 1. "You are getting a surge of oxytocin when you breast feed." 2. "I need to let the doctor know that you need a pelvic exam." 3. "Lie down so I can massage your fundus." 4. "You cannot have pain medication while you are breast feeding."
1. Correct: Afterpains are common for the first 2 to 3 days and will continue to be common if the mother chooses to breast feed. Every time she nurses the baby, she is going to get a surge of oxytocin, which makes the uterus contract. 2. Incorrect: A pelvic exam is not necessary. Afterpains are common after delivery for 2-3 days. Longer if mom is breast feeding. 3. Incorrect: You do want to massage the fundus and check fundal hight while the client is in the hospital. However, the clues in the question indicate a surge of oxytocin while breast feeding. This is normal, so you can relieve mom's anxiety. 4. Incorrect: The afterpains can be severe, so mom's may receive pain medication while breast feeding.
A 7 month old infant is brought to the emergency department with a sudden onset of inconsolable crying and currant jelly-like stools. The infant is drawing up the knees toward the abdomen and grimacing. What diagnosis should the nurse anticipate? 1. Intussusception 2. Hirschsprung's Disease 3. Pyloric Stenosis 4. Meconium Ileus
1. Correct: Intussusception is a condition in which a piece of the bowel telescopes in on itself, forming an obstruction. This causes a sudden onset of cramping and abdominal pain. The client tends to be inconsolable and draws the knees upward in response to the pain. The stool may appear normal at first and then currant jelly-like stools may be noticed as blood and mucus become mixed with the stool. 2. Incorrect: Hirschsprung's disease, known as aganglionic megacolon is a congenital anomaly in which there is an absence of nerves in a portion of the bowel, typically the sigmoid colon. This results in mechanical obstruction. Here, you would see constipation and abdominal distention. If stools are passed, they are often ribbon-like that have a foul smell. 3. Incorrect: Pyloric Stenosis is a condition in which there is enlargement of the pylorus. Symptoms include projectile vomiting due to the pressure that increases in the stomach as a result of the inability of the food to pass through the enlarged pylorus to the small intestine. 4. Incorrect: Meconium ileus is a bowel obstruction that results when the first infant stools (meconium) are thicker and stickier than normal. This blockage typically occurs in the ileum of the small intestines, and the cause of most cases of a meconium ileus in infants is cystic fibrosis.
A 7 month old is being evaluated in the emergency department for a possible head injury following a reported fall from the parent's bed. What would the nurse consider when evaluating the fontanels for evidence of increased intracranial pressure? 1. The anterior fontanel should be open at 7 months of age. 2. The anterior fontanel closes at 2 to 4 months of age. 3. The posterior fontanel should be open at 7 months of age. 4. The posterior fontanel closes at 4 to 6 months of age.
1. Correct: The anterior fontanel closes between 12 to 18 months of age. The nurse could assess the anterior fontanel in this 7 month old with a normal finding being soft and flat. A bulging anterior fontanel would be indicative of increased intracranial pressure. 2. Incorrect: The anterior fontanel does not close until 12 to 18 months of age. Closure before this time would be considered premature closure which could affect brain growth. 3. Incorrect: The posterior fontanel should be closed in this client. The posterior fontanel is expected to close at 2 to 3 months of age. Therefore, the posterior fontanel would not be useful for assessing for increased intracranial pressure in this 7 month old. 4. Incorrect: The posterior fontanel closes at 2 to 3 months of age, not 4 to 6 months, and would be expected to be closed in this 7 month old infant.
A client in her third trimester comes to the clinic for a routine prenatal visit. The nurse notes a weight gain of 4 pounds (1.8 kg) in a week. What action should the nurse take? 1. Check urine for protein. 2. Educate on proper weight gain during pregnancy. 3. Notify the primary healthcare provider. 4. Send client to the labor and delivery unit.
1. Correct: We are worried about pre-eclampsia, so we need to check the client's BP and check urine for protein. 2. Incorrect: If the client's BP and urine are ok, then you can educate the client about proper weight gain. 3. Incorrect: It is a little premature to notify the primary healthcare provider. Let's check some things first. 4. Incorrect: Again, let's check the client out some more first.
The nurse is teaching a client diagnosed with mastitis about treatment. The client states she wants to continue breast feeding. What interventions should the nurse include? Select All That Apply 1. Get plenty of bed rest. 2. Wear a support bra. 3. Place chilled cabbage leaves on breasts. 4. Take antibiotic prior to breast feeding. 5. Offer the unaffected breast first at each feeding. 6. Take cool showers to relieve breast discomfort.
1., & 2. Correct: Treatment for mastitis includes bed rest. And of course they're going to want a support bra. Because they are going to be engorged. 3. Incorrect: Binding the breast and the use of cabbage leaves will relieve engorgement but they are only used if breast feeding is being discontinues permanently. 4. Incorrect: The antibiotic should be taken right after feeding the baby so that the baby does not get much of the antibiotic. 5. Incorrect: If mom is nursing the baby and has mastitis, she should always offer the affected breast first. This will ensure that all the milk is emptied from the affected breast. 6. Incorrect: Mom should take hot showers. This will cause the breast to leak which will help relieve pressure and soften the breast.
The nurse is performing a neurological assessment on an adult client suspected of having a traumatic brain injury (TBI). Which signs/symptoms would indicate to the nurse that the client's ICP is increasing. Select All That Apply 1. Projectile vomiting 2. Narrowing pulse pressure 3. Delay in verbal response 4. DTR: left 2+/4+, right 2+/4+ 5. (-) Babinski 6. Glasgow Coma Scale Score 13
1., & 3. Correct: Projectile vomiting can occur because the vomiting center in the brain is being stimulated. Anytime you have a head thing and the client begins to vomit, you have to assume that the ICP is going up! With increasing ICP the client's speech may change - it may become slow or slurred. There is a delay in verbal suggestion. In other words, they may be slow to respond to commands. 2. Incorrect: With increasing ICP the client will develop systolic hypertension with a widening pulse pressure. A narrowed pulse pressure is seen with cardiac tamponade. 4. Incorrect: 2+/4+ is normal (active or expected response). 5. Incorrect: We do not want to see a (+) Babinski in the adult. So a (-) Babinski is a good thing. 6. Incorrect: The best possible score is 15 on the Glasgow Coma Scale. We like to see a high number, like 13-15.
The nurse is teaching couples in their final weeks of pregnancy about "Kangaroo Care". What points should the nurse include in this session? Select All That Apply 1. Trust in the newborn is an emotional and physiologic need fulfilled through "Kangaroo Care". 2. "Kangaroo Care" requires skin to skin contact between the newborn and parent. 3. The newborn is held quietly for an hour at least 4 times a day. 4. "Kangaroo Care" will only be encouraged if your newborn is premature. 5. Research shows that skin to skin bonding stabilizes the newborn's heart rate.
1., 2., & 5. Correct: In the infant, trust is an emotional need and a physiologic need. So that makes it a priority. Maslow says that "physiologic needs" come first! Skin to skin contact provides trust through physiologic bonding. Baby is placed skin to skin on mom or dad's chest. Research shows that skin to skin holding stabilizes the infant's heart rate, improves O2 sats, regulates the infant's temp., and conserves the infant's calories. They have even found that the breast can change in temperature to warm or cool the infant. 3. Incorrect: The infant is wrapped inside the parent's shirt or covered with a blanket and the baby is quietly held for an hour at least 4 times a week. 4. Incorrect: The focus of "Kangaroo Care" has been the premature baby, but most hospitals now have this as standard care for all babies.
The nurse is performing a neurological assessment on a client who reports frequent headaches. What question(s) should the nurse ask during this assessment? Select All That Apply 1. "When did the headaches begin?" 2. "What symptoms accompany the headaches?" 3. "Does anything relieve the headaches?" 4. "Does anything make the headaches worse?" 5. "Are you experiencing depression?"
1., 2., 3., & 4. Correct. These are all questions that are part of a focused neurological assessment. You want to inquire about the client's current condition, onset of symptoms, description of symptoms, and associated factors. 5. Incorrect. Keep questions open-ended to gather more data. This is very specific and not the best way to get overall information. A better question would be: "What current and past illnesses have you experienced?"
Which signs/symptoms would lead the clinic nurse to suspect that a client may have bacterial meningitis? Select All That Apply 1. Nuchal rigidity 2. Photophobia 3. (+) Kernig 4. (-) Brudzinski 5. Fever 102.8 F (39.3 C) 6. Reports headache 9/10
1., 2., 3., 5., & 6. Correct. Signs and Symptoms of meningitis include nuchal rigidity, photophobia, a positive Kernig sign, chills and high fever, and severe headache. 4. Incorrect. The Brudzinski sign would be positive.
What interventions should the nurse provide when caring for a client prescribed oxytocin IV? Select All That Apply 1. Label IV bag and IV tubing with oxytocin sticker. 2. Monitor for late decelerations. 3. Position client supine. 4. Piggyback oxytocin at the lowest primary IV site. 5. Provide one on one care.
1., 2., 4., & 5. Correct: Always label both the IV bag with an oxytocin sticker and the IV tubing and ports. Nothing else goes through the tubing and we want it easily identified if it must be stopped. The nurse must monitor for late decelerations while the client is receiving oxytocin. If late decels occur, turn of the oxytocin immediately. Oxytocin is given IVPB at the lowest port so that if it has to be turned off, the client does not get more from the primary IV tubing. Oxytocin is a high risk alert drug. This means there is a high risk of client harm, so never underestimate the problems that can occur with oxytocin administration. The client needs one on one care. 3. Incorrect: The client receiving oxytocin can be placed in any position except flat on their back.
What assessment finding by the nurse would support a client diagnosis of basilar skull fracture? Select All That Apply 1. (+) Halo test 2. Hyper-reflexia 3. Raccoon eyes 4. Battle's sign 5. Kernig sign
1., 3., & 4. Correct. Basilar skull fractures are the most serious fracture. You see bleeding where? Eyes, ears, nose, and throat. So, you will see cerebrospinal rhinorrhea with a (+) Halo test. If you have a bloody spot on the sheet, or wherever, when CSF is present, it will settle out and form a ring or halo around the blood spot. Raccoon eyes, is perioribital bruising which is seen with a basilar skull fracture. Battle's sign or bruising over the mastoid is also indicative of a skull fracture. 2. Incorrect. Hyper-reflexia has to do with deep tendon reflexes.It is not a sign of a basal skull fracture. 5. Incorrect. Think meningitis with Kernig sign.
A client in her first trimester of pregnancy has been attending educational sessions on pregnancy. What statements by the client would indicate to the nurse that client teaching has been successful?Select All That Apply 1. "Good food sources of iron includes spinach, raisins, and dark chocolate." 2. "I will eat at least 40 grams of protein a day." 3. "Taking folic acid will help prevent heart defects from occurring." 4. "Swimming is an acceptable exercise for me while I am pregnant." 5. "I can gain 2 pounds (0.9 kg) per week during my first trimester." 6. "I need to stay out of hot tubs while pregnant."
1., 4., & 6. Correct: Good sources of iron include liver, spinach, lentils, raisins, fortified cereals, dark chocolate, and dried fruits. Walking and swimming are the best exercises for a pregnant woman. Remember, no high impact. We also do not want them to get overheated, so do not let mom get into hot tubes or under heating blankets because this will increase body temperature and can cause birth defects. 2. Incorrect: Pregant women should increase protein intake to 60 grams per day. Here's the deal, normal protein intake is about 40 to 45 grams per day. But when you are pregnant, you have a lot of tissue growth going on in your body, so you need more protein. 3. Incorrect: Folic acid helps to prevent what type of defect? Neural Tube Defects. Spinal bifida or myelomeningocele and anencephaly are the big neutral tube defects. 5. Incorrect: During the entire 1st trimester, the client should gain no more than 4 pounds (1.8 kg).
A facility housekeeper approaches the nurse, reporting their sibling with no advanced directive has been admitted in a coma following a massive stroke. As the client's only family member, the housekeeper requests information on the client's condition and prognosis. What actions by the nurse are most appropriate? Select All That Apply 1. Offer to contact a spiritual leader to provide comfort. 2. Inform housekeeper that you are not the client's nurse. 3. Check the chart data and provide brief update on client. 4. Ask Social Services to help housekeeper with legal issues. 5. Offer to call primary healthcare provider for housekeeper.
1.,4., and 5. CORRECT. There are obvious legal issues which complicate this situation. Though the housekeeper claims to be the only living relative, unless this claim can be legally proven, the nurse cannot verify this information. However, the nurse can still assist the housekeeper or any family member with other needs. Contacting a spiritual leader of choice can be easily accomplished. Even more important is involving Social Services as part of an interdisciplinary team which can assist the housekeeper with multiple needs, including legal requirements to obtain guardianship or power of attorney. It would also be helpful to advise the primary healthcare provider that the housekeeper is the sole relative, and allow that physician to make a determination what to reveal under such dire circumstances. 2. INCORRECT. The nurse's statement may be correct but does not provide the housekeeper with usable information or alternatives to achieve the goal regarding sibling's condition. 3. INCORRECT. HIPAA prohibits accessing charts of client's unless directly involved with the care for that individual. Even if the nurse was assigned to the sibling, it is a violation to share information, even under the unique circumstances described in the scenario.
A new nurse is assigned to address quality improvement on a medical-surgical unit. The nurse is aware what tasks could not be safely completed by a UAP? Select All That Apply 1. Obtain vitals on a client following a colonoscopy. 2. Reinforce teaching for a client awaiting discharge. 3. Feed pureed food to client with left-sided paralysis. 4. Get finger stick on confused client with diaphoresis. 5. Provide ice packs to client with a new long leg cast.
2 and 3. CORRECT. Unlicensed assistive personnel, often referred to as a 'nursing assistant', should be assigned repetitive, uncomplicated tasks on stable clients. These tasks include activities of daily living, routine vital signs and ambulation. The UAP is not able to reinforce teaching because this requires an evaluation of client learning. The client with left-sided paralysis is at risk for aspiration and requires specific knowledge about position during feeding. An LPN or RN should be assigned to feed this client. 1. INCORRECT. Obtaining vitals on a post-procedure client is based on the type of test and potential for complications. A colonoscopy is generally an uncomplicated procedure and the UAP would certainly be able to do vitals on this client. 4. INCORRECT. Getting a blood sugar by finger-stick is within the abilities of a UAP. Even though this client is confused and diaphoretic, this symptom would not preclude obtaining the blood sugar. 5. INCORRECT. Filling and providing ice packs to a client with a cast is within the scope of activities for unlicensed assistive personnel. The nurse would need to provide instruction about placing ice packs to the side of the cast, rather than on top, but this activity can definitely be assigned to the UAP.
The charge nurse is assigning several immediate tasks to on-coming shift personnel. What task should the nurse assign to a licensed nurse only? 1. Reposition a client with a long term Peg tube. 2. Obtain scheduled vital signs during blood transfusion. 3. Assist diabetic client with neuropathy to walk to bathroom. 4. Ambulate client following laparoscopic appendectomy.
2. CORRECT. Blood transfusions present a potential for complications the entire time the blood is transfusing, even though any problems which might occur generally happen in the first 15 minutes. But data collection regarding client response, including skin color, respiratory status and IV site should be assessed during vitals sign monitoring. 1. INCORRECT. Repositioning a client with a Peg tube can be safely accomplished by unlicensed assistive personnel. A Peg tube is secured inside the stomach wall and simply repositioning a client would not create an issue requiring a nurse. 3. INCORRECT. Ambulating a diabetic client requires the same precautions as walking with any individual. Neuropathy may cause pain or numbness to the soles of the client's feet, but the UAP is still capable of ambulating this client safely. A licensed nurse is not required at this time. 4. INCORRECT. A laparoscopy is the process of performing a surgical procedure without cutting open the body. Three or four small holes are created through which instruments are passed, including a camera, allowing the surgery to be completed. Ambulating this client is no different than any other post-operative walk, and therefore can easily be accomplished by the UAP.
When working in a new facility, the nurse identifies several violations of client privacy and confidentiality. What situation should the nurse report immediately to the supervisor? 1. Primary healthcare provider left client chart opened on the desk while completing rounds. 2. Students in teaching hospital observe client care without permission. 3. Staff personnel in an elevator laughing about "crazy guy" on 4th floor. 4. Secretary copying client charts leaves several pages in office copier.
2. CORRECT. Client confidentiality and privacy are guaranteed by both federal and state regulations as well as those principles outlined in the nurse's code of ethics. As a client advocate, the nurse has the responsibility to protect those rights by reporting infractions to the appropriate personnel. An actual violation has occurred when students enter a client's room to observe a procedure without first asking the client's permission. Even though the client is in a teaching hospital, this does not eliminate the client's right to privacy or to refuse to have students present. 1. INCORRECT. Opened and unattended charts represent the potential for confidential information to be viewed by others, including non-medical persons. The potential exists for client information to be seen or used by those not entitled to view such information. Charts should remain closed when not in use. 3. INCORRECT. Such a breach of ethics violates multiple healthcare principles. However, though unprofessional and rude, the staff did not mention a client name or room number. That does not mean there will be no disciplinary action, but actual client details were not revealed. 4. INCORRECT. Leaving client data in a copier violates client privacy and a potential breach of confidentiality. The copy machine is in facility office, not a public location; however, there are individuals within an office which should not have access to those client records.
A client, with a T5 injury, has not had a bowel movement in three days. Today, the client reports a headache rated 10/10. The nurse takes the client's vital signs: BP 180/110, HR 52, RR 20. What action by the nurse takes priority? 1. Administer hydralazine 20 mg IV. 2. Elevate head of bed 45 degrees. 3. Remove impaction with topical anesthetic. 4. Close air vents in the room.
2. Correct. These signs/symptoms should lead the nurse to realize that the client is experiencing autonomic dysreflexia. The priority is to lower the blood pressure by raising the head of the bed to a semi-fowler's position. 1. Incorrect. You may have to give antihypertensive medications, but first elevate the head of the bed. 3. Incorrect. You have to remove the stimuli, but first get that BP down, so the client does not have a hypertensive stroke. 4. Incorrect. Again, drafts can cause autonomic dysreflexia, but the priority is to decrease that BP.
The charge nurse in a psychiatric facility is assigning morning tasks to an unlicensed assistive personnel (UAP). What task should the nurse instruct the UAP to complete first? 1. Accompany client off unit to smoking area. 2. Obtain a morning weight on anorexic client. 3. Assist a client who is depressed to get out of bed. 4. Prepare the day room for group breakfast.
2. Correct: An accurate daily weight is obtained each morning at the same time, on the same scale, in the same clothing. The accuracy of this procedure is particularly critical for the anorexic client and should be performed prior to breakfast. The nurse will also remind the UAP to be particularly vigilant of the client attempting to alter the scale reading, perhaps by hiding an object in a bathrobe pocket. 1. Incorrect: Clients who smoke often request an early morning cigarette, prior to breakfast, and must be accompanied by a member of the staff during that time. Although many facilities are non-smoking, older clients who do smoke are provided with a specific location to do so, but this is not a priority at this time. 3. Incorrect: It is important to help clients who are depressed to participate in daily routines, such as eating breakfast in a group setting. Based on the degree of depression, many clients may also require assistance to even get out of bed and dress. The UAP will need to complete this task before breakfast but it is not the first priority of the morning. 4. Incorrect: It will be important to get the day room ready for group breakfast. However, preparing the dayroom will likely take quite a bit of time and there is a more important task that needs yo be completed prior to breakfast preparations.
The nurse is preparing to perform Leopold maneuvers on a newly admitted laboring client. What should the nurse remember when performing this procedure? 1. Ask the client to drink water prior to the procedure. 2. Perform procedure between contractions. 3. Monitor for heart beat acceleration with fetal movement. 4. Connect client to fetal heart monitor.
2. Correct: If you try to do the maneuvers during a contraction, what are you going to feel? A hard uterus. You're not going to feel the baby. 1. Incorrect: You want to have the client drink water to distend the bladder prior to an ultrasound of the uterus to bring it closer to the surface. For Leopold maneuvers we want the client to void first. A distended bladder can push the uterus to one side. 3. Incorrect: With a non-stress test, you look for two or more acceleration of 15 beats per minute or more with fetal movement. 4. Incorrect: This test does not require the client to be connected to the fetal monitor. What you're doing with Leopold maneuvers is you're palpating around the abdomen trying to find the baby's head, back, booty. Why do I care where the baby's back is? That's where you listen for the fetal heart rate.
A parent voices concern because the 6 year child has not been eating as much in the last 3 months. What response from the nurse would be appropriate? 1. "You need to make the child eat more frequent meals to avoid becoming anorexic." 2. "This is not unusual in this age child because the growth rate has slowed down." 3. "Try providing high calorie foods that the child likes to increase the calories to 3500 per day." 4. "You are just being overly cautious. There is no need to worry about how much the child eats."
2. Correct: Think about normal growth and development here. Remember that the growth rate slows down in the school age child between 6 to 12 years of age. Therefore, they may not seem as hungry as they are during periods of growth spurts. 1. Incorrect: Forcing a child to eat can cause aversions to foods. There is nothing in the stem to indicate that the child is losing an abnormal amount of weight or is showing signs of anorexia. Although it can start this early, anorexia is not a problem that is generally seen in this age child. 3. Incorrect: This 6 year old child needs foods that are healthy but yet provide the calories needed. However, since the growth rate has slowed, the caloric needs at this age is about 2400 calories per day. Giving high calorie foods and increasing this to 3500 calories per day could lead to unhealthy weight gain and poor overall nutrition. 4. Incorrect: This response dismisses the parent's concern and does not address the issue. The parent should be provided with an explanation that this age child's appetite often decreases in relation to a decrease in the growth rate. However, the parent should be told that if weight loss or other problems begin to be noted, further evaluation may be needed.
A teen male was diagnosed with infectious mononucleosis. What would be of most concern for the nurse when performing a history on this client? 1. Rides a bicycle three times a week 2. Plays on the varsity football team 3. Member of the swim team 4. Dances with the performing arts group
2. Correct: With infectious mononucleosis, the liver and spleen are often enlarged. Therefore, participation in contact sports should be limited to prevent injury. We worry about splenic rupture with contact sports such as football. 1. Incorrect: Although many activities are reduced in the acute phase due to fatigue and general malaise, riding a bicycle would not be as potentially dangerous as contact sports. 3. Incorrect: Swimming is considered a low impact sport. The client may be on bedrest or have limited activity due to fatigue. The client may need to delay swimming activities during the acute phase, but this would not be as dangerous as participation in contact sports. 4. Incorrect: Dancing can be strenuous. The client may be on bedrest or have limited activity due to fatigue. The client may need to delay strenuous activities during the acute phase, but this would not be as dangerous as participation in contact sports.
A client comes to the clinic and states that she believes she is pregnant. What probable signs of pregnancy does the nurse expect to see? Select All That Apply 1. Amenorrhea 2. Facial chloasma 3. Fetal movement 4. Breast tenderness 5. Positive pregnancy test 6. Urinary frequency
2., & 5. Correct: Probable signs are things that most likely indicate pregnancy and are signs the primary healthcare provider will identify. Facial chloasma, also known as the mask of pregnancy, is a probable sign. A positive pregnancy test is also a probable sign of pregnancy. Why isn't it a positive sign of pregnancy? There are other conditions that can increase hCG levels. 1. Incorrect: Amenorrhea is a presumptive sign of pregnancy. What does the word presumptive sign mean? Well, these signs suggest or indicate pregnancy but they could be attributed to something else. Presumptive signs are things that the client will recognize. 3. Incorrect: Fetal movement felt by the nurse is a positive sign. 4. Incorrect: Breast tenderness is a presumptive sign. 6. Incorrect: Urinary frequency is a presumptive sign.
A nurse is providing teaching to parents of a child diagnosed with Cystic Fibrosis. Which teaching points should the nurse include?Select All That Apply 1. Liver enzyme replacements must be administered to aid in digestion. 2. A well-balanced, high fat, and high calorie diet is important. 3. Water-miscible forms of fat soluble vitamins A, D, E, and K will be needed. 4. Pancreatic enzymes should be taken at least 1 hour after meals. 5. Respiratory and GI systems are often affected by thick, sticky secretions. 6. Both parents have the gene for this autosomal recessive disorder.
2., 3., 5., & 6 Correct: Nutrition is a major part of the care for clients with Cystic Fibrosis (CF). These clients are often underweight due to digestive problems. Fats are easier to digest than proteins or carbohydrates and provide more calories than other foods do. Increased pancreatic enzyme replacements will be needed as more foods that are higher in fat are consumed. Since these clients do not absorb fat well, the water-miscible forms of the fat soluble vitamins are needed. CF affects the exocrine glands. The mucous secretions are thick and sticky which often leads to problems and blockage in the respiratory and GI systems. Because it is a genetic disease with autosomal recessive transmission, this means that both parents must have the gene. The parents would need to know this when considering future pregnancies. 1. Incorrect: Pancreatic enzymes, not liver enzymes, are the ones needed to aid digestion and are administered with all snacks and meals. 4. Incorrect: Pancreatic enzymes must be taken within 30 minutes of eating. Keep in mind that the beads should not be crushed or chewed.
A competent elderly client is admitted with a diagnosis of malnutrition following a 30-pound (13.6 kg) weight loss in a month. The family requests insertion of Peg tube for enteral feedings, despite the client's advanced directives indicating "no life-prolonging measures". What is the most appropriate comment by the nurse to the family? 1. "Perhaps you could convince your parent to allow a Peg tube insertion." 2. "Maybe the client just needs family to prepare meals and help feed the client." 3. "The client completed an advanced directive form specifying what we may do." 4. "It is the client's right to refuse procedures not wanted."
3. CORRECT. This statement by the nurse provides an explanation of advanced directives as well as the fact the client has completed such a form. The focus is placed on the purpose of advanced directives and how medical personal must abide by the client's wishes. The nurse has given the family a response which includes accurate knowledge as well as advocating for the client. 1. INCORRECT. Such a statement does not focus on the client's right to refuse life-extending procedures as noted in the advanced directives. The family is given false hope rather than a correct explanation regarding advanced directives and client rights. 2. INCORRECT. The nurse is attempting to refocus the family on the client's weight loss rather than the client's choices. The issue at this time is not the cause of the weight loss, but rather the client's right to refuse life-extending procedures as detailed in the advanced directives. 4. INCORRECT. Though this statement is accurate, it is abrupt and closed-ended. When addressing family, the nurse needs to remember that stress, fear and frustration can overwhelm judgment. The family may fear losing the client and the nurse's statement would not address those fears or the advanced directives.
A child, admitted to the emergency department is noted to be drooling and has dysphagia. No cough is noted, and the child appears worse than the sound indicates. The parent states the child seemed "fine" when put to bed. History reveals that the child has not received some of the recommended immunizations. What should the nurse anticipate as part of the care for this child? 1. Placement in the lateral, supine position. 2. Prompt initiation of respiratory syncytial virus immune globulin. 3. Transfer to OR for placement of ET tube. 4. Oral dose of dexamethasone.
3. Correct: Did you recognize these symptoms as being characteristic of epiglottitis? Yes! It is considered a medical emergency in which there can be rapid progression to severe respiratory distress due to airway occlusion. An endotracheal tube (ET) may be needed, but it is best for the child to be in the OR where anesthesia can be administered, and an emergency trach can be performed if the airway is too occluded for the passage of the ET tube. 1. Incorrect: Did you pick the lateral, supine position because there is drooling present? Don't let that trick you here. The drooling occurs because of the degree of inflammation affecting the epiglottis. Because of the potential for rapid progression of respiratory distress, we want to promote ease of respirations, minimize agitation, and allow the child to be in the position of comfort. A great position is to be upright being comforted in the parent's arms. 2. Incorrect: Respiratory syncytial virus immune globulin is not used for the treatment of epiglottitis. 4. Incorrect: Although steroids may be used in the treatment of epiglottitis, you would never want to try to administer anything by mouth to this child who has drooling and dysphagia. The child can't swallow effectively! IV medication administration would be the route of choice in the acute period.
A child is admitted in a sickle cell crisis. What treatment should the nurse anticipate being most helpful in reducing the painful crisis? 1. Antibiotics 2. Oxygen 3. Hydration 4. Bedrest
3. Correct: Hydration is crucial with a sickle cell crisis. It helps minimize the vaso-occlusive process that is causing the pain as it pushes the sickled cells apart, allowing them to flow through the vessels more freely. 1. Incorrect: Antibiotics may be needed if an infection is present, but this is not the most beneficial in reducing the painful crisis. 2. Incorrect: Oxygen does not reverse the sickling process and does not help improve circulation of the sickled cells that is occluding the vessels and causing the pain. It may be given to help improve hypoxia and prevent further sickling. 4. Incorrect: Bedrest is needed to help conserve O2. In addition, activity can lead to increased pain. However, it is not the treatment that is most helpful in reducing the blockage from the sickled cells that leads to the painful episodes.
A nurse is preparing to obtain vital signs on a 2 year old. What should the nurse consider when preparing to perform this task? 1. The blood pressure should be obtained first to get an accurate reading. 2. Count the RR and HR for 30 seconds to avoid prolonged disturbance. 3. If the child becomes upset, record the behavior with the measurements. 4. The axillary route is the most reliable route for checking the temperature.
3. Correct: Infants, toddlers, and young children often become anxious or upset during procedures, such as vital sign measurement, and we know that this activity could affect the vital sign results. Nurses or other healthcare providers would need this information to consider when evaluating the results. 1. Incorrect: We want to obtain the least invasive vital sign first. Start with observation before touching the child. What vital sign can you get by observing? Yes! Respirations! 2. Incorrect: In infants and toddlers, it is important to count the RR and HR for one full minute because of irregularities due to their immature nervous system regulation. 4. Incorrect: The rectal route is considered the most reliable route for assessing the temperature in infants and children.
Which intervention would the nurse include when planning care for a client who has increased intracranial pressure (IICP)? Select All That Apply 1. Place client supine. 2. Hyperextend head to maintain airway. 3. Maintain body temperature below 100.4 F (38 C). 4. Cluster nursing care. 5. Monitor vital signs for Cushing's Triad. 6. Limit suctioning.
3., 5., & 6. Correct. The goal of treatment is to relieve the IICP by reducing cerebral edema, reducing the amount of cerebrospinal fluid, or reducing the blood volume in the brain, We also have to maintain cerebral perfusion. An increased temperature will increase cerebral edema, which will increase ICP. Monitor vital signs for Cushing's Triad. This is systolic hypertension with a widening pulse pressure, a slow, full and bounding pule, and irregular respirations. Limit suctioning and coughing as these can make the client's ICP go up. 1. Incorrect. It is standard practice to elevate the head of the bed. ICP varies with position. 2. Incorrect. The head should be in midline or neutral position so that the jugular veins can drain. 4. Incorrect. Nursing interventions should be spaced. Anytime you do something to your client, their ICP is going to go up.
A client is admitted with a diagnosis of bacterial meningitis. Which action should the nurse initiate first? 1. Darken room. 2. Provide sponge bath for fever of 102 F (38.8 C). 3. Pad side rails. 4. Place on Droplet precautions
4. Correct. Bacterial meningitis is transmitted through the respiratory system. According to the Center of Disease Control (CDC), clients with bacterial meningitis should be placed on "Droplet Precautions". 1. Incorrect. Darkening the room will help comfort the client with photophobia, however, placing the client on droplet precautions will take priority. 2. Incorrect. The nurse will give a sponge bath to cool the client with a fever, but again, the priority is infection control. 3. Incorrect. The client with meningitis is at risk for seizures, but first place on droplet precautions. You must protect yourself and others first.
A 5 year old girl is upset and saying she is to blame for her brother getting hit by a car on his bike because she was mad at him earlier and wanted to hit him. What does the nurse recognize this type thinking to be in a child? 1. Abstract 2. Egocentric 3. Animism 4. Magical
4. Correct: Magical thinking is common in young children and is the belief that the world around them can be influenced or impacted by their own thoughts, desires, or wishes. Therefore, when something happens that is related to their thoughts, the child may perceive that it occurred because of those thoughts. This child may have connected the thoughts of being upset with the brother and the desire to hit him with the aspect of the car hitting him later. Other times, this magical thinking may be linked to a desire to make positive things happen by their thoughts. The interesting part about magical thinking is that young children may believe that they can make things or events in life be anything or anyway they want them to be. 1. Incorrect: Abstract thinking is the ability to think about objects, ideas, and principles that do not physically exist. It is the ability to understand relationships, critically think or reason, and think symbolically using a symbol to substitute for an object or idea. It is a higher level of thinking that begins in adolescence but does not fully mature until adulthood. 2. Incorrect: Egocentric thinking is where the child thinks the world revolves around them. "It's all about me, me, me!" 3. Incorrect: Animism is the child's way of thinking in which they believe that inanimate objects have feelings, thoughts, and abilities like living things. They think that non-living things behave just like humans.
The nurse provided a community safety presentation for parents and included car seat safety. Which would demonstrate to the nurse that the parents correctly understood the teaching for a 2 month old weighing 10 pounds (4.55 kg)? 1. The car seat is placed upright in the rear facing position in the front passenger seat. 2. Padding is placed under the young infant's head in the semi-reclined car seat in a rear facing position. 3. The car seat is secured in the side of the rear seat in a reclined, front-facing position. 4. The car seat is placed semi-reclined in the middle of the back seat in a rear-facing position.
4. Correct: The guideline for infants < 20 pounds (9kg) is to place them in the middle of the back seat in a rear-facing, semi-reclined car seat. This provides the best protection for their heavy head and weak neck. 1. Incorrect: Infants and young children should never be placed in the front passenger seat, regardless of the direction that the car seat is facing. 2. Incorrect: Padding should not be placed under or behind an infant or child in the car seat because this could become compressed during a crash and cause slackness in the car seat harness. The infant or child could then be ejected from the car seat. 3. Incorrect: Although the car seat is in the back seat, it should be rear-facing, not front-facing, for this 2 month old infant. Also, the middle of the back seat is preferable for car seat placement.
The nurse has presented information regarding true versus false labor to a woman in her third trimester of pregnancy. Which statement by the woman would indicate to the nurse that the client understands the information provided? 1. "With false labor the discomfort starts in the back and radiates to the abdomen." 2. "I will experience irregular contractions with both true and false labor." 3. "Contractions during true labor will increase in duration but will decrease in frequency." 4. "Pain increases with a change in activity if I am having true labor."
4. Correct: The pain level will increase with a change in activity if the woman is in true labor. It decreases or goes away if it is false labor. 1. Incorrect: With true labor the discomfort is often in the back and radiates all the way around to the abdomen. False labor discomfort is just in the abdomen. 2. Incorrect: Contractions will be regular with true labor and irregular with false labor. 3. Incorrect: Contractions during true labor will increase in duration and in frequency.
The nurse performs an initial assessment on a client admitted following a motor vehicle crash. Based on this assessment, what Glasgow Coma Scale (GSC) score would the nurse assign to the client? Client obtunded, with occasional moaning noted. Opened eyes and extended arm during IV start.
6 Remember, that the GCS looks at eye opening, motor response and verbal response. So the client opened eyes because of pain with the IV start so that is a 2 for eye opening. During the painful experience, the client extended the arm which is a 2 for motor response. The client is obtunded an occasionally moans, so verbal response is a 2. So the GCS score is 6.
