Kahoot Review Q's #2
The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? 1. I should increase the fiber in my diet 2. I will need to avoid caffeinated beverages 3. I'm going to learn some stress reduction techniques 4. I can have exacerbations and remissions with Crohn's disease
1. I should increase the fiber in my diet Rationale: A low-fiber diet may be prescribed, especially during periods of exacerbation
A client with chronic bronchitis tells the home health nurse of being exhausted all day, coughing all night, and being unable to sleep. The client can feel thick mucus in the chest and throat. Which interventions can the nurse suggest to help mobilize secretion and improve sleep? SATA 1. Increase fluids to at least eight glasses (2-3L) of water a day 2. Sleep with a cool mist humidifier 3. Take prescribed guaifenesin cough medicine before bedtime 4. Use abdominal breathing and a huff cough technique at bedtime 5. Use pursed lip breathing during the night
1. Increase fluids to at least eight glasses (2-3L) of water a day 2. Sleep with a cool mist humidifier 3. Take prescribed guaifenesin cough medicine before bedtime 4. Use abdominal breathing and a huff cough technique at bedtime Rationale: Chronic bronchitis is characterized by excessive mucus production, chronic cough and recurrent respiratory tract infections. Interventions to help reduce the viscosity of mucus, facilitate secretion removal, and promote comfort include increasing fluids, cool mist humidifier, guaifenesin, abdominal breathing with a huff, chest physiotherapy, airway clearance handheld devices.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? SATA 1. Keeping linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 3. Limiting bladder catheterization to once every 12 hours 4. Turning and repositioning the client at least every 2 hours 5. Ensuring that the client has a bowel movement at least once a week
1. Keeping linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 4. Turning and repositioning the client at least every 2 hours Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and urinary catheters 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 from tactile, thermal, or painful stimulus. The nurse administers care to minimize risk in these areas.
A client with chronic dyspnea is scheduled for CT using contrast, which assessment information would the nurse communicate to the health care provider before the procedure? SATA 1. Metformin taken today 2. Hematocrit 38% 3. Serum creatinine 2.1 mg d/L 4. coronary artery disease 5. Shellfish allergy 6. Respiratory rate 22 breaths/min
1. Metformin taken today, 3. Serum creatinine 2.1, 5. Shellfish allergy Rationale: Because the iodine-containing contrast can lead to acidosis in clients who use metformin, the medication is stopped 24-hours before procedure that require contrast injection and not restarted for a few days after the procedure. The contrast is nephrotoxic, and the nurse would inform the provider that the creatinine is elevated. A shellfish allergy will require the client receive treatment with corticosteroids before receiving the iodine-containing contrast for the CT.
When monitoring your client who is now started on an intravenous antibiotic therapy for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your FIRST PRIORITY intervention? 1. Stop the intravenous flow 2. Slow down the intravenous flow 3. Notify the doctor 4. Begin CPR
1. Stop the intravenous flow Rationale: It's highly likely that the signs of anaphylaxis have occurred as a result of the client's adverse effect to this antibiotic
When caring for a client with ulcerative colitis, which nursing activities are appropriate for the nurse to delegate to an LPN? SATA 1. Administer blood transfusion 2. Administer a prescribed suppository 3. Discuss dietary modifications with the dietician 4. Monitor for a change in bowel sounds 5. Remind the patient to check daily weights
2. Administer a prescribed suppository 4. Monitor for a change in bowel sounds 5. Remind the patient to check daily weights Rationale: LPNs can monitor a change to something the nurse has already assessed and can perform limited assessment such as lung sounds, bowel sounds, and neurovascular checks. LPNs can also reinforce teaching provided. Anything that requires clinical judgment is up to the nurse.
The nurse is caring for a client immediately post bronchoscopy. Which assessment data indicate that the nurse needs to contact the health care provider immediately? 1. Absence of a gag reflex 2. Bright red blood mixed with sputum 3. Headache 4. Respirations 10/min and saturation of 92%
2. Bright red blood mixed with sputum Rationale: Blood-tinged sputum is common and can occur from inflammation of the airway, but hemoptysis of bright red blood can indicate hemorrhage, especially if a biopsy was performed
the client with a closed head injury has a respiratory rate of 30, irregular blood pressure of 198/110 mm Hg, and a pulse rate of 48. The nurse is reporting these vital signs to the healthcare provider because they indicate: 1. Papilledema 2. Cushing's triad 3. An impending seizure 4. A stroke
2. Cushing's triad Rationale: Cushing's triad is characterized by irregular breathing, widened pulse pressure, and bradycardia, indicating a loss of compensatory mechanisms within the brainstem
The nurse reinforces teaching to a client prescribed metronidazole. Which statement indicates a need for further education? 1. I might have a metallic taste in my mouth when I'm taking this medicine 2. I need to decrease the amount of alcohol I drink while taking this medicine 3. I should not worry if my urine turns a dark color while taking this med 4. I will immediately call the clinic if I get a new rash or have skin peeling
2. I need to decrease the amount of alcohol I drink while taking this medicine Rationale: The client should be instructed to abstain completely from consuming food, drinks, or products containing alcohol during, and for three days after therapy. The combination of alcohol and metronidazole may cause clients to experience facial flushing, headache, nausea, vomiting, and abdominal cramping
The nurse is reviewing the home medication list for a client admitted with peptic ulcer disease (PUD). Which medication would the nurse question? 1. Iron 2. Ibuprofen 3. Famotidine 4. Acetaminophen
2. Ibuprofen Rationale: Clients with PUD should avoid taking Aspirin or NSAID products as this can cause GI bleeding
A 66-year-old female patient has deep partial thickness burns to both legs on the back, front and back of the trunk, both arms on the front and back, and front and back of the head and neck. Using the rule of nines, calculate the total body surface area percentage that is burned. 1. 72% 2. 62% 3. 81% 4. 45%
3. 81% Rationale: Both of the legs on the back -18% Front and back of the trunk -36% Both arms on the front and back -18% Front and back of the head and neck -9%
A healthcare provider is caring for a patient who has gone into septic shock. Which of these should the healthcare provider administer to the patient first? 1. Corticosteroids to reduce inflammation 2. Antibiotics to treat the underlying infection 3. IV fluids to increase intravascular volume 4. Vasopressors to increase blood volume
3. IV fluids to increase intravascular volume Rationale: Circulation and perfusion should be addressed first, so IV fluids will be started immediately. After blood cultures are obtained, broad-spectrum antibiotics should be administered without delay. Vasopressors are administered if the patient is not responding to the fluid challenge.
A client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes. Which of the following nursing actions is a priority? 1. Examine the client's visual acuity 2. Patch the eye 3. Use Restasis (Allergan) drops in the eye 4. Flush the eyes repeatedly using sterile normal saline
4. Flush the eyes repeatedly using sterile normal saline Rationale: Following a chemical splash to the eye, the afflicted eye should be immediately and continuously irrigated with normal saline
Which of the following types of anginas is most closely related with an impending MI? 1. Angina decubitus 2. Chronic stable angina 3. Nocturnal angina 4. Unstable angina
4. Unstable angina Rationale: Unstable angina progressively increases in frequency, intensity, and duration and is related to an increased risk of MI within 3 to 18 months.
Kevin is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with: A. antisocial personality disorder B. borderline personality disorder C. obsessive-compulsive personality disorder D. narcissistic personality disorder
A. antisocial personality disorder Rationale: The client's history of delinquency, running away from home, vandalism, and dropping out of school are characteristics of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others.