Level 1 Panola: Exam 2 EAQ's

A client is brought to the emergency department triage by private car with bone protruding from the right lower leg. Which assessment would the triage nurse perform first? 1 Vital signs 2 Pain level 3 Neurologic check 4 Pedal pulses

4

After a total knee replacement, a client will be using a continuous passive motion device. Which therapy goal stated by the client would indicate to the nurse that teaching was effective? 1 Improve joint flexion. 2 Maintain muscle tone. 3 Prevent tissue breakdown. 4 Prevent formation of a blood clot.

1

At which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter? 1 Tubing injection port 2 Distal end of the tubing 3 Urinary drainage bag 4 Catheter insertion site

1

In which position would the nurse place a toddler to elicit the Trendelenburg sign? 1 Standing on the affected leg 2 Supine with the back arched 3 Side-lying on the unaffected side 4 Sitting upright with the legs separated

1

A child is administered a rotavirus vaccine. Which adverse medication effect would the nurse monitor for? 1 Intussusception 2 Encephalopathy 3 Thrombocytopenia 4 Guillain-Barré syndrome

1

A client who has an above-the-knee amputation is fitted for a prosthesis. Two days after beginning to use the prosthesis, a small blister develops on the residual limb near the healed incision. Which action will the nurse anticipate when planning care for this client? 1 Remeasuring the residual limb for correct prosthesis sizing 2 Increasing the frequency of limb-toughening exercises 3 Changing the type of covering used to avoid irritation 4 Placing a bandage on the blister before putting the prosthesis back on

1

A client who takes rifampin tells the nurse, "My urine looks orange." Which action would the nurse take? 1 Explain that this is expected. 2 Check the liver enzymes. 3 Ask the provider to order a urinalysis. 4 Ask what foods were eaten.

1

The nurse prepares a male client with a history of recurrent urinary tract infections (UTIs) for discharge after a ureterolithotomy. Which clinical manifestations of a UTI would the nurse teach this client to recognize? 1 Urgency or frequency of urination 2 An increase of ketones in the urine 3 The inability to maintain an erection 4 Pain radiating to the external genitalia

1

Upon entering a client's room, the nurse sees the client exhibiting seizure activity. Which is the first action the nurse would take? 1 Assess the client's airway. 2 Place pads on the side rails. 3 Notify the client's health care provider. 4 Leave to obtain the crash cart.

1

Which antidepressant may be prescribed to a new mother diagnosed with depression? 1 Sertraline 2 Fluoxetine 3 Amphetamine 4 Carbamazepine

1

Which characteristic of urine changes in the presence of a urinary tract infection (UTI)? 1 Clarity 2 Viscosity 3 Glucose level 4 Specific gravity

1

Which finding would the nurse expect when taking a health history of a 15-month-old child with celiac disease? 1 Has bulky, foul, frothy stools 2 Drinks large amounts of fluid 3 Is irritable throughout the day 4 Voids strong, concentrated urine

1

Which instruction would the nurse include in a health practices teaching plan for a female client with a history of recurrent urinary tract infections? 1 "Wear cotton underwear or lingerie." 2 "Void at least every 6 hours around the clock." 3 "Increase foods containing alkaline ash in the diet." 4 "Wipe the perineum from back to front after toileting."

1

Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. One, some, or all responses may be correct. 1 Diuretics 2 Low-salt diet 3 Daily weight checks 4 Fluid restriction 5 Intake and output 6 Oxygen administration

1 2 3 4 5 6

An ambulatory client with relapsing-remitting multiple sclerosis is to receive every-other-day injections of interferon beta-1a. Which adverse effects would the nurse explain may occur when taking this medication? Select all that apply. One, some, or all responses may be correct. 1 Depression 2 Polycythemia 3 Flu-like symptoms 4 Increased risk for infection 5 Decreased perspiration

1 3 4

Which electrolyte deficiency triggers the secretion of renin? 1 Sodium 2 Calcium 3 Chloride 4 Potassium

1 Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin.

For which condition would an infant born with exstrophy of the bladder be at risk? 1 Infection 2 Dehydration 3 Urine retention 4 Intestinal obstruction

1 The greatest problem facing this infant is infection of the bladder mucosa and excoriation of the surrounding tissue; meticulous hygiene is necessary both before and after surgery. Dehydration is not a problem, because fluid intake and the amount of urine output are not affected. Urine retention is not a problem, because the urine drains continuously. The congenital abnormality involves the genitourinary system, not the intestines.

Which statement reflects the nurse's suspicions regarding a client's cloudy urine noted on a urinalysis report? 1 The client has a urinary infection. 2 The client has a biliary obstruction. 3 The client has diabetic ketoacidosis. 4 The client has been on a starvation diet.

1 The urine becomes cloudy when an infection is present due to the presence of leukocytes. The nurse concludes the client has a urinary infection. In cases of biliary obstruction, the urine contains bilirubin. The presence of ketones in the urine indicates diabetic ketoacidosis or prolonged starvation.

Which is the maximum recommended length for enema tube insertion in an adolescent? Record your answer using a whole number. _____ cm

10

A 20-lb infant has a normal saline enema ordered, at a dose of 10 mL/kg. Which dose would the nurse administer? 1 9 mL 2 90 mL 3 130 mL 4 210 mL

2

A client who has been diagnosed with a myocardial infarction receives digoxin, fluoxetine, morphine, and docusate sodium. Which medication would the nurse identify as a risk factor for straining due to constipation? 1 Digoxin 2 Morphine 3 Docusate 4 Fluoxetine

2

In which age group is scoliosis usually identified? 1 Adolescence 2 Preadolescence 3 Early school years 4 Middle school years

2

The nurse finds a client lying on the floor next to a wheelchair. The client states, "I was trying to get back to bed and slipped." Which action would the nurse take first? 1 Call the nurse manager to alert administration. 2 Arrange for the client to be examined by the in-house health care provider. 3 Complete an incident report to ensure documentation of the event. 4 Provide information about the incident to the client's primary health care provider.

2

The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome? 1 Skin condition 2 Fluid and electrolyte balance 3 Food intake 4 Fluid intake and output

2

When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report which clinical manifestation? 1 Nervousness 2 Polyuria 3 Nocturia 4 Diaphoresis

2

Which assessment would be most useful in monitoring the client, who had a total hip replacement, for hemorrhage? 1 Checking vital signs every 4 hours 2 Examining the bedding under the client 3 Measuring the circumference of the thigh 4 Observing for ecchymosis at the operative site

2

Which is the recommended length of insertion of the enema tube in a child of 3 years? 1 1 to 2.5 cm 2 5 to 7.5 cm 3 7.5 to 10 cm 4 2.5 to 3.7 cm

2

The nurse understands which are the pharmacokinetic reasons for medication sensitivity in infants? Select all that apply. One, some, or all responses may be correct. 1 Small body size 2 Medication absorption 3 Renal medication excretion 4 Protein binding of drugs 5 Hepatic medication metabolism

2 3 4 5 Increased medication sensitivity in infants is a result of the immature state of pharmacokinetic processes such as medication absorption, renal medication excretion, protein binding of drugs, and hepatic medication metabolism. A small body is not a pharmacokinetic parameter.

Which nursing intervention would the nurse direct toward a child admitted for acute glomerulonephritis? 1 Enforcing bed rest 2 Promoting diuresis 3 Encouraging fluids 4 Removing dietary salt

2 With the reduction of edema the child's health improves, the appetite increases, and the blood pressure normalizes. Ambulation does not have an adverse effect on this disorder; most children voluntarily restrict their activities and remain in bed during the acute phase. Fluids are not encouraged because the kidneys are inflamed and cannot tolerate large amounts of fluid. Sodium intake is decreased, not eliminated; sodium restriction is not tolerated well by children and may further decrease their appetite.STUDY TIP: Establish your study priorities and the goals by which to achieve these priorities. Write them out and review the goals during each of your study periods to ensure focused preparation efforts.

A client is scheduled for discharge after surgery. The medical record indicates that the client has not had a bowel movement since before surgery, which was 4 days ago. Which prescribed medication will the nurse administer to ensure a bowel movement before discharge? 1 Lactulose 2 Docusate sodium 3 Bisacodyl suppository 4 Psyllium

3

A client recovering from deep, partial-thickness burns develops chills, fever, flank pain, and malaise. Which prescribed diagnostic test would the nurse expect to confirm a tentative urinary tract diagnosis? 1 Cystoscopy and bilirubin level 2 Specific gravity and pH of the urine 3 Urinalysis and urine culture and sensitivity 4 Creatinine clearance and albumin/globulin (A/G) ratio

3

A client had a colon resection and formation of a colostomy 2 days ago. Which color indicates to the nurse that the stoma is viable? 1 Blue 2 Gray 3 Brick red 4 Dark purple

3 A brick red stoma indicates adequate vascular perfusion. A blue, gray, or dark purple color indicates inadequate perfusion of the stoma.

A health care provider prescribes a diuretic for a client with hypertension. Which mechanism of action explains how diuretics reduce blood pressure? 1 They facilitate vasodilation. 2 They promotes smooth muscle relaxation. 3 They reduce the circulating blood volume. 4 They block the sympathetic nervous system.

3 Diuretics decrease blood volume by blocking sodium reabsorption in the renal tubules, thus promoting fluid loss and reducing arterial pressure. Direct relaxation of arteriolar smooth muscle is accomplished by vasodilators, not diuretics. Vasodilators, not diuretics, act on vascular smooth muscle. Medications that act on the nervous system, not diuretics, inhibit sympathetic vasoconstriction.

A client with Hodgkin's disease adds doxorubicin to current therapy. Which advice will the nurse provide about this medication? 1 Cease taking any medication that contains vitamin D. 2 Keep the doxorubicin in a dark place protected from light. 3 Expect urine to turn red for a few days after taking this medication. 4 Take the doxorubicin on an empty stomach with large amounts of fluids.

3 Doxorubicin causes the urine to turn red for a few days; the client should be informed of this expectation so as not to become alarmed when it occurs. Discontinuing the intake of vitamin D is true for plicamycin, not the medications in this protocol. It is unnecessary to keep doxorubicin in a dark area, protected from light. Doxorubicin is not given orally, only via the intravenous route.

Which primary symptom would the nurse assess for in a boy who has encopresis? 1 Practicing self-mutilation 2 Practicing self-induced vomiting 3 Passing feces either voluntarily or involuntarily into inappropriate places 4 Passing urine either voluntarily or involuntarily into inappropriate places

3 The primary symptom the nurse would observe in encopresis is passing feces either voluntarily or involuntarily into inappropriate places. Encopresis is the passage of feces into inappropriate places such as clothing, closets, floors, or toy boxes, either voluntarily or involuntarily. It may severely limit a child's social development and results in parental disapproval and rejection. Encopresis does not involve self-mutilation; self-mutilation occurs in borderline personality disorder. Encopresis does not involve self-induced vomiting; self-induced vomiting occurs with eating disorders. The passage of urine into inappropriate places is called enuresis.

The nurse shares the discharge instructions with a client who has prostate cancer. The client asks, "How much more blood will they need? Don't they have enough?" Which laboratory test would the nurse discuss the need to monitor throughout the course of the disease? 1 Albumin 2 Creatinine 3 Blood urea nitrogen (BUN) 4 Prostate-specific antigen (PSA)

4

Which hormonal deficiency causes diabetes insipidus in a client? 1 Prolactin 2 Thyrotropin 3 Luteinizing hormone 4 Antidiuretic hormone (ADH)

4

Which hormone would the nurse identify as being excreted in urine during pregnancy? 1 Estrogen 2 Oxytocin 3 Progestin 4 Human chorionic gonadotropin

4

Which medication turns urine reddish-orange in color? 1 Amoxicillin 2 Ciprofloxacin 3 Nitrofurantoin 4 Phenazopyridine

4

Which nursing action is most effective in controlling the spread of infection for an infant with diarrhea? 1 Wearing a gown and gloves during care 2 Allowing only registered nurses to give direct care 3 Restricting visitors to the infant's immediate family 4 Washing hands before and after contact with the infant

4

Which musculoskeletal changes directly place pregnant clients at increased risk for falls? Select all that apply. One, some, or all responses may be correct. 1 Back pain 2 Joint laxity 3 Weight gain 4 Impaired balance 5 Shifting center of gravity

4 5

In which parts of the kidney are glucose and amino acids reabsorbed? 1 Distal tubule 2 Loop of Henle 3 Collecting duct 4 Proximal tubule

4 Glucose, amino acids, electrolytes, and bicarbonate are reabsorbed in the proximal tubule. In distal tubules, water and bicarbonate are reabsorbed, but not glucose and amino acids. Sodium and chloride are reabsorbed in the ascending limb, and water in the descending loop, of the Loop of Henle. Water is reabsorbed in the presence of antidiuretic hormone in the collecting duct.

The nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client. Which is the volume of solution that would be prepared? 1 150 to 250 mL 2 250 to 350 mL 3 300 to 500 mL 4 500 to 750 mL

4 In adolescents, the volume of solution required is 500 to 750 mL. The nurse would prepare 150 to 250 mL of warmed solution for infants. The nurse would prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis report. Which urinary finding indicates the need to notify the primary health care provider? 1 Acidic pH 2 Glucose negative 3 Bacteria negative 4 Presence of large proteins

4 The glomeruli are not permeable to large proteins such as albumin or red blood cells, and finding them in the urine is abnormal; the nurse would report their presence to the primary health care provider to modify the client's treatment plan. The urine can be acidic; normal pH is 4.0 to 8.0. Glucose and bacteria should be negative and are normal findings.

Which factor would the nurse assess in a client reporting constipation? Select all that apply. One, some, or all responses may be correct. 1 Diet 2 Fluid intake 3 Use of laxatives 4 Date of last bowel movement 5 Use of opioid pain medications

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