NCLEX: midterm B
Which of the following is significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply? 1. Quality of breath sounds. 2. Presence of bowel sounds. 3. Occurrence of chest pain. 4. Amount of peripheral edema. 5. Color of nail beds.
1., 3., 5. A respiratory assessment, which includes auscultating breath sounds, and assessing the color of the nailbeds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the clients ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the client with pneumonia.
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notices that the client has a 1" x 1" area on his sacrum in which there is a skin breakdown as far as the dermis. What should the nurse note on the chart? 1. Stage I pressure ulcer 2. Stage II pressure ulcer 3. Stage III pressure ulcer 4. Stage IV pressure ulcer
2. Stage one pressure ulcer's appear as non-blanching macules that are red in color. Stage two ulcers have breakdown of the dermis. Stage III ulcers have full thickness skin breakdown. In stage four ulcers, the bone, muscle, and supporting tissue are involved. The nurse should immediately initiate plans to relieve the pressure, ensure good nutrition, and protect the area from abrasion.
The nurse should place the client being admitted to the hospital with suspected tuberculosis on what type of isolation? 1. Standard precautions 2. Contact precautions 3. Droplet precautions 4. Airborne precautions
4. Airborne precautions prevent transmission of infectious agents that remain infectious over long-distance when suspended in the air. The preferred placement is in an isolation single client room that is equipped with special air handling and ventilation. Droplet precautions are intended to be prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.
Which of the following symptoms is common in clients with active tuberculosis? 1. Weight loss. 2. Increased appetite. 3. Dyspnea on exertion. 4. Mental status changes.
1. Tuberculosis typically produces anorexia and weight loss. Other signs and symptoms may include fatigue, low-grade fever, and night sweats. Increased appetite is not a symptom of tuberculosis; dyspnea on exertion and change in mental status are not common symptoms of tuberculosis.
A client with deep vein thrombosis suddenly develops dyspnea, tachypynea, and chest discomfort. What should the nurse do first? 1. Elevate the head of the bed 30 to 45°. 2. Encourage the client to cough and deep breathe. 3. Auscultate the lungs to detect abnormal breath sounds. 4. Contact the physician.
1. elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The physician must be kept informed of changes in a client status, but the priority in this case is alleviating the symptoms.
The nurse should teach clients that the most common route of transmitting tubercle bacilli from person to person is through contaminated: 1. Dust particles 2. Droplet nuclei 3. Water 4. Eating utensils
2. Droplet nuclei are the residue of evaporated droplets containing the bacilli, which remain suspended are circulated in the air.
An alert and oriented elderly client is admitted to the hospital for treatment of cellulitis of the left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this client? 1. Keep all the lights on in the room at all times 2. Use a night light in the bathroom 3. Keep all four side rails up at all times 4. Place the client in a room with a camera monitor
2. Many falls occur when older clients attempt to get to the bathroom at night. The risk is even greater in an unfamiliar environment. Use of a night light in the bathroom enables the older adult client to see the way to the bathroom. Keeping the lights on in the room at all times may contribute to sensory overload and prevent adequate rest. Raised side rails paradoxically contribute to falls when the older client tries to climb over them to get to the bathroom. The upper side walls may be raised but is not recommended that all four siderails be elevated. Camera monitoring can be used but does nothing to prevent a fall.
Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to: 1. Altered balance 2. Altered protective pressure sensation 3. Impaired hearing ability 4. Impaired visual acuity
2. Pressure ulcers usually occur over bony prominences. An alteration in the protective pressure sensation results from a decline in the number of Meissner's and pacinian corpuscles. Older adults do have alteree balance that may result in falls, but not skin breakdown. Impaired hearing and vision do not contribute to pressure ulcers.
A nurse notes that the client has kyphosis and generalized muscle atrophy. Which of the following problems as a priority when the nurse develops a nursing plan of care? 1. Infection. 2. Confusion. 3. Ineffective coughing and deep breathing. 4. Difficulty chewing solid foods.
3. In kyphosis, the thoracic spine bends forward with convexity of the curve in a posterior direction, making effective coughing and deep breathing difficult. Although the client may develop other problems because respiratory status deteriorates when pulmonary secretions are not adequately cleared from the airways, ineffective coughing and deep breathing should receive priority attention.
A stage II pressure ulcer is characterized by: 1. Redness in the involved area 2. Muscle spasms in the involved area 3. Pain in the involved area 4. Tissue necrosis in the involved area
3. Stage two breakdown involves epidermal sloughing and pain. Redness without blanching is noted in stage one. Stage III involves tissue necrosis with subcutaneous involvement stage four involves muscle or bone destruction. Muscle spasms are not a criterion used in the staging process.
The nurse is assessing a client with dark skin for presence of a stage I pressure ulcer. The nurse should: 1. Use a fluorescent light source to assess the skin 2. inspect the skin only when that Braden score is above 12 3. look for skin color that is darker than the surrounding tissue 4. avoid touching the skin during inspection
3. When assessing the client with dark skin, the nurse should observe for skin that is darker, brownish, purpleish, or bluish compared to surrounding skin. Fluorescent light casts a blue light making skin assessment difficult; natural or halogen light sources help to accurately assess the skin. Risk assessment using the Braden scale should be performed on all clients. Braden score of 12 indicates a high risk for pressure ulcer and the lower the Braden score, the higher the risk. The nurse should touch the skin to assess consistency and temperature differences.
A client has been admitted with draining foot lesions. The nurse should do which of the following? Select all that apply. 1. Place the client in a room with negative air pressure. 2. Admit the client to a semi private room. 3. Admit the client to a private room. 4. Post a "contact isolation" sign on the door. 5. Wear a protective gown when in the clients room. 6. Wear latex free gloves when providing direct care.
3., 4. , 5. Infection control policies must be followed to prevent the spread of infection. Until the pathogens are identified, the client must be isolated in a private room. Utilizing contact isolation, wearing a protective isolation gown and clean gloves, in addition to following isolation protocol to exit the room, may aid in the prevention of spread of infectious agents to others. A draining foot lesion does not require a negative air pressure room, which is primarily reserved for preventing the spread of tuberculosis. Latex free gloves are not needed unless a client has a latex allergy.
