Nurs 4 - RN EAQ's -Concepts: Clinical Decision-Making/Clinical Judgement

A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have? 1 7.20 2 7.35 3 7.45 4 7.48

1 - 7.20 The pH of blood is maintained within the narrow range of 7.35 to 7.45. When there is an increase in hydrogen ions, the respiratory, buffer, and renal systems attempt to compensate to maintain the pH. If compensation is not successful, acidosis results and is reflected in a lower pH.

A newly admitted client with an obsessive-compulsive personality disorder frequently performs a handwashing ritual. When attempts are made to set limits on the frequency or length of the ritual, the client's anxiety escalates and the client becomes verbally aggressive. What is most important for the nurse to do when the client performs the ritual? 1 Allow the client sufficient time to carry out the ritual. 2 Promote reality by showing that the ritual serves little purpose. 3 Try to ascertain the meaning of the ritual by discussing it with the client. 4 Interrupt the ritual to demonstrate that the ritual does not control what happens.

1 - Allow the client sufficient time to carry out the ritual. Rituals provide a means for the individual to control anxiety. If not permitted to carry out the ritual, the client will probably experience unbearable anxiety. The client has exhibited verbally aggressive behavior in the past, and this behavior may escalate. Safety of the client and others becomes an issue. The client probably already understands that the ritual is useless but is unable to stop the activity. These clients have no idea of what the ritual means, only that they must continue the ritual. Interrupting the ritual will have the effect of increasing anxiety, possibly to a panic level.

Which clinical manifestation should the nurse monitor the preschool-age client diagnosed with lead toxicity for that is associated with the hematologic system? 1 Anemia 2 Glycosuria 3 Distractibility 4 Hyperactivity

1 - Anemia Anemia is a clinical manifestation associated with lead toxicity due to the effects that lead has on the hematological system. Glycosuria is a clinical manifestation caused by the effects of lead toxicity on the renal system. Distractibility and hyperactivity are clinical manifestations caused by the effects of lead toxicity on the neurological system.

While caring for a client on phenelzine, the nurse finds an excess elevation of the client's temperature. Which other medication currently being taken by the client may be responsible for this condition? 1 Meperidine 2 Desipramine 3 Amitriptyline 4 Amphetamine

1 - Meperidine Phenelzine is a monoamine oxidase inhibitor (MAOI) used to treat depression. Meperidine is a strong analgesic that when taken concurrently with MAOIs may result in excessive elevation of the temperature. Desipramine and amitriptyline are tricyclic antidepressants that may cause hypertensive episodes or hypertensive crisis when taken concurrently with MAOIs. Amphetamine is an indirectly acting sympathomimetic that causes a hypertensive crisis when taken concurrently with MAOIs.

An explosion resulted in massive injuries in a client requiring resuscitation. What is the correct sequence of actions for treating this client? 1. Monitor vital signs. 2. Establish a patent airway. 3. Assess breath sounds and respiratory effort. 4. Evaluate the client's level of consciousness.

1. - Establish a patent airway. 2. - Assess breath sounds and respiratory effort. 3. - Monitor vital signs. 4. - Evaluate the client's level of consciousness. The priority action when resuscitating a client is establishing a patent airway by positioning the client and using suctioning. Establishing a patent airway is followed by assessing breath sounds and respiratory effort and observing for chest wall trauma and physical abnormality. After ensuring adequate breathing, the health care provider should ensure circulation by monitoring vital signs. Finally, the client's level of consciousness should be evaluated.

Arrange the order of steps in which a nurse conducts a research project. 1. Use the findings. 2. Conduct the research. 3. Analyze the outcomes. 4. Develop the hypotheses. 5. Design the research study. 6. Identify the problem.

1. - Identify the problem. 2. - Develop the hypotheses. 3. - Design the research study. 4. - Conduct the research. 5. - Analyze the outcomes. 6. - Use the findings. When conducting a research project, the nurse should first identify the problem. The nurse should then develop a hypotheses based on this problem. Next, the nurse should design the research study. After designing the study, the nurse conducts the study, which involves obtaining the required approvals, recruiting research subjects and implementing the study protocol. The nurse should then analyze the outcomes after conducting the study and interpret the demographics of the study population, analyze every research hypothesis and interpret the conclusions and limitations of the study. The last step of the research process is using the findings of the study. At this stage, the nurse formulates recommendations for conducting further research and determines the implications of the research for nursing.

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present, and the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of what? 1 Binder 2 Ice bag 3 Elastic bandage 4 Warm compress

2 - Ice bag Application of ice directly to a soft tissue injury causes vasoconstriction, which results in decreasing hemorrhage, edema, and pain. Use of a binder or elastic bandage on the area of a soft tissue injury is contraindicated and may cause compartment syndrome (constriction resulting in decreased circulation and nerve function). A warm compress would result in vasodilation and cause increased hemorrhage (hematoma formation), edema, and pain.

How should a nurse assess a client's trigeminal nerve function? 1 Observing pupil constriction 2 Identifying corneal sensation 3 Determining the ability to smell 4 Determining the ability to shrug the shoulders

2 - Identifying corneal sensation The afferent sensory branch of the trigeminal nerve (cranial nerve V [1] [2]) innervates the cornea. Observing pupil constriction tests the function of cranial nerve III. Determining the ability to smell tests cranial nerve I. Determining the ability to shrug the shoulders tests the function of cranial nerve XI.

What comprises the prehospital priority care delivered by a nurse for a heatstroke victim? 1 The nurse should provide cold compresses. 2 The nurse should not give food or liquid to the victim. 3 The nurse should stabilize the spine of the victim with a board. 4 The nurse should closely monitor the blood pressure and respiratory function.

2 - The nurse should not give food or liquid to the victim. The nurse should not give food or liquid to the victim as prehospital care for heatstroke because vomiting and aspiration are risks. The nurse should provide cold compresses over the bite site in case the client is bitten by the brown recluse spider. The nurse should stabilize the spine of the victim with a board as prehospital care for a drowning victim. The nurse should closely monitor the blood pressure and respiratory function as a part of hospital care for a victim of a snake or spider bite.

An emergency nursing staff member is performing defibrillation/cardioversion and special resuscitation for clients who sustained injuries in a tsunami. Which certification does the emergency nursing staff member possess? 1 Basic Life Support(BLS) 2 Certified Emergency Nurse (CEN) 3 Advanced Cardiac Life Support (ACLS) 4 Pediatric Advanced Life Support (PALS)

3 - Advanced Cardiac Life Support (ACLS) Advanced Cardiac Life Support (ACLS) certification allows nurses to perform electrical therapies, special resuscitation, and invasive airway management. Basic Life Support(BLS) certification is granted when the nurse performs airway maintenance or cardiopulmonary resuscitation. Certified Emergency Nurse (CEN) certification indicates that a nurse has core emergency nursing skill and knowledge. Pediatric Advanced Life Support (PALS) certification is needed to perform neonatal and pediatric resuscitation.

While performing a physical assessment of a female client, a nurse notices hair on the client's upper lip, chin, and cheeks. Which condition may result in this condition? 1 Aging 2 Poor nutrition 3 Endocrine disease 4 Arterial insufficiency

3 - Endocrine disease Endocrine diseases such as hirsutism will result in excessive hair growth on the upper lip, chin, and cheeks. Aging and poor nutrition will result in decreased hair growth. Arterial insufficiency will result in decreased hair growth due to compromised blood supply.

Which nursing action is appropriate when conducting a secondary survey during the emergency assessment? 1 Maintaining privacy 2 Having suction available 3 Giving supplemental oxygen 4 Assigning a nurse to support family members

4 - Assigning a nurse to support family members A nursing action that is appropriate during the secondary survey is assigning a nurse, or other team member, to support family members. Maintaining privacy, having suction available, and giving supplemental oxygen are all interventions during the primary survey.

What is the first nursing intervention for a newborn with a 1-minute Apgar score of 7? 1 Administering oxygen 2 Performing a brief physical assessment 3 Cutting the umbilical cord and attaching a clamp 4 Drying and placing the infant in a warm environment

4 - Drying and placing the infant in a warm environment Preventing heat loss conserves the newborn's oxygen and glycogen reserves; this is a priority. Warming the infant will reduce cyanosis if no respiratory obstruction is present. Performing a brief physical assessment is important; however, it is not a priority; assessment should be delayed until the infant is warm. Cutting the umbilical cord and attaching a clamp may be done after provisions to prevent heat loss have been made.

An 8-month-old infant undergoes surgical correction for hypospadias. What is a priority nursing intervention during the postoperative period? 1 Ensuring that privacy is maintained 2 Minimizing pain with adequate analgesia 3 Restricting fluid intake until the stent is removed 4 Gradually increasing the time that the urinary catheter is clamped

2 - Minimizing pain with adequate analgesia Although analgesia is important to minimize pain, it also relaxes the infant, who may be immobilized to maintain the position of the urethral stent and to ensure optimal healing of the newly formed urethra. Infants are accustomed to a lack of privacy because of the need to expose the perineum and touch the genitalia when cleaning the area. Fluid intake should be encouraged, not restricted. The indwelling catheter is not clamped; backup pressure could disturb the suture line.

A client with the diagnosis of schizophrenia refuses to get out of bed and becomes upset. What is the nurse's initial therapeutic response? 1 Requiring the client to get out of bed at once 2 Allowing the client to stay in bed for a while 3 Staying at the bedside until the client calms down 4 Giving the prescribed as-needed tranquilizer to the client

3 - Staying at the bedside until the client calms down Staying at the bedside until the client calms down provides support and security without rejecting the client or placing value judgments on behavior. Eventually limits will have to be set, but this is not the immediate nursing action. Allowing the client to stay in bed for the time being ignores the problem, and isolation may imply punishment. Although medication will calm the client, it does not address the problem.

A primiparous client is admitted to the birthing room in active labor. The fetus' head is engaged and the cervix is dilated 9 cm when there is a gush of fluid from the vagina. Place the nursing actions in order of priority. 1. Test the fluid's pH with Nitrazine paper. 2. Notify the practitioner. 3. Monitor the fetal heart rate for signs of compromise. 4. Perform a vaginal examination to ascertain the progression of labor.

1. - Monitor the fetal heart rate for signs of compromise. 2. - Test the fluid's pH with Nitrazine paper. 3. - Perform a vaginal examination to ascertain the progression of labor. 4. - Notify the practitioner. Whenever there is a change in the progress of labor, fetal well-being must be assessed first. The fluid should then be tested to determine whether it is amniotic fluid. A vaginal examination may be performed to gather more data. The practitioner should then be notified about the progress of labor.

The parents of an infant with pyloric stenosis ask a nurse many questions about the problem. What information should the nurse communicate when answering these questions? 1 It is unlikely that surgery will be necessary. 2 This is a condition with an excellent prognosis. 3 This condition results from an error of metabolism. 4 Special feedings will be needed for a few weeks after surgery.

2 - This is a condition with an excellent prognosis. In the absence of severe dehydration and malnutrition, the mortality rate is very low; immediate fluid and electrolyte replacement followed by surgery usually results in full recovery. Surgery usually is necessary; the success rate is high, and it produces a rapid recovery. Pyloric stenosis is a structural defect; hypertrophy of the circular muscle of the pylorus causes obstruction at the pyloric sphincter; this is not caused by an inborn error of metabolism. The infant usually resumes regular feedings within 48 hours of surgery.

A client is to have hemodialysis. What must the nurse do before this treatment? 1 Obtain a urine specimen to evaluate kidney function. 2 Weigh the client to establish a baseline for later comparison. 3 Administer medications that are scheduled to be given within the next hour. 4 Explain that the peritoneum serves as a semipermeable membrane to remove wastes.

2 - Weigh the client to establish a baseline for later comparison. A baseline weight must be obtained to be able to determine the net fluid loss from dialysis. Obtaining a urine specimen to evaluate kidney function is not necessary; clients with advanced kidney disease may not produce urine. Medications often are delayed until after dialysis to prevent them from being filtered into the dialysate. Explaining that the peritoneum serves as a semipermeable membrane to remove wastes applies to peritoneal dialysis, not hemodialysis.

While the nurse is caring for a client in active labor whose fetus is at station 0, the client's membranes rupture spontaneously. The nurse determines that the fluid is clear and odorless. What should the nurse do next? 1 Change the bedding. 2 Notify the practitioner. 3 Assess the fetal heart rate (FHR). 4 Obtain the client's blood pressure.

3 - Assess the fetal heart rate (FHR). The FHR will reflect how the fetus tolerated the rupture of the membranes; if there is compression of the cord, it will be reflected in a change in the FHR. Although the client's comfort is important, it is not the priority. Although the practitioner should be notified, it is not the priority. Blood pressure is not influenced by rupture of the membranes.

The nurse is advising an older adult client to apply moisturizer when the skin is moist. Which physical change in the client is associated with this advice? 1 Thinning subcutaneous layer 2 Degeneration of elastic fibers 3 Decreased dermal blood flow 4 Benign proliferation of capillaries

3 - Decreased dermal blood flow With decreased dermal blood flow the client is susceptible to dry skin; the nurse should advise the client to apply moisturizer when the skin is moist. If a client is found to have a thinning subcutaneous layer, the nurse should teach the client to dress warmly in cold weather. If a client presents with degenerated elastic fibers, the nurse should check the skin turgor on the forehead or chest of the client. If a client has benign proliferation of the capillaries, this indicates cherry hemangiomas; the nurse should teach the client that these are benign.

A client is admitted to the hospital for a surgical resection of the lower left lobe of the lung. After surgery the client has a chest tube to a closed chest drainage system. What should the nurse do to determine if the chest tube is patent? 1 Milk the chest tube toward the drainage unit 2 Check the amount of bubbling in the suction control chamber 3 Observe for fluctuations of the fluid in the water-seal chamber 4 Assess for extent of chest expansion in relation to breath sounds

3 - Observe for fluctuations of the fluid in the water-seal chamber Fluctuations of the fluid in the water-seal chamber indicate effective communication between the pleural cavity and the drainage system. Milking the chest tube toward the drainage unit should be avoided because it raises pressure in the pleural space, which can result in a tension pneumothorax. Bubbling in the suction control chamber is expected and should be continuous. Extent of chest expansion in relation to breath sounds does not directly reflect the patency of the chest tube.

Several hours after admission of a child to the pediatric unit with laryngotracheobronchitis (viral croup), the nurse determines that tachypnea and tachycardia, accompanied by intercostal and substernal retractions and increased restlessness, have developed. What is the priority nursing action? 1 Suctioning secretions from the trachea 2 Dislodging mucus by striking the back 3 Reporting the respiratory status to the practitioner 4 Increasing the concentration of oxygen being delivered

3 - Reporting the respiratory status to the practitioner These are signs of increasing hypoxia; intubation may be necessary to maintain an open airway. The signs are not indicative of increased secretions; suctioning could precipitate sudden laryngospasm. Striking the back is ineffective against laryngeal spasms. The inflammation is preventing the oxygen from reaching the lungs; increasing the amount of oxygen will not be effective until the inflammation is reduced.

A client is admitted to the hospital with suspected liver disease, and a needle biopsy of the liver is performed. After the procedure, the nurse should maintain the client in what position? 1 Supine 2 Semi-Fowler 3 Right side-lying 4 Dorsal recumbent

3 - Right side-lying The liver is on the right side of the body; the right side-lying position provides pressure at the needle insertion site and promotes hemostasis. The supine position does not provide pressure over the liver or promote hemostasis. The semi-Fowler position does not provide pressure over the liver or promote hemostasis. The dorsal recumbent position keeps the liver uppermost, thus no pressure is exerted to promote hemostasis.

The first responders rescue and bring submersion victims of a natural disaster to the emergency department. Which is an appropriate intervention for treating clients with submersion injuries? 1 Refrain from inserting urinary catheter 2 Immediately provide intubation and mechanical ventilation 3 Stabilize or immobilize cervical spine in all near-drowning victims 4 Immediately apply heating devices to keep the client's body temperature elevated

3 - Stabilize or immobilize cervical spine in all near-drowning victims The nurse should assume cervical spine injury in all near-drowning victims and stabilize or immobilize the victim's cervical spine. The nurse should insert a gastric tube and urinary catheter as an initial intervention for a submersion victim. The nurse should anticipate the need for intubation and mechanical ventilation if the airway is compromised, such as if the gag reflex is absent; intubation and mechanical ventilation need not be provided immediately to all clients if not required. While the client should be warmed if needed, the nurse needs to monitor the client's temperature and maintain normothermia.

The nurse notes that a client has mild hypothermia based on what body temperature? 1 29 °C 2 30 °C 3 33 °C 4 35 °C

4 - 35 °C Hypothermia occurs when the body temperature falls below 36.2 °C. Based on the severity, it is classified as mild, moderate, and severe. Mild hypothermia refers to a body temperature of 34 °C to 36 °C (93.2 °F to 96.8 °F). In this case, the client's body temperature is 35 °C, which indicates mild hypothermia. Moderate hypothermia refers to a body temperature of 30 °C to 34 °C (86 °F to 93 °F), and severe hypothermia refers to a body temperature below 30 °C (86 °F). The client does not have severe hypothermia; therefore, the client does not have a body temperature of 29 °C. The client does not have moderate hypothermia; therefore, the client does not have a body temperature of 30 °C or 33 °C.

When a client is receiving dexamethasone for adrenocortical insufficiency, what action does the nurse take to monitor for an adverse effect of the medication? 1 Auscultate for bowel sounds. 2 Assess deep tendon reflexes. 3 Culture respiratory secretions. 4 Measure blood glucose levels.

4 - Measure blood glucose levels. Corticosteroids, such as dexamethasone, have a hyperglycemic effect, and blood glucose levels should be monitored routinely. Assessing bowel sounds is unnecessary; corticosteroids are not known to precipitate cessation of gastrointestinal activity. Although corticosteroids may increase the risk of developing an infection, routine culturing of respiratory secretions is unnecessary. Culturing respiratory secretions becomes necessary when the client exhibits adaptations of a respiratory infection. Monitoring deep tendon reflexes is required when administering magnesium sulfate, not dexamethasone.

A postpartum client is being prepared for discharge. The laboratory report indicates that she has a white blood cell (WBC) count of 16,000/mm3. (16 X 109/L) What is the next nursing action? 1 Checking with the nurse manager to see whether the client may go home 2 Reassessing the client for signs of infection by taking her vital signs 3 Delaying the client's discharge until the practitioner has conducted a complete examination 4 Placing the report in the client's record because this is an expected postpartum finding

4 - Placing the report in the client's record because this is an expected postpartum finding Leukocytosis (15,000 to 20,000/mm3 WBC) (15 to 20 X 109/L) typically occurs during the postpartum period as a compensatory defense mechanism. There is no need for further intervention because the client is exhibiting an expected postpartum leukocytosis.

A client is brought to emergency services after a motor vehicle accident. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. Based on this information, the nurse assesses the client for which early response to decreased arterial pressure? 1 Warm and flushed skin 2 Confusion and lethargy 3 Increased pulse pressure 4 Reduced peripheral pulses

4 - Reduced peripheral pulses Hypovolemia results in a decreased cardiac output and a decreased arterial pressure, which are reflected by a feeble, weak peripheral pulse. The skin will be cool and pale because of vasoconstriction. Confusion and lethargy are late signs of shock. The pulse pressure narrows with decreased cardiac pressure associated with hypovolemic shock.

A nurse notices that a diabetic client is consuming chocolate brought by a family member. Which nursing action should a nurse perform to adhere to the principle of autonomy? 1 The nurse should ask if the client has a weakness for sweets. 2 The nurse requests that the client refrain from eating chocolates. 3 The nurse explains the consequences of eating chocolates to the client. 4 The nurse collaborates with a dietician to obtain a special diet chart for the client.

4 - The nurse collaborates with a dietician to obtain a special diet chart for the client. The nurse adheres to the principle of autonomy by collaborating with other healthcare providers to pursue the best treatment plan for the client. In this case, the nurse should collaborate with a dietician to obtain a special diet chart for a diabetic client. As a communicator, the nurse enquires if the client has a weakness for sweets. As a caregiver, the nurse should request that the client refrain from eating chocolates. As an educator, the nurse should explain the disadvantages of eating chocolates to the client.

What are the primary nursing interventions to check the circulation in a client? Select all that apply. 1 The nurse should prepare for chest decompression. 2 The nurse should evaluate the level of consciousness. 3 The nurse should prepare for endotracheal intubation. 4 The nurse should monitor the vital signs, especially the pulse. 5 The nurse should maintain vascular access with a large-bore catheter.

4 - The nurse should monitor the vital signs, especially the pulse. 5 - The nurse should maintain vascular access with a large-bore catheter. As a primary nursing intervention for circulation, the nurse should check the vital signs of the client, especially the pulse and blood pressure of the client. The nurse should maintain vascular access with a large bore catheter during an intervention involving the circulation. The nurse should prepare for chest decompression if required with a tension pneumothorax, because this could lead to cardiovascular collapse. Evaluation for level of consciousness is a nursing intervention to assess disability. The nurse should prepare for endotracheal intubation as a nursing intervention for cervical spine and airway.