practice exam
The nurse is caring for a client in the recovery room after electroconvulsive therapy (ECT). Which would be the priority nursing assessment?
vital signs Although ECT is an operative procedure, and a failure or reduction of peristalsis (also known as paralytic ileus) can accompany some surgical procedures, it is least expected after ECT procedure. Headache, disorientation, and memory loss are common short-term side effects, but the priority assessment would be client vital signs in the postictal state. The nurse would not be able to assess the client's response to ECT immediately postprocedure.
When developing the teaching plan for an adolescent with insulin-dependent diabetes, the nurse should include what information about the relationship between exercise, diet, and insulin?
Strenuous exercise, such as running, should be avoided if the adolescent's blood glucose level is 240 mg/dL (13.3 mmol/L) or above because it places the client at risk for hypoglycemia. When insulin levels are not adequate, the cells cannot receive glucose, even though the blood glucose level is high. With low insulin levels, glucagons act to increase hepatic glucose production, thus raising the blood glucose level, which cannot be used at the muscle site. Taking extra insulin prior to strenuous exercise also increases the risk of hypoglycemia. Vigorous muscle contraction increases local blood flow and absorption of insulin injected into that area. Because exercise decreases blood glucose levels, snacks should be given before strenuous exercise to prevent hypoglycemia. If the adolescent cannot tolerate the extra needed food, insulin dosage may have to be reduced.
A client is admitted to the hospital for evaluation of recurrent episodes of ventricular tachycardia as observed on Holter monitoring. The client is scheduled for electrophysiology studies (EPS) the following morning. Which statement should the nurse include in a teaching plan for this client?
"During the procedure, the health care provider will insert a special wire used to increase the heart rate and produce the irregular beats that caused your signs and symptoms."
A client receiving chemotherapy has pruritus. In educating the client about the care plan, the nurse should caution the client against which measure?
taking daily baths with a deodorant soap. Use of deodorant soaps is drying to the skin. Cotton clothing is the least irritating to skin. A cool, humidified environment adds to the client's comfort and provides hydration for the skin. Fluid intake of 3,000 mL/day is recommended for adequate hydration.
A client is scheduled to receive a blood transfusion. In addition to taking vital signs and verifying that the unit of blood cells is checked, what other assessments/actions would the nurse be responsible for? Select all that apply.
Assess the client for chills or low back pain. Stop the transfusion for reports of dyspnea or itching. Checking for the possibility of transfusion reactions is an important responsibility. Chills can be associated with blood contamination, low back pain can be associated with incompatible blood, and dyspnea and skin itching can be associated with an allergic reaction. The transfusion would need to be stopped. Rapidly transfusing blood is incorrect because the transfusion is started slowly for the first 15 minutes to detect abnormal reactions. Transfusing blood over a prolonged period, e.g., 5 hours, increases the risk of blood contamination. Transfusion of a unit of red blood cells can take up to 4 hours, and there are no restrictions on intake of food or fluid during the transfusion.
A client with bacterial pneumonia is coughing up tenacious, purulent sputum. Which action would help liquefy these viscous secretions?
Breathe humidified air. Humidified air helps to liquefy respiratory secretions, making them easier to raise and expectorate. Postural drainage may be helpful for respiratory hygiene but will not affect the nature of secretions. Vibration and percussion of the chest wall may be helpful for respiratory hygiene but will not affect the nature of secretions. Coughing and deep-breathing exercises may be helpful for respiratory hygiene but will not affect the nature of secretions.
Which goal is most important for a client with acute pancreatitis?
The client reports minimal abdominal pain. Abdominal pain can be a significant problem in acute pancreatitis. An expected outcome is to decrease or eliminate the pain the client is experiencing. Patterns of bowel elimination and liver function are not typically affected by pancreatitis. The client should avoid alcohol.
unlicensed assistive personnel (UAP) are helping a client who has had knee surgery 2 days ago get into bed. As the nurse makes rounds, which information requires the nurse to intervene?
The side rails on the head and foot of the bed are in the up position. Side rails are considered restraints and are not used at both the head and foot of the bed. Using side rails at the head of the bed will aid the client in sitting up and are safe, but using side rails at both the head and the foot of the bed presents risks for a client who might become wedged between the rail and the bed or attempt to climb over them. The nurse discusses side rail use with the UAP and lowers the side rail at the foot of the bed. The nurse assures the bed is placed in low position. The accessible call light, dim lighting, and clear path to the bathroom are factors that contribute to fall prevention.
A physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should
collect the specimen in a sterile container. The nurse should collect the stool specimen using sterile technique and a sterile stool container. The stool may be collected for 3 consecutive days. Although a stool culture should be taken to the laboratory as soon as possible, it need not be delivered immediately (unlike stool being examined for ova and parasites). Applying a solution to a stool specimen would contaminate it; this procedure is done when testing stool for occult blood, not organisms. The nurse shouldn't store a stool culture on ice because the abrupt temperature change could kill the organisms.
The nurse should assess a client taking chlorpropamide for:
hypoglycemia. Chlorpropamide is an antidiabetic agent. Clients should be observed for signs and symptoms of hypoglycemia. Other common side effects include anorexia, nausea, vomiting, and heartburn.The drug does not cause dumping syndrome, oral candidiasis, or extrapyramidal symptoms.
A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?
increased urine output. Glucose supplies most of the calories in TPN; if the glucose infusion rate exceeds the client's rate of glucose metabolism, hyperglycemia arises. When the renal threshold for glucose reabsorption is exceeded, osmotic diuresis occurs, causing an increased urine output. A decreased appetite and diaphoresis suggest hypoglycemia, not hyperglycemia. Cheyne-Stokes respirations are characterized by a period of apnea lasting 10 to 60 seconds, followed by gradually increasing depth and frequency of respirations. Cheyne-Stokes respirations typically occur with cerebral depression or heart failure.
A nurse is assessing a client's abdomen after abdominal surgery. Place the assessment techniques in the order in which the nurse should conduct them. All options must be used.
inspection auscultation percussion palpation When assessing a client's abdomen, the nurse should first inspect the contour and symmetry of the abdomen. Next, the nurse should auscultate for bowel sounds. Auscultation is performed before percussion and palpation because these latter techniques can alter the character of the bowel sounds. Percussion and palpation are the last steps of physical assessment of the abdomen.
Following an eclamptic seizure, the nurse should assess the client for which complication?
uterine contractions After an eclamptic seizure, the client commonly falls into a deep sleep or coma. The nurse must continually monitor the client for signs of impending labor because the client will not be able to verbalize that contractions are occurring. Oliguria is more common than polyuria after an eclamptic seizure. Facial flushing is not common unless it is caused by a reaction to a medication. Typically, the client remains hypertensive unless medications such as magnesium sulfate are administered.
The health care provider (HCP) verbally prescribed carboprost tromethamine 0.25 mg IM stat for a client experiencing a postpartum hemorrhage. The nurse administers the medication, but later finds that the HCP has written a prescription for 0.25 mg carboprost tromethamine IV stat. How should the nurse respond?
Call the HCP, discuss the prescription, and request revision if heard correctly. In emergency situations, verbal prescriptions should be entered into the medical record or chart and signed immediately after the emergency. The nurse taking this prescription and giving the medication needs to call the HCP, explain the prescription and that the medication was administered per the verbal prescription, and request that the HCP write the correct prescription. If the nurse misunderstood the prescription and gave the medication by the wrong route, an incident report will need to be initiated. The charge nurse would become involved if an error has occurred, an incident report is needed, or there is difficulty between the nurse and HCP that cannot be remediated. Rectifying this prescription is the responsibility of the implementing nurse. Waiting until the HCP comes back to the hospital unit may not occur quickly enough to safely care for the client.
An older adult who lives alone is admitted to the hospital for debility and weakness. What is the most important intervention to ensuring cost-effective care is provided for this client?
Ensure case management is actively involved in the client's care to facilitate care coordination. The nurse should ensure case management is actively involved in the client's care, as case management is essential to coordinating care for this client such as social work, physical therapy, home health care, and more. Clients are discharged from hospitals sooner and managing more complex health concerns at home in the current health care environment, and social work is instrumental in ensuring clients have access to all services they need. Administering home medications is important, but not the most important intervention for cost-effective care. This client may be able to return to previous independent living arrangements, especially with social work and additional home care services, so requesting nursing home placement is inappropriate for this client. The nurse should always listen to a client's concerns with compassion, but this client may be able to live independently still, and so a nursing home is not the most cost-effective intervention
A client has a newly created colostomy. After participating in a teaching session with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image?
The client touches the altered body part. By touching the altered body part, the client recognizes the body change and establishes that the change is real. Talking about the surgery and making menu choices shows the nurse that the teaching was successful, but does not show acceptance. Asking the spouse to leave the room signifies that the client is ashamed of the change and not coping with it.
A physician orders lithium carbonate for a client who has just been diagnosed with bipolar disorder. The nurse is teaching the client about signs and symptoms of lithium toxicity, which include:
lethargy, vomiting, and diarrhea. Lethargy is an early sign of lithium toxicity; if it goes undetected, vomiting and diarrhea soon develop. Lithium doesn't cause extrapyramidal effects, such as skeletal muscle contractions, cogwheel rigidity, and a thick tongue, or cholinergic effects, such as dry mouth, blurred vision, and urine retention. The drug also doesn't cause edema, orthostatic hypotension, or rash.
The nurse is creating a medication list and notes that the client takes saw palmetto. What should the nurse assess next?
"Tell me about your normal voiding patterns." It would be important to assess about the client's ability to void. Saw palmetto is used to relieve symptoms of benign prostatic hypertrophy. Joint pain would be important if the client was taking glucosamine. Niacin could be used to lower cholesterol, and melatonin would be appropriate for insomnia.
A client is attempting to give birth vaginally despite the fact that her previous child was born by cesarean birth. Her contractions are 2 to 3 minutes apart, lasting from 5 to 100 seconds. Suddenly, the client complains of intense abdominal pain and the fetal monitor stops picking up contractions. The nurse recognizes which complication has occurred?
complete uterine rupture In complete uterine rupture, the client feels a sharp pain in the lower abdomen and contractions stop. Fetal heart rate also stops within a few minutes. In abruptio placentae, uterine instability would continue to be indicated by the fetal heart monitor tracing. With cord prolapse, contractions would continue and the client wouldn't experience pain from the prolapse itself. Although vaginal bleeding occurs with partial placenta previa, the client has no pain outside of the expected pain of contractions.
The nurse should assess a client for which complications associated with disseminated intravascular coagulation (DIC)?
pulmonary embolism Pulmonary embolism is an indication of intravascular clotting due to the fact that platelets have been significantly decreased and there is clotting and bleeding. Low prothrombin levels will also show that there is a delay in clotting, so the person will bleed for a longer time. The other conditions are not associated with DIC.
A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl (26.1 mmol/L). Which finding is most likely to accompany this blood glucose level?
rapid, thready pulse. This client's abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respirations — not slow, shallow ones — are associated with hyperglycemia.
