Prof Kolesar's Adult Health Midterm EAQs

Which client with complications of fracture would the nurse expect may be treated with a fasciotomy? A. Client 1 - Acute Respiratory Distress Syndrome (ARDS) B. Client 2 - Compartment syndrome C. Client 3 - Venous thromboembolism D. Client 4 - Fat embolism syndrome

B. Compartment syndrome is most likely to need a fasciotomy - cut open to release pressure

A client is receiving combination chemotherapy for the treatment of metastatic carcinoma. For which systemic side effect would the nurse monitor the client? A. Ascites B. Nystagmus C. Leukopenia D. Polycythemia

C. Leukopenia is a reduction in WBC and is a systemic effect from chemo (Nystagmus - involuntary rapid eye movement is local not systemic and not an effect from chemo)

Which clinical indicator would the nurse identify when a client has a fat embolus, but would not be present with a thromboembolus? A. Anxiety B. Restlessness C. Pinpoint red spots on the chest D. Decreased arterial oxygen level

C. Fat emboli cause capiallry fragility

After teaching a post-radiation therapy client regarding proper skin care to the treatment area, which client statements indicate understanding? Select all that apply A. "I will wear loose-fitting clothing over the area" B. "I will avoid using adhesive bandages" C. "I will avoid exposing the area to cold temperatures" D. "I will avoid rinsing the area with a saline solution" E. "I will use lotions to moisten the area when wearing makeup"

A., B., C.

The nurse is caring for a child who has an external fixation device on the leg. Which is the nurse's priority goal when providing pin care? A. Easing pain B. Minimizing scarring C. Preventing infection D. Preventing skin breakdown

C.

The nurse teaches a student nurse about caring for a patient with decreased bone density. Which statements made by the student nurse indicates effective learning? Select all that apply A. "I will instruct the client to refrain from running as exercise" B. "I will instruct the client to be very careful to prevent injuries" C. "I will instruct the client to perform weight-bearing activities" D. "I will instruct the client to drink at least 2L of water every day" E. "I will instruct the client to change positions every two hours"

B., C. exercise will help maintain bone density

Which arterial blood gas (ABG) value would indicate diabetic ketoacidosis? A. increased pH B. decreased Po2 C. increased Pco2 D. decreased HCO3

D.

The nurse is obtaining a health history from the parents of a toddler who has recently been diagnosed with acute lymphocytic leukemia. Which early physiologic changes would the nurse expect the parents to report? Select all that apply A. Pale skin B. Loss of hair C. Eating less food D. Sores in the mouth E. Purplish spots on the skin

A., C., E. Pallor, anorexia, and petechiae are symptoms of leukemia

When caring for a patient with peripheral arterial disease, which assessment findings will the nurse expect? Select all that apply A. Absence of hair on the toes B. Pink and moist ankle ulcers C. Pitting edema of the lower legs D. Reports of pain when exercising E. Increased pigmentation of the medial malleolus area

A., D.

Compromised nutrition during chemotherapy can contribute to an increased risk on infection and other problems. Which actions would the nurse take to offset nutritional deficiencies? A. Provide oral supplements B. Offer the client's favorite foods C. Restrict intake from dairy products D. Encourage the client to drink low-protein shakes

A.

The client is on neutropenic precautions. From which direction does the protective environment isolation help prevent the spread of infection? A. To the client from outside sources B. From the client to others C. From the client by using special techniques to destroy infectious fluids and secretions D. To the client by using special sterilization techniques for linens and personal items

A.

A client with cancer of the cervix has an intracavity radioactive sealed implant in place. Which precaution would the nurse take to protect against excessive exposure to radiation? A. Disposing of body fluids in specially marked containers B. Cohorting two clients who have implanted radiation therapy C. Leaving used linens in the room until cleared by the Radiation Safety team D. Encouraging visitors to stay with the client and sit near the lead wall

C. The sealed implant could have fallen out or been removed so need to make sure no radiation leaves the room

Which care issues are priorities during chemotherapy? Select all that apply A. Resources available for the nurse B. Handling the chemotherapy medications C. Managing the client's complications D. Protecting the client from side effects E. Treatment areas in which to serve clients

C., D. Client comes first

To avoid complications in a client who has developed severe bone marrow depression after receiving chemotherapy for cancer, which actions by the nurse are appropriate? Select all that apply A. Monitor for signs of alopecia B. Encourage an increase in fluids C. Wash hands before entering the client's room D. Advise use of a soft bristled toothbrush for oral hygiene E. Report an elevation in temperature immediately F. Teach the client to avoid eating raw fruits and vegetables

C., D., E. - Bone marrow depression causes NEUTROPENIA (impt to prevent infection) - Thrombocytopenia occurs with chemo

Which action would the nurse take to protect against radiation exposure while caring for a client receiving radiation therapy via internal implant? A. Wear a dosimeter badge B. Place a caution sign on the patient's bed C. Limit care to 2 hours a day D. Ensure linens are washed in bleach daily

A. This measures how much radiation the nurse ahs been exposed to

The registered nurse is teaching a nursing student about ways to minimize heat radiation. Which statements by the nursing student indicate effective learning? Select all that apply A. "I will apply an ice pack to the client." B. "I will cover the client with dark clothes" C. "I will instruct the client to remove extra clothes" D. "I will instruct the client to lie in the fetal position" E. "I will advise the client to wear sparsely woven clothes"

A., B., D. I literally just don't understand this one. it's fine

Which actions could the RN assign to an LPN caring for the client with a cast or traction? Select all that apply A. Monitoring skin integrity around the cast B. Marking circumference of any drainage on the cast C. Teaching the client and caregiver range of motion exercises D. Instructing family members on assisting the client with cast care E. Checking color, temperature, capillary refill, and pulses distal to the cast

A., B., E.

While caring for a client in traction, which actions could the nurse delegate to a licensed practical nurse (LPN)? Select all that apply A. Padding traction connections B. Determining correct body alignment C. Assessing complications associated with immobility D. Teaching the client about range of motion (ROM) exercises E. Assisting the client with passive and active range of motion exercises

A., E. RN needs to teach and assess

A client has seeds containing radium implanted in the pharyngeal area. What should the nurse include in the client's plan of care? A. Have the client void every two hours. B. Maintain the client in an isolation room. C. Spend time with the client to allow verbalization of feelings. D. Wear two pairs of gloves when touching the client during care.

B.

After an above-the-knee amputation of a right leg, a client reports pain in the right foot. The nurse should inform the client that phantom limb pain is the result of: A. Tactile illusions associated with severed blood vessels. B. Nerve endings in the limb that are still intact and react to stimuli. C. An unconscious phenomenon to aid with grieving over the lost body part. D. Hallucinations secondary to emotional symptoms associated with the distress of amputation.

B.

An older adult with a history of small cell lung carcinoma reports muscle cramping, thirst, and fatigue. The primary care provider diagnoses the client with a pituitary disorder and is treating the client accordingly. Which is an effective outcome of treatment? A. Urine output of 10L/day B. Urine specific gravity less than 1.025 C. Urine osmolarity of 80 mOSM/kg D. Serum osmolarity of 600 mOSM/kg

B.

Which finding in a client who has syndrome of inappropriate antidiuretic hormone (SIADH) is an expected finding? A. preservation of salt B. retention of water C. decrease of vasopressin D. Presence of pedal edema

B. characterized by free water retention

Which assessment findings are consistent with a client diagnosis of right-sided heart failure? Select all that apply A. Collapsed neck veins B. Distended abdomen C. Dependent edema D. Decreased appetite E. Cool extremities

B., C., D.

Upon review of morning lab reports, which client's report indicates acquired immunodeficiency syndrome (AIDS)? A. Client 1 - 750 CD4 B. Client 2 - 550 CD4 C. Client 3 - 175 CD4 D. Client 4 - 450 CD4

C.

Which explanation would the nurse include when teaching a client with heart failure about the reason for a low-sodium diet? A. Body weight control B. Decreased fluid retention C. Lowering of blood pressure D. Prevention of hypernatremia

B.

Which clinical manifestations would lead the nurse to contact the health care provider regarding the potential development of acute osteomyelitis? Select all that apply A. Presence of a foot ulcer B. Temperature of 102 F C. Erythema of the affected area D. Tenderness of the affected area E. Drainage from the affected area

B., C., D. Bone infection - fever, swelling, tenderness

Which interventions will be contraindicated for a client for a client who has a fracture and compartment syndrome? Select all that apply A. Splitting the cast in half B. Applying cold compresses C. Reducing the traction weight D. Loosening the client's bandage E. Elevating the extremity above heart level

B., E. cold compresses lead to vasoconstriction and make compartment syndrome worse. elevating will reduce venous pressure

Which priority interventions would the nurse implement for a client with neutropenia in an emergency department? Select all that apply A. Monitor for rashes and pruritus B. Prepare an appropriate diet plan C. Obtain blood cultures immediately D. Teach hygiene measures to be followed E. Administer antibiotic STAT as prescribed

C., E.

How can the nurse BEST manage a common side effect of chemotherapy? A. Restricting fluid intake B.Instituting contact precautions C. Keeping the hair closely cropped D. Providing meticulous oral hygiene

D. A common side effect is oral ulcers

The registered nurse is caring for a client who is receiving chemotherapy. Which statement made by the client shows a need for the registered nurse (RN) to delegate unlicensed assistive personnel (UAP) to help the client with activities of daily living (ADLs)? Select all that apply A. "I have severe nausea after my treatments" B. "I developed a rash after my last chemotherapy treatment" C. "I am unable to tolerate the pain of chemotherapy" D. "I am unable to eat by myself because of the IV catheter" E. "I am unable to get out of bed because I am so weak from the chemotherapy treatment"

D., E.

Which items would the nurse need when caring for a client undergoing treatment from an internal radiation implant that has become dislodged? Select all that apply A. Mask B. Latex gloves C. Biohazard bag D. Lead-lined container E. Long-handled forceps

D., E.

The nurse is caring for a client with the following ABG values indicate which finding? PO2 - 89 PCO2 - 35 pH - 37 A. Respiratory alkalosis B. Poor oxygen perfusion C. Normal acid-base balance D. Compensated metabolic acidosis

C. PO2 - 80-100 PCO2 - 35-45 pH - 34-45

An older client who has been undergoing months of treatment for osteomyelitis reports perianal itching and diarrhea. Which assessment finding would the nurse expect to identify? A. Whitish-yellow lesions in the oral cavity B. Presence of glucose and ketones in urine C. Flexion contracture of the lower extremities D. Overgrowth of genital wart-like lesions

A. long-term antibiotics and cause candida and c. diff overgrowth

A client with a fractured hip is placed in traction until surgery can be performed. Which goal would the nurse explain as the purpose of the traction? A. Relieving muscle spasm and pain B. Preventing contractures from developing C. Keeping the client from turning and moving in bed D. Maintaining the limb in a position of external rotation

A. keeps the muscles from spasming and bone fractures moving and causing pain

A client expresses concern about being exposed to radiation therapy. Which statement would the nurse emphasize when informing the client about exposure to radiation? A. The dosage is kept at a minimum B. Only a small part of the body is irritated C. The client's physical condition is not a risk factor D. Nutritional environment of the affected cells is a risk factor

B.

When a client with acute myelocytic leukemia who is receiving chemotherapy develops tumor lysis syndrome, the nurse will anticipate a need to implement which collaborative action? A. Offer analgesics frequently B. Infuse large amounts of fluids C. Administer antibiotic therapy D. Give anticoagulant medication

B. TLS happens when chemo destroys a lot of abnormal cells quickly. hydration helps dilute all the things released into the body.

Which client statement indicates the need for further teaching about the traction device after a major fracture? A. Traction must be applied continuously to be affective B. Weights of 5 to 45 pounds are used to apply the counterweight C. The risks of skeletal traction include infection at the pin insertion site D. Traction pushes the fractured ends together to prevent them from pulling apart

D. Traction uses counterweight to pull instead of push the extremity into alignment

The client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? A. fever and chest pain B. Positive Homans sign C. Loss of sensation in the operative leg D. Tachycardia and petechiae over the chest

D. Tachycardia - impaired oxygen exchange Petechiae - occlusion of small vessels Homan's sign is with thrombophlebitis

Which assessment finding supports the nurse's conclusion that a prosthesis for a client with an above-the-knee amputation fits correctly? A. Skin that is cool to the touch B. Shrinking of the residual limb C. Absence of phantom limb pain D. Evenly darkened skin of the residual limb

D. This indicates even distribution of hemosiderin in response to the pressure of the prosthesis

Which client indicates the presence of hemorrhage? A. Client 1 - 6.3 million RBC B. Client 2 - 4.0 million RBC C. Client 3 - 4.8 million RBC D. Client 4 - 5.7 million RBC

B. RBC - 4.5-6 million

A client who is in skin traction while awaiting surgery for repair of a fractured femur asks the nurse to release the traction because of leg pain. Which response would the nurse make? A. "I can't do that because the weights are needed to keep the bone aligned" B. "I will remove half of the weights and notify your primary health care provider" C. "I'll get your prescribed pain medication increased to help relieve your discomfort" D. "I follow the primary health care provider's directions, and that is not prescribed"

A.

The nurse is caring for two clients with a below-the-knee amputation. The first client was in a motor vehicle collision. The second client has a history of chronically decreased arterial perfusion. Which information would cause the nurse to conclude that the postoperative courses of these two clients may differ? A. The first client probably will adjust more quickly B. The second client's incision will likely take longer to heal C. These clients are likely to have very different occupations D. The first client is more likely to have phantom limb sensations

B.

A client has a platelet count of 49,000/mL. The nurse would instruct the client to avoid what activity? A. Ambulation B. Blowing their nose C. Visiting with children C. Eating fresh fruits and vegetables

B. These numbers indicate Thrombocytopenia so need to avoid anything that could cause bleeding

Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply A. Burns B. Skin Cancer C. Osteomyelitis D. Diabetic ulcers E. Myocardial infarction

A., C., D. Hyperbaric Oxygen therapy - administering oxygen under pressure and raises oxygen in tissues

A client receiving cisplatin therapy developed tumor lysis syndrome (TLS). Which medication would the nurse anticipate administering to this client for treatment of TLS? A. Mesna B. Flavoxate C. Allopurinol D. Aprepitant

C. It promotes purine excretion TLS is the precipitation of metabolites (purine and potassium) of cell breakdown

A client with myasthenia gravis begins taking pyridostigmine. Two days later, the client develops loose stools and increased salivation. Which conclusion would the nurse make about these new developments? A. The client is experiencing myasthenic crisis B. The medication is causing cholinergic side effects C. The medication is triggering a paradoxical reaction D. The client is exhibiting toxic effects of the medication

B. This med inhibits destruction of acetylcholine - so parasympathetic activity may increase Myasthenic crisis - difficulty breathing, speaking, headaches, fatigue, and more

Which action would the nurse take in caring for a client after surgical placement of an external fixator on a client's leg A. Cleanse the pin sites with alcohol several times a day B. Perform a neuromuscular assessment of the lower extremities C. ambulate the client with partial weight bearing on the affected leg D. Maintain placement of an abduction pillow between the client's legs

B. important because it can help identify early signs and symptoms of compartment syndrome

Which type of treatment is the Buck extension? A. Skeletal traction B. Cutaneous traction C. Halter transfixation D. Balanced suspension

B. type of traction applied directly to the skin by tape or foam boot.

A client with multiple myeloma who has been receiving chemotherapy comes to the emergency department because of confusion, muscle weakness, and diarrhea. Based on the client's history and the data from the chart, which complication would the nurse expect that the patient is experiencing? Labs: super elevated potassium A. septic shock B. tumor lysis syndrome C. superior vena cava syndrome D. disseminated intravascular coagulation

B. Hyperkalemia!

A postpartum client receiving a continuous heparin infusion for a deep vein thrombosis has an aPTT of 98 seconds. Which action would the nurse take in response to this situation? A. Increase the IV rate of heparin B. Interrupt the infusion and notify the primary health care provider of the aPTT result C. Document the result of the aPTT and recheck in 4 hours D. Call the primary care provider to obtain a prescription for low-molecular-weight heparin

B. Way too high of an aPTT and prolonged bleeding may result