QBank Comprehensive 8

A client seeks medical attention for cramping pelvic pain and saturating five sanitary napkins over a 2 hour period. Which questions are most important for the nurse to ask the client when conducting the health history of the current issue? (Select all that apply.) 1. "Are you feeling dizzy?" 2. "When was the first day of your last period?" 3. "Are you taking ibuprofen for your pain?" 4. "When did the bleeding start?" 5. "When did you last have intercourse?" 6. "What did you eat at your last meal?"

1. "Are you feeling dizzy?" 2. "When was the first day of your last period?" 4. "When did the bleeding start?" Dizziness = adverse effect from blood loss, LMP = important to determine pregnancy potential. Asking when bleeding started = gather history of event.

The home care nurse visits a client undergoing external radiation therapy after a lumpectomy of the right breast. Which statement, made by the client, indicates that the nurse's teaching is effective? 1. "I should wear a loose-fitting bra made of 100% cotton." 2. "I can apply scented lotion to the right side of my chest." 3. "I should expose my right breast to the air and sun." 4. "I can apply cold compresses to the right side of my chest."

1. "I should wear a loose-fitting bra made of 100% cotton." Cotton clothing to prevent irritation and avoid restrictive clothing to prevent skin chafing. Cotton = breathable and will reduce perspiration buildup on skin.

The school nurse teaches a group of school-age and adolescent clients about menstruation with a discussion about toxic shock syndrome (TSS). Which participant statement indicates to the nurse a need for additional teaching? 1. "I use only super absorbent tampons when I am menstruating." 2. "I will avoid all kinds of vaginal products that contain deodorants." 3. "If I begin to vomit or have diarrhea during my period, I will contact my health care provider." 4. "I will use tampons during the day and sanitary pads at night."

1. "I use only super absorbent tampons when I am menstruating." Super absorbant = too dry of vagina leading to vaginal wall damage and bacteria leading to TSS.

The nurse provides teaching to a client receiving ferrous sulfate 300 mg per day. Which client statement indicates that teaching is effective? 1. "I will have to eat more fresh fruits and whole-grain bread." 2. "This medication may cause fine motor tremors." 3. "My bowel movements may become light in color." 4. "I may have problems with blurred vision."

1. "I will have to eat more fresh fruits and whole-grain bread." Constipation is a side effect of ferrous sulfate. The patient should increase fruits, vegetables, fiber and fluids. Other side effects are gastric irritation, nausea, abdominal cramps, anorexia, vomit, dark colored stools.

The nurse provides care for a client with a history of a heart murmur who has been receiving clozapine for 2 weeks. The nurse reviews discharge instructions. Which client statement indicates that teaching is successful? 1. "I will return to the lab in 1 week to have my white blood count taken." 2. "I can take two pills the next morning if I miss my dose." 3. "I will limit my intake of sodium to 2 mg a day." 4. "I will increase my dose if I am feeling 'moody'."

1. "I will return to the lab in 1 week to have my white blood count taken." Clozapine is atypical antipsychotic. Side Effects = agranulocytosis (life threatening). The drug will be d/c if WBC fall below 2000/mm^3 (2x10^9/L).

The nurse in the newborn nursery receives report on a group of clients. Which client does the nurse assess first? 1. A 2-day-old client, quietly alert, heart rate of 185 beats per minute. 2. A 1-day-old client, crying, and the anterior fontanel is bulging. 3. A 12-hour-old client, respirations 45 and irregular. 4. A 5-hour-old client, hands and feet are blue bilaterally.

1. A 2-day-old client, quietly alert, heart rate of 185 beats per minute. Newborn has tachycardia. Normal respirations is 120 to 160bpm. 12-hour old baby normally is apneic.

he unlicensed assistive personnel (UAP) reports to the nurse that four clients are vomiting. Which client does the nurse see first? 1. A client with a nasogastric (NG) tube attached to low suction. 2. A client diagnosed with cirrhosis of the liver who has extensive ascites. 3. A client diagnosed with lung cancer who is undergoing chemotherapy. 4. An older adult client diagnosed with irritable bowel syndrome (IBS).

1. A client with a nasogastric (NG) tube attached to low suction. Assess for patency of the NG tube first. Clients should not vomit around an NG tube. The tube is there to maintain decompression of gastrointestinal pressure and continuous removal of contents. The nurse must assess the client and the NG system and suction to ensure patency and rule out emergent needs.

The nurse prepares to discharge a client who had a laryngectomy. Which information will the nurse include in the discharge instructions regarding stoma and laryngectomy care? (Select all that apply.) 1. Avoid swimming. 2. Use a home dehumidifier. 3. Avoid direct exposure to cold air. 4. Restrict fluid intake to 500 mL per day. 5. Get a medical identification bracelet.

1. Avoid swimming. 3. Avoid direct exposure to cold air. 5. Get a medical identification bracelet. Avoid swimming to prevent aspiration of water into stoma. Inhalation of cold air can cause tracheal spasm, having a medical ID tag allows EMT to be aware of stoma. Use of home dehumidifier may increase risk of excessive drying of secretions/mucus plug formation.

The nurse learns that a client received a dose of aminophylline four hours earlier than prescribed. Which action by the nurse is best? 1. Complete an incident report and notify the health care provider. 2. Change the time for the next medication administration. 3. Assess for bradycardia and lethargy before notifying the health care provider. 4. Skip the next dose of the medication.

1. Complete an incident report and notify the health care provider. Tachycardia and anxiety (not Brady and lethargy) are adverse effects of aminophylline. Used to treat asthma/lung diseases.

The nurse provides care to a client experiencing hypokalemia. Which is a risk factor for the development of this electrolyte imbalance? 1. Diarrhea. 2. Insulin deficiency. 3. Adrenal insufficiency. 4. Renal failure.

1. Diarrhea. Normal potassium = 3.5-5mEqL. Renal failure = HYPERkalemia. All other options are HYPERkalemia

The nurse provides care to a client with stage 1 Lyme disease. Which finding will the nurse expect when assessing this client? 1. Flu-like symptoms. 2. Arthralgias. 3. Signs of neurological disorders. 4. Enlarged and inflamed joints.

1. Flu-like symptoms. In stage 1 Lyme disease, most people develop flu-like symptoms. Enlarged/inflamed joints and neurological disorders can occur during later stages of the disease.

The nurse notes that a client with type 2 diabetes mellitus has a glycosylated hemoglobin A1c level of 6.5% (0.065). Which action will the nurse implement based on the current data? 1. Inform the client that the current treatment is effective. 2. Obtain a fingerstick blood sample for glucose testing. 3. Counsel the client about measures to better control blood glucose. 4. Notify the health care provider immediately of the test result.

1. Inform the client that the current treatment is effective. Normal glycosylated hemoglobin A1c values typically range from 4% to 6%. The target range for people with diabetes is less than 7%, so the nurse should inform the client that the current treatment regimen is effective.

The nurse provides care for a client admitted for the surgical repair of a detached retina in the left eye. Which intervention does the nurse include in the client's postoperative plan of care? 1. Limit the movement of both eyes. 2. Limit the amount of talking. 3. Wear patches over both eyes. 4. Perform self-care activities.

1. Limit the movement of both eyes. The patient should be on bed rest with an eye patch or shield. There is no restriction on talking.

A client diagnosed with Crohn disease experiences acute pain. Which action will the nurse teach the client to avoid to reduce the discomfort associated with the health problem? 1. Lying supine with legs straight. 2. Massaging the abdomen. 3. Using relaxation techniques. 4. Taking antispasmodic medication.

1. Lying supine with legs straight. Lying supine with legs straight will increase muscular tension in the abdomen, which aggravates inflamed intestinal tissues as the abdominal muscles are stretched.

The nurse provides care for a client who had a transurethral resection of the prostate (TURP). The client has a three-way urinary catheter connected by gravity with continuous bladder irrigation (CBI) of normal saline. Which observations require the nurse to intervene? (Select all that apply.) 1. Temperature of 101.4°F (38.3°C). 2. Urinary output of 100 mL in 4 hours. 3. Fluid leakage around the catheter tubing. 4. Blood pressure of 112/76 mm Hg. 5. 230 mL of sanguinous fluid in the catheter bag. 6. Client reports pressure in the pelvis.

1. Temperature of 101.4°F (38.3°C). 2. Urinary output of 100 mL in 4 hours. 3. Fluid leakage around the catheter tubing. 5. 230 mL of sanguinous fluid in the catheter bag. Elevated temp. = infection, at least 30ml/hr in addition to bladder irrigation fluid, fluid leakage suggests inflation/positioning error, hemorrhage is greatest danger = pink tinged urine expected with clots, patient should not have sanguineous drainage b/c its hemorrhage.

The nurse provides care for a client who had a hypophysectomy. The nurse observes clear drainage coming from the client's nostril. Which action does the nurse take immediately? 1. Test the drainage for glucose. 2. Document the drainage. 3. Lower the head of the bed. 4. Obtain a culture of the drainage.

1. Test the drainage for glucose. Complication r/t hypophysectomy = CSF leak which contains glucose. Hypophysectomy = removal of pituitary gland

The home care nurse visits a client diagnosed with cerebral palsy. The client's primary caregiver has been experiencing diarrhea secondary to viral gastroenteritis. Which observation indicates a need for follow up by the nurse? 1. The primary caregiver prepares a sandwich for the client. 2. The primary caregiver refuses to ask the health care provider for an antibiotic medication. 3. The primary caregiver drinks a glass of fruit juice. 4. The primary caregiver uses a bleach-based product when cleaning the bathroom.

1. The primary caregiver prepares a sandwich for the client. Someone WITH Gastroentrovirus (norovirus) can spread it easily to others = don't allow them to make food.

The nurse performs an assessment of a client diagnosed with Parkinson disease. The nurse expects to assess which symptoms? (Select all that apply.) 1. Tremors. 2. Diplopia. 3. Bradykinesia. 4. Slurred speech. 5. Respiratory distress. 6. Propulsive gait.

1. Tremors. 3. Bradykinesia. 4. Slurred speech. 6. Propulsive gait. Resting tremors, abnormally slow muscle movement and trouble imitating movement = common, propulsive gait is expected = instruct client to walk erect, watch horizon and use broad based gait.

The nurse provides care for a client with a leg amputation who is being considered for prosthetic fitting. Which nursing action is appropriate? 1. Wrap the residual limb with a bandage. 2. Provide on-site psychotherapy to the client. 3. Have the client participate in mirror therapy. 4. Perform passive range-of-motion exercises.

1. Wrap the residual limb with a bandage Proper residual limb bandaging fosters shaping and molding for the prosthesis fitting. Mirror therapy = phantom limb pain treatment.

The home health nurse conducts a home visit with a client who is the first-time parent of a newborn. Which client statements require further assessment by the nurse? (Select all that apply.) 1. "My baby nurses about every other hour. Is that normal?" 2. "The baby's just so quiet and sleeps almost through the night!" 3. "I sleep when the baby sleeps, and I can't get anything done." 4. "I'm afraid of hurting my baby, and I can't keep my baby happy." 5. "Why does my baby throw out arms and legs when startled?"

2. "The baby's just so quiet and sleeps almost through the night!" 4. "I'm afraid of hurting my baby, and I can't keep my baby happy." Newborns should eat 2-3 hours, lethargy/decreased activity = signs of neonatal hyperbilirubinemia, anxiety/despair are postpartum depression.

The nurse provides care for a client receiving haloperidol for 3 days. The client's temperature is 103.5°F (39.7°C), blood pressure 200/100 mm Hg, and pulse 122 beats/min. The client is pale and sweating excessively. Which action does the nurse take first? 1. Monitor vital signs every 15 minutes. 2. Administer bromocriptine as prescribed. 3. Administer the haloperidol as prescribed. 4. Assess the client's level of consciousness

2. Administer bromocriptine as prescribed. Neuroleptic Malignant Syndrome (NMS) is serious complication r/t psych drugs. Symptoms = high fever, rigidity, hen, decreased LOC. Manage fluid balance, reduce temperature, monitor for complications,, discontinue med and administer bromocriptine and dantrolene (to counteract effects).

A client is tested for suspected amyotrophic lateral sclerosis (ALS). Which early symptom will the nurse expect the client to exhibit? 1. Incontinence of bowel and bladder. 2. Difficulty swallowing. 3. Paresthesia of the face. 4. Disorientation to time and place.

2. Difficulty swallowing. Speech or swallowing difficulties, failure to accurately grasp a writing or eating utensil, gait impairments, or clumsiness may be initial symptoms. These symptoms progress rapidly over the course of less than five years, resulting in loss of all muscle control, including the muscles that control respiration.

The nurse reviews laboratory reports for a client diagnosed with acute kidney injury who will begin prescribed hemodialysis treatment later today. The client is prescribed 3000 units epoetin alfa subcutaneous three times a week. Which laboratory report requires immediate notification of the health care provider? 1. Hematocrit 31% (0.31). 2. Hemoglobin 12 g/dL (120 g/L). 3. Serum potassium 6.2 mEq/L (6.2 mmol/L). 4. Platelets 154,000 mm3 (154 x 109/L).

2. Hemoglobin 12 g/dL (120 g/L). Healthy kidneys produce a hormone called erythropoietin (EPO). This hormones causes the bone marrow to make red blood cells, which then carry oxygen throughout the body. With acute kidney injury, the kidneys do not make enough EPO. As a result, the bone marrow makes fewer red blood cells, causing anemia. A hemoglobin of 12 g/dL (120 g/L) indicates anemia and is associated with a higher risk of thromboembolic events such as a stroke, myocardial infarction, and heart failure.

The nurse on the neurology unit prepares a client for discharge after an exacerbation of multiple sclerosis. Which statement from the client to the nurse indicates that teaching is successful? 1. "When I exercise, I push beyond feeling tired and then stop." 2. "When my muscles are spastic, I will take a hot bath." 3. "I will sleep on my stomach as much as I can." 4. "I will be firm and steady when I stretch a spastic leg open."

3. "I will sleep on my stomach as much as I can." Sleeping prone may minimize spasm of the flexor muscles of the hips and knees of a person with multiple sclerosis. If these spasms are not relieved, joint contractures may occur. For the client who is unable to effectively reposition, prolonged periods of supine positioning increase the risk for developing pressure injury on the sacrum and hips. A spastic extremity should not be forced into position but gently rotated.

The nurse in the emergency department provides care for a client admitted with a possible cervical spinal cord injury (SCI). Which action does the nurse perform first? 1. Ask how the accident occurred. 2. Assess neurological functioning. 3. Auscultate respirations. 4. Ask about previous medical conditions.

3. Auscultate respirations. ABC. The nerves that control respiratory function arise from the cervical spinal cord region. If an injury to this area occurs, there is a risk of the client losing the ability to independently maintain respiratory functioning

The nurse provides care for a client who requires neurological checks every 2 hours. The nurse identifies which components as part of the Glasgow Coma Scale (GCS)? (Select all that apply.) 1. Eye-opening response — partially. 2. Best motor response — unsteady gait. 3. Best verbal response — confused. 4. Eye-opening response — none. 5. Best verbal response — incomprehensible sounds. 6. Best motor response — localizes pain.

3. Best verbal response — confused. 4. Eye-opening response — none. 5. Best verbal response — incomprehensible sounds. 6. Best motor response — localizes pain. The higher score indicates a higher level of neurological functioning. The maximum score is 15 and the minimum score is 3

The nurse notes that after a laboratory technician draws a blood specimen from a client that there are drops of blood on the floor and the wall next to the needle container. Which action does the nurse take first? 1. Contact the laboratory supervisor to report the incident. 2. Contact the nurse manager to report the incident. 3. Call housekeeping to clean and disinfect the area. 4. Counsel the laboratory technician about appropriate technique.

3. Call housekeeping to clean and disinfect the area. Have the area cleaned BEFORE reporting it. Safety first.

A client is in a hip spica cast after a fall and dislocation of the right hip. The LPN/LVN reports to the nurse that the client is feeling bloated, is reporting abdominal pain and nausea, and has vomited for the past 2 hours. After assessing the client, which action will the nurse take next? 1. Ask the LPN/LVN why it took so long to report to the registered nurse. 2. Administer prochlorperazine maleate as prescribed. 3. Call the health care provider and report the symptoms. 4. Get assistance and turn the client onto the left side.

3. Call the health care provider and report the symptoms. These symptoms indicate cast syndrome, also known as superior mesenteric artery syndrome. This is an unusual, but serious and urgent complication most often seen in clients in a hip spica or body cast. The cast pressure itself and/or accumulated intestinal gases cause the duodenum to be compressed between the aorta and the superior mesenteric artery, resulting in distention, abdominal pain, nausea, and vomiting. The nurse may need to cut a window into the abdominal area of the cast to relieve pressure. Alternative options include bivalving the cast or inserting a nasogastric tube to decompress the intestine.

The nurse assigns a client after a left mastectomy to an LPN/LVN. The nurse reminds the LPN/LVN to take the client 's blood pressure on the right arm. Later in the shift, the nurse notes that the deflated blood pressure cuff is on the client 's left arm. Which action does the nurse take? 1. Talk with the LPN/LVN after the shift is over. 2. Ask why the LPN/LVN did not follow directions. 3. Explain to the LPN/LVN the importance of taking the blood pressure on the right side . 4. Write a report about the incident and place it in the LPN/LVN 's personnel folder.

3. Explain to the LPN/LVN the importance of taking the blood pressure on the right side . Incident report is important, but don't place it in the personnel folder. Filing an incdient report without explaining to the LVN will not prevent future harm too patient.

The nurse provides care for a client with a peptic ulcer. Which initial assessment finding indicates to the nurse that the client has a perforated ulcer? 1. Nausea and vomiting. 2. Bradycardia. 3. Rigid, boardlike abdomen. 4. Swelling in the legs.

3. Rigid, boardlike abdomen. Sharp, sudden, intolerable pain spreads over abdomen and boardlike, rigid abdomen appears. Nausea/vomit happens AFTER perforation.

The nurse provides care to a client with a tracheostomy who is receiving oxygen. Which action is considered negligence by the nurse? 1. Wears goggles when changing the tracheostomy dressing. 2. Applies cream on the feet and legs after a bath. 3. Sprinkles powder on the chest after a bath. 4. Places a pre-cut gauze dressing around the tracheostomy.

3. Sprinkles powder on the chest after a bath. Powder on chest with tracheostomy could occlude the airway.

The nurse provides care for a client hospitalized for treatment of uncontrollable aggressive impulses. Which observation does the nurse record before beginning a behavior modification plan for the aggressive impulses? 1. The client tells each nurse that she is his favorite nurse. 2. The client is flirtatious with female members of the staff. 3. The client threatened to hit two other clients within 2 hours. 4. The client appears insincere and superficial in his interactions.

3. The client threatened to hit two other clients within 2 hours. Concrete evidence of aggressive behavior must be documented. The nurse intercedes early, continues nonthreatening behavior toward the client, but will restrain the client when necessary to protect self and others.

The nurse completes post-operative teaching for a client scheduled for a total abdominal hysterectomy. Which statement by the client indicates to the nurse the need for further teaching? 1. "I will call the health care provider if I have a temperature greater than 100.0°F (37.7°C)." 2. "I will use sanitary pads until the bleeding stops and will call about increased bleeding." 3. "I will report any problems with urination to my nurse as soon as possible." 4. "I will avoid any activity for the first 24 to 48 hours after my surgery."

4. "I will avoid any activity for the first 24 to 48 hours after my surgery." Early ambulation to prevent thromboembolism is necessary. Cough, deep breathing, incentive spirometry and avoiding heavy lifting are also used.

A nurse teaches a client who is being discharged home. The client has a T-tube after an open cholecystectomy. Which statement made by the client requires clarification by the nurse? 1. "The T-tube allows the bile to flow into my intestines. " 2. "I will measure and record the amount of drainage twice a day. " 3. "I will be careful to protect the skin around the T-tube site. " 4. "My T-tube should drain about 3 cups of bile per day. "

4. "My T-tube should drain about 3 cups of bile per day. " T-Tube expected daily output is 400ml (1 1/12 cups). T-Tube allows continuous flow of bile into small intestine.

The nurse admits a school-age client diagnosed with an open wound that tests positive for methicillin-resistant Staphylococcus aureus (MRSA). Which room assignment is appropriate for this client? 1. A semiprivate room with a toddler diagnosed with respiratory syncytial virus. 2. A semiprivate room with a preschool client diagnosed with acute respiratory virus. 3. A private room that is close to the nurse's station. 4. Any private room that is available.

4. Any private room that is available. Can only room with other MRSA patients. No need for close monitoring.

The nurse assesses a neonate at birth. The neonate's heart rate is 115 beats/min. The neonate has regular respirations with a rate of 40 breaths/min with a vigorous cry. The neonate has some flexion of extremities and grimaces with reflexive response. The nurse also notes that acrocyanosis is present. Which Apgar score does the nurse assign the neonate? 1. Apgar score 2. 2. Apgar score 3. 3. Apgar score 6. 4. Apgar score 7.

4. Apgar score 7. The neonate's Apgar score is 7. The neonate is assigned 2 points for heart rate greater than 100 beats/min, 2 points for respiratory effort, 1 point for muscle tone, 1 point for reflexes, and 1 point for color. An Apgar score of 0 to 3 is poor, a score of 4 to 6 is fair, and a score of 7 to 10 is excellent.

The nurse provides care for the client on bed rest who must maintain immobilization of the right leg. Which nursing action is most important? 1. Install a trapeze on the client's bed. 2. Assess bony prominences once per shift. 3. Place foam dressings on bony prominences. 4. Assist the client to turn safely every two hours.

4. Assist the client to turn safely every two hours. Turning the client at frequent intervals prevents skin breakdown caused by pressure, friction, or shearing forces. This is the most critical intervention for the nurse to employ to keep the client's skin healthy and to maintain the immobility of the right leg.

A client diagnosed with a spinal cord injury is being treated for a neurogenic bladder. Which medication does the nurse expect to be prescribed as part of this client's bladder retraining program? 1. Diphenhydramine. 2. Diazepam. 3. Dicyclomine. 4. Bethanechol.

4. Bethanechol Bethanechol is a cholinergic or parasympathomimetic medication used to treat functional urinary retention. It mimics the action of acetylcholine.

The school nurse is observing a high school basketball game. Two cheerleaders are tumbling and hit each other in midair. One of the cheerleaders begins to cry and says, "I think my arm is broken." Which action should the school nurse take first? 1. Call 911. 2. Immobilize the arm. 3. Notify parents of incident. 4. Inspect the affected arm.

4. Inspect the affected arm. Inspect first in order to see if it needs to be immobilized. Inspection is FIRST STEP in assessment. Remove clothing and inspect for bleeding, swelling, deformities.

A client diagnosed with a chronic idiopathic seizure disorder, controlled with antiseizure medication, will be married in five weeks. The client is concerned about having a seizure during the ceremony. Which is the best action for the nurse to implement? 1. Ask the health care provider to increase the client's medication dosage for the wedding day. 2. Ask a nurse to attend the wedding and assist as needed. 3. Teach the client how to perform relaxation exercises. 4. Tell the client to make a medication and seizure chart.

4. Tell the client to make a medication and seizure chart. A chart will identify triggers for seizures such as alcohol, stress or caffeine. Seizure activity also increases during menses.