Unit 8-18
A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse should respond knowing that which can occur if the crutches rest underneath the arm? 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates
2. Injury to the brachial plexus nerves Rationale: Crutches are measured so that the tops are three or four fingerbreadths or 1 to 2 inches from the axilla. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the body. This could result in injury to the nerves of the brachial plexus.
The nurse is assisting in caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? 1. Limiting movement and abduction of the left arm 2. Limiting movement and abduction of the right arm 3. Assisting the client to get out of bed and ambulate with a walker 4. Having the physical therapist do active range of motion to the right arm
2. Limiting movement and abduction of the right arm Rationale: In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client's activities.
A client with multiple sclerosis is receiving diazepam (Valium), and the home care nurse reinforces instructions to the client regarding the side effects of the medication. The nurse tells the client that which is a side effect of this medication? 1. Insomnia 2. Incoordination 3. Inability to urinate 4. Increased salivation
Rationale: Incoordination and drowsiness are common side effects resulting from this medication. Options 1, 3, and 4 are unrelated to the use of this medication. 2. Incoordination
Enoxaparin sodium (Lovenox) is prescribed for the client following hip replacement surgery. The nurse prepares to have which available in the event that an overdose of the medication occurs?Protamine sulfate 1. Protamine sulfate 2. Naloxone (Narcan) 3. Epinephrine (Adrenaline) 4. Phytonadione (vitamin K
1. Protamine sulfate Rationale: Enoxaparin sodium is a low molecular weight heparin anticoagulant. Accidental overdose of this medication may lead to bleeding complications. The antidote is protamine sulfate. Naloxone is the antidote for opioids. Vitamin K is the antidote for warfarin sodium (Coumadin). Epinephrine is used to treat hypersensitivity reactions, or acute bronchial asthma attacks and bronchospasms.
A client with a prescription to take theophylline (Theo-24) daily has been given medication instructions by the nurse. The nurse determines that the client needs further teaching about the medication if the client makes which statement? 1.I will take the daily dose at bedtime." 2. "I will drink at least 2 L of fluid per day." 3. "I will avoid over-the-counter (OTC) cough and cold medications unless approved by the HCP." 4. "I will avoid changing brands of the medication without health care provider (HCP) approval."
1.I will take the daily dose at bedtime."Rationale: The client taking a single daily dose of theophylline, a xanthine bronchodilator, should take the medication early in the morning. This enables the client to have maximal benefit from the medication during daytime activities. In addition, this medication causes insomnia. The client should take in at least 2 L of fluid per day to decrease viscosity of secretions. The client should check with the HCP before changing brands of the medication. The client also checks with the HCP before taking OTC cough, cold, or other respiratory preparations because they could cause interactive effects, increasing the side effects of theophylline and causing dysrhythmias.
A client is scheduled for an intravenous pyelogram and has been instructed to take liquid magnesium citrate on the day before the scheduled procedure. The client asks the nurse about the administration procedure for this medication. Which instruction should the nurse provide to the client? 1.Take the medication on ice." 2. "Mix the medication with apple juice only." 3. "Mix the medication with a full glass of water." 4. "Drink the medication at room temperature."
1.Take the medication on ice." Rationale: Magnesium citrate is available as an oral solution. It is used commonly as a laxative before or following certain diagnostic studies. It should be served on ice and should not be allowed to stand for prolonged periods. This would reduce the carbonation and make the solution even less palatable.
A client with benign prostatic hypertrophy (BPH) undergoes a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigations postoperatively. Which are the signs/symptoms of transurethral resection (TUR) syndrome? 1. Tachycardia and diarrhea 2. Bradycardia and confusion 3. Increased urinary output and anemia 4. Decreased urinary output and bladder spasms
2. Bradycardia and confusion Rationale: TUR syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure, such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting.
A client has been instructed by the health care provider to alternate the use of hydrogen peroxide and glycerin eardrops to loosen an impacted accumulation of earwax. The nurse gives the client which directions to accomplish this daily procedure safely and independently? 1. Use the solutions chilled for 3 to 5 days." 2. "Use the solutions heated to 120 degrees for 5 to 7 days." 3. "Use the solutions at body temperature for 7 to 14 days." 4. "Use the solutions at room temperature for 1 to 3 days."
3. "Use the solutions at body temperature for 7 to 14 days." Rationale: The solutions should be used at body temperature for 7 to 14 days. This prevents injury to the ear and allows sufficient time for the material to soften. The other options are incorrect procedures.
A client is taking brompheniramine (BroveX). The nurse reinforces instructions to the client to expect which side effect of this medication? 1.Diarrhea 2. Excitability 3. Drowsiness 4. Excess salivation
3. Drowsiness Rationale: This medication is an antihistamine, and frequent side effects are drowsiness or sedation. Others include blurred vision, hypertension (and sometimes hypotension), dry mouth, constipation, urinary retention, and sweating. The other options are incorrect.
Sucralfate (Carafate) 1 g four times daily has been prescribed for a client with a diagnosis of gastric ulcer, and the nurse reinforces instructions to the client regarding administration of the medication. Which statement by the client indicates an understanding of the use of the medication?"I need to take the medication every 6 hours around the clock." 2. "I need to take the medication with my meals and again at bedtime." 3. "I need to take the medication 1 hour after meals and again at bedtime." 4. "I need to take the medication 1 hour before my meals and at bedtime."
4. "I need to take the medication 1 hour before my meals and at bedtime." Rationale: This medication is timed to allow it to form a protective coating over the gastric ulcer before food intake stimulates gastric acid production and mechanical irritation. Therefore, the medication should be scheduled for administration 1 hour before meals and at bedtime. The other options are incorrect.
The nurse is assisting a client who is new to a low-potassium diet to select food items from the menu. Which food item is lowest in potassium and should be recommended to the client on this dietary restriction? Spinach 2. Lima beans 3. Cantaloupe 4. Strawberries
4. strawberries Rationale: Cantaloupe, spinach, and strawberries are high-potassium foods. Lima beans contain potassium but in lower amounts than options 1, 3, and 4.
The nurse is assisting a client with cystitis to select foods that are appropriate for an acid-ash diet. The nurse encourages the client to eat which food? 1. Cheese 2. Ice cream 3. Garden peas 4. Strawberries
Rationale: A client trying to lower fat and cholesterol in the diet should decrease the use of fatty cuts of meats such as beef, lamb or pork, organ meats, sausage, hot dogs, bacon, and sardines; avoid vegetables prepared in butter, cream, or other sauces; use low-fat milk products instead of whole milk products and cream; and decrease the amount of commercially prepared baked goods. Option 3 is the only option that identifies low-fat and low-cholesterol foods. 3. Garden peas
A client who is postoperative with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed for which reason?To expel mucus from the airways 2. To dilate the terminal bronchioles 3. To exercise the muscles of respiration 4. To provide for increased oxygen tension in the alveoli
Rationale: 1.To expel mucus from the airways Coughing is one of the protective reflexes. Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways. The other options do not accurately address the purpose of coughing in the postoperative client.
The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which complication of hypothermia blanket use? 1. Frostbite 2. Skin breakdown 3. Arterial insufficiency 4. Venous insufficiency
Skin breakdown Rationale: When a hypothermia blanket is used, the skin is inspected frequently for pressure points that over time could lead to skin breakdown. Options 1, 3, and 4 are not complications of hypothermia blanket use.
Cycloserine (Seromycin) is added to the medication regimen for a client with tuberculosis. Which instruction should the nurse suggest to include in the client teaching plan regarding this medication? 1. Take the medication before meals 2. Return to the clinic weekly for serum drug levels. 3. It is not necessary to restrict alcohol intake with this medication. 4. It is not necessary to call the health care provider if a skin rash occurs.
answer: Return to the clinic weekly for serum drug levels. Rationale: Cycloserine is an antitubercular medication that requires weekly serum drug level determinations to monitor for the potential of neurotoxicity. A serum drug level less than 30 mg/mL reduces the incidence of neurotoxicity. The medication needs to be taken after meals to prevent gastrointestinal irritation. The client needs to be instructed to notify the health care provider if a skin rash or early signs of central nervous system toxicity are noted. Alcohol needs to be avoided because it increases the risk of seizure activity.
A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which sign or symptom that differentiates pericarditis from other cardiopulmonary problems? 1. Anterior chest pain 2. Pericardial friction rub 3. Weakness and irritability 4. Chest pain that worsens on inspiration
2. Pericardial friction rub Rationale: A pericardial friction rub is heard when there is inflammation of the pericardial sac during the inflammatory phase of pericarditis. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy. Anterior chest pain may be experienced with angina pectoris and myocardial infarction. Weakness and irritability are nonspecific complaints that could accompany a wide variety of disorders.
Isotretinoin (Amnesteem, Clavaris) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? 1. Platelet count 2. Triglyceride level 3. Complete blood count 4. White blood cell count
2. Triglyceride level Rationale: Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. Options 1, 3, and 4 do not need to be monitored specifically during this treatment.
A client who is scheduled for surgery and who is to be placed in skeletal traction says to the nurse, "I'm not sure if I want to have this skeletal traction or if the skin traction would be best to stabilize my fracture." Based on the client's statement, the nurse should make which response to the client?1. There is no reason to be concerned. I have seen lots of these procedures." 2. "Skeletal traction is much more effective than skin traction in your situation." 3. "You have concerns about skeletal versus skin traction for your type of fracture?" 4. "Your fracture is very unstable. You will die if you don't have this surgery performed."
3. "You have concerns about skeletal versus skin traction for your type of fracture?"Rationale: Option 3 identifies the therapeutic communication technique of paraphrasing. Paraphrasing is restating the client's message in the nurse's own words. Option 4 identifies a communication block that reflects a lack of the client's right to an opinion. It also will cause fear in the client. In option 2, the nurse is offering a false reassurance, and this type of response will block communication. Option 1 is also a communication block and reflects a lack of the client's right to an opinion.
A client with spinal cord injury has experienced more than one episode of autonomic dysreflexia. The nurse should avoid which action that could trigger an episode of this complication? 1. Preventing pressure on the client's lower limbs 2. Rigidly adhering to a bowel retraining program 3. Allowing the client's bladder to become distended 4. Keeping the linen under the client free of wrinkles
3. Allowing the client's bladder to become distended Rationale: Autonomic dysreflexia is triggered most frequently by a distended bladder. To prevent this, straight catheterization is done every 4 to 6 hours, and Foley catheters are checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas. The interventions in options 1, 2, and 4 would not trigger an episode of autonomic dysreflexia.
The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure should the nurse include in client teaching to help prevent dumping syndrome? 1.Ambulate after a meal. 2. Eat high-carbohydrate foods. 3. Limit the fluids taken with meals. 4. Sit in a high-Fowler's position during meals.
3. Limit the fluids taken with meals. Rationale: The client should be instructed to decrease the amount of fluid taken at meals. The client should also be instructed to avoid high-carbohydrate foods, including fluids such as fruit nectars; assume a low-Fowler's position during meals; lie down for 30 minutes after eating to delay gastric emptying; and take antispasmodics as prescribed.
The nurse is monitoring a client with a diagnosis of cancer for signs and symptoms related to vena cava syndrome. The nurse understands that which is an early sign of this oncological emergency? 1. Confusion 2. Disorientation 3. Periorbital edema 4. Mental status changes
3. Periorbital edema Rationale: Vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client's complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Mental status changes are late signs.
A client is receiving supplemental therapy with folic acid (Folate). The nurse evaluates the effectiveness of this therapy by monitoring the results of which laboratory study? 1. Blood glucose 2. Blood urea nitrogen 3. Alkaline phosphatase 4. Complete blood count
4. Complete blood count Rationale: Folic acid is necessary for red blood cell production and is classified as a vitamin and an antianemic agent. The effectiveness of therapy can be measured by monitoring the results of periodic complete blood count levels, noting particularly the hematocrit level. Options 1, 2, and 3 are not associated with the use of this medication.
The nurse is determining the need for suctioning in a client with an endotracheal tube (ETT) attached to a mechanical ventilator. Which observation by the nurse is inconsistent with the need for suctioning? `1. Restlessness 2. Gurgling sounds with respiration 3. Presence of congestion in the lungs 4. Low peak inspiratory pressure on the ventilator
4. Low peak inspiratory pressure on the ventilator Rationale: Indications for suctioning include moist, wet respirations; restlessness; congestion on auscultation of the lungs; visible mucus bubbling in the ETT; increased pulse and respiratory rates; and increased peak inspiratory pressures on the ventilator. A low peak inspiratory pressure would indicate a leak in the mechanical ventilation system.
The nurse is assigned to care for a client following a cataract extraction. The nurse plans to place the client in which position?1.prone 2. Supine 3. On the operative side 4. On the nonoperative side
4. On the nonoperative side Rationale: Postoperatively, cataract extraction clients should be positioned on their backs in a semi-Fowler's position or on the nonoperative side to prevent edema in the surgical site. The remaining positions are incorrect and will cause swelling at the surgical site.
