Flashcards Quiz on Nursing Part 4

The nurse enters a client's room and Reposition the restraint tie onto the bedframe. observes the client's wrist restraint secured as seen in the picture. What action should Rationale: Restraints should be secured to the bedframe, which is the nurse take? more stable than the side rails. A is difficult to release quickly. The a. Use a full knot to secure the restrain tie. the side rail is changed. restrain should be removed from the side rail before the position of b. Reposition the restraint tie onto the bedframe. c. Raise the button side rail of the client's bed d. Document that the restrain is secured. A female client with acute respiratory Diminished left lower lobe sounds distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as Rationale: Diminished lobe sounds indicate collapsed alveoli or assist-control ventilator using 50% FIO2. tension pneumothorax, which required immediate chest tube insertion Which assessment finding warrants to re-inflate the lung. immediate intervention by the nurse? a. Premature atrial contractions (PAC) b. Hemoccult-positive nasogastric fluid c. Diminished left lower lobe sounds. d. Increasing endotracheal secretions. The development of atherosclerosis is a 1. Arterial endothelium injury causes inflammation process of sequential events. Arrange the 2. Macrophages consume low density lipoprotein (LDL), creating foam pathophysiological events in orders of cells occurrence. (Place the first event on top 3. Foam cells release growth factors for smooth muscle cells and the last on the bottom) 4. Smooth muscle grows over fatty streaks creating fibrous plaques 5. Vessel narrowing results in ischemia 1. Arterial endothelium injury causes inflammation Rationale: Prolonged low blood pressure leads to renal ischemia, 2. Macrophages consume low density which is the common etiology of acute tubular necrosis(ATN) lipoprotein (LDL), creating foam cells Decreasing urine output is an early indicator of ATN. 3. Foam cells release growth factors for smooth muscle cells 4. Smooth muscle grows over fatty streaks creating fibrous plaques 5. Vessel narrowing results in ischemia. Following a motor vehicle collision, an Oliguria signals tubular necrosis related to hypoperfusion adult female with a ruptured spleen and a blood pressure of 70/44, had an Rationale: Prolonged low blood pressure leads to renal ischemia, emergency splenectomy. Twelve hours which is the common etiology of acute tubular necrosis(ATN) after the surgery, her urine output is 25 Decreasing urine output is an early indicator of ATN. ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider a. This output is not sufficient to cleat nitrogenous waste b. Oliguria signals tubular necrosis related to hypoperfusion c. Low urine output puts the client at risk for fluid overload d. An increased urine output is expected after splenectomy A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most costeffective? a. Client geographic location and age b. Number of staff and number of clients c. Weekend and weekday staff availability d. Skills of staff and client acuity Skills of staff and client acuity When performing postural drainage on a Explain that the client may be placed in five positions client with Chronic Obstructive Pulmonary Disease (COPD), which approach should Rationale: Frequently, the client is placed in five positions (head down, the nurse use? prone, right and left lateral, and sitting upright) to aid in drainage of each of the five lobes of the lungs (D). Postural drainage should be a. Perform the drainage immediately after performed before meals to prevent nausea, vomiting and meals aspiration(A). The client should breath slow and exhale through b. Instruct the client to breath shallow and pursed lips to help keep airway open so that secretions can be fast drained while assuming the various positions. C is not required c. Obtain arterial blood gases (ABG's) prior to procedure d. Explain that the client may be placed in five positions A client presents in the emergency room Inability to close the affected eye, raise brow, or smile with right-sided facial asymmetry. The nurse asks the client to perform a series of Rationale: Because the motor function controlling eye closure, brow movements that require use of the facial movement and smiling are all carried on the 7th cranial (facial) nerve, muscles. What symptoms suggest that the the combination of symptoms directly relating to an impairment of all client has most likely experience a Bell's branches of the facial nerve indicate that Bell's palsy has occurred. palsy rather than a stroke? a. Slow onset of facial drooping associated with headache b. Inability to close the affected eye, raise brow, or smile c. A flat nasolabial fold on the right resulting in facial asymmetry. d. Drooling is present on right side of the mouth, but not on the left. The nurse is teaching a client how to Keeps the irrigating container less than 18 inches above the stoma perform colostomy irrigations. When observing the client's return Rationale: Keeping the irrigating container less than 18 inches above demonstration, which action indicated that the stoma permits the solution to flow slowly with little excessive the client understood the teaching? peristalsis does not cause immediate release of stool. a. Turns to left the side to instill the irrigating solution into the stoma b. Keeps the irrigating container less than 18 inches above the stoma c. Instills 1,200 ml of irrigating solution to stimulate bowel evacuation d. Inserts irrigating catheter deeper into stoma when cramping occurs The nurse should teach the client to b. Avoid grapefruits and its juice observe which precaution while taking dronedarone? Rationale: Grapefruit increase the effect of dronedarone thereby increasing the possibility of serious side effects. A does not cause a a. Stay out of direct sunlight serious effect. C may potentiate lethal arrhythmias and should be b. Avoid grapefruits and its juice avoided. D does not directly affect those taking dronedarone. c. Reduce the use of herbal supplements d. Minimize sodium intake. A client who sustained a head injury Confusion and papilledema following an automobile collision is admitted to the hospital. The nurse include Rationale: papilledema is always an indicator of increased ICP, and the client's risk for developing increased confusion is usually the first sign of increased ICP. Other options do intracranial pressure (ICP) in the plan of not necessarily reflect increased ICP. care. Which signs indicate to the nurse that ICP has increased? a. Increased Glasgow coma scale score. b. Nuchal rigidity and papilledema. c. Confusion and papilledema d. Periorbital ecchymosis. The nurse is caring for a client receiving Confirm the necessity for continued use of the CVC continuous IV fluids through a single lumen central venous catheter (CVC). Based on Rationale: Increase the length of use increase the risk for infection. the CVC care bundle, which action should The CVC care bundle includes the review of the need for continued be completed daily to reduce the risk for use of the CVC. Effective hand hygiene and standard precautions infection? should be maintained but protective environment precautions are not needed. B is not needed if continuous IV fluid are infused, ad may a. Remind staff to follow protective introduce contaminants. Use of a transparent dressing allows the site environment precautions to be visualized for any signs of infection but changing the dressing b. Gently flush the catheter lumen with daily increases the risk for infection. sterile saline solution c. Cleanse the site and change the transparent dressing. d. Confirm the necessity for continued use of the CVC. During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)? a. An increased thirst with frequent urination b. Blood glucose range during past two weeks was 110 to 125 mg/dl or 6.1 to 7.0 mmol/L(SI) c. Two-hour postprandial glucose tolerance test (GTT) is 160 mg/dL or 8.9 mmol/L (SI) d. Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). A new mother tells the nurse that she is Determine if she can ask for support from family, friend, or the baby's unsure if she will be able to transition into father parenthood. What action should the nurse take? Rationale: Emotional support of significant family and friends can help a new mother cope with anxiety about transitioning to parenthood. a. Provide reassurance to the client that The nurse should ask the client who is available to support her. these feeling are normal after delivery b. Discuss delaying the client's discharge from the hospital for another 24 hrs. c. Determine if she can ask for support from family, friend, or the baby's father. d. Explain the differences between postpartum blues and postpartum depression. A client who was admitted yesterday with Stop the normal saline infusion. severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing Rationale: If the IV has infiltrated or become dislodges, the fluid is at a rate of 150 ml/hour. Which intervention infusing into surrounding tissue and not into the vein. Stopping the should the nurse implement first? infusion C is the priority action. Establishing another IV site is necessary for fluid resuscitation after the infiltrated infusion is a. Establish the second IV site discontinuing the IV (D) is necessary due to the pain, and a large b. Asses the IV for blood return gauge needle is preferable. c. Stop the normal saline infusion. d. Discontinue the 24-gauge IV An elderly female is admitted because of a Ensure proper alignment of the leg in traction. change in her level of sensorium. During the evening shift, the client attempts to get Rationale: A fractured hip results in external rotation and shortening out bed and falls, breaking her left hip. of the affected extremity. With the application of Buck's skin traction Buck's skin traction is applied to the left leg proper alignment ensures the transaction while waiting for surgery. Which S pull is exerted to align the fracture hip with the distal leg, intervention is most important for the nurse immobilize the fractured bone, and minimize muscle spasms and to include in this client's plan care? surrounding tissue injury related to the fracture. A should be implement but improper pull of traction can increase pain and soft a. Evaluate her response to narcotic tissue damage. B and C should be implemented but the greatest risk analgesia is improper alignment of the traction. b. Asses the skin under the traction moleskin c. Place a pillow under the involved lower left leg d. Ensure proper alignment of the leg in traction. An Unna boot is applied to a client with a Document the ongoing wound healing venous stasis ulcer. One week later, when the Unna boot is removed during a follow- Rationale: Appearance of granulation tissue is the best indicator of up appointment, the nurse observes that increased venous retuns and ongoing wound healing the ulcer site contains bright red tissue. What action should the nurse take in response to this finding? a. Immediately apply a pressure dressing b. Document the ongoing wound healing. c. Irrigate the wound with sterile saline d. Obtain a capillary INR, measurement At the end of a preoperative teaching anxiety session on pain management techniques, a client starts to cry and states, "I just know I Rationale: The client is demonstrating only anxiety. There is no can't handle all the pain." What is the indication that the client is presenting signs of A, C or D priority nursing diagnosis for this client? a. Knowledge deficit b. Anxiety c. Anticipatory grieving d. Pain (acute) The nurse note a visible prolapse of the Elevate the presenting part off the cord umbilical cord after a client experiences spontaneous rupture of the membranes Rationale: The nurse should immediately elevate the presenting part during labor. What intervention should the off the cord because when the cord prolapses, the presenting part nurse implement immediately? applies pressure to the cord, especially during each contraction, and reduces perfusion to the fetus. A can be delayed until pressure is a. Administer oxygen by face mask at removed from the cord. B and D are important but do not have 6L/mint priority. b. Transport the client for a cesarean delivery c. Elevate the presenting part off the cord. d. Place the client to a knee-chest position. A client who had a right hip replacement 3 Reassess readiness for SNF transfer. day ago is pale has diminished breath sound over the left lower lung fields, a Rationale: Based on the client's symptoms, reassessing the client's temperature of 100.2 F, and an oxygen readiness for rehabilitation in the SNF is critical saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare provider? a. Reassess readiness for SNF transfer. b. Obtain specimens for culture analysis c. Confer with family about home care plans d. Arrange physical therapy for strengthening. A client who is newly diagnosed with type b. Recognize signs and symptoms of hypoglycemia. 2 diabetes mellitus (DM) receives a c. Report persist polyuria to the healthcare provider. prescription for metformin (Glucophage) e. Take Glucophage with the morning and evening meal. 500 mg PO twice daily. What information should the nurse include in this client's Rationale: Glucophage, an antidiabetic agent, acts by inhibiting teaching plan? (Select all that apply.) hepatic glucose production and increases peripheral tissue sensitivity to insulin. The client and family should be taught to recognize signs a. Take an additional dose for signs of and symptoms of hypoglycemia. If the dose of Glucophage is hyperglycemia inadequate, signs of hypoglycemia, such as polydipsia and polyuria, b. Recognize signs and symptoms of should be reported to the healthcare provider. Glucophage should hypoglycemia. be taken with meals to reduce GI upset and increase absorption (E). c. Report persist polyuria to the healthcare provider. d. Use sliding scale insulin for finger stick glucose elevation. e. Take Glucophage with the morning and evening meal. The nurse is developing an educational program for older clients who are being b. Contains a list with definitions of unfamiliar terms discharged with new antihypertensive c. Uses common words with few Syllables medications. The nurse should ensure that e. Uses pictures to help illustrate complex ideas the educational materials include which characteristics? Select all that apply Rationale: During the aging process older clients often experience sensory or cognitive changes, such as decreased visual or hearing acuity, slower thought or reasoning processes, and shorter attention a. Written at a twelfth-grade reading level span. Materials for this age group should include at least of terms, b. Contains a list with definitions of such as a medical terminology that incline may not know and use unfamiliar terms common words that expresses information clearly and simply. Simple, c. Uses common words with few Syllables attractive pictures help hold the learner’s attention. The reading level d. Printed using a 12-point type font of material should be at the 4th to 5th grade level. Materials should e. Uses pictures to help illustrate complex be printed using large font (18-point or higher), not the standard 12- ideas point font. During the admission assessment, the 4-5th intercostal space midclavicular nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client's point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location) An older male adult resident of long-term -Notify the healthcare provider of the client's change in mental status. care facility is hospitalized for a cardiac -Include q2 hour's reorientation in the client's plan of care. catheterization that occurred yesterday. Since the procedure was conducted, the Rationale: The client's condition reflects mental changes that could be client has become increasingly disoriented. related to post procedure stress, sundowner's syndrome, or cerebral The night shift nurse reports that he complications, the nurses should inform the healthcare provider of attempted to remove the sandbag from his the client's change in mental status for the client's safety, q2 hour femoral artery multiple times during the orientation evaluations and reorientation should be included in the night. What actions should the nurse take? plan of care. (Select all that apply.) a. Recommend a 24-hour caregiver on discharge to the long-term facility. b. Notify the healthcare provider of the client's change in mental status. c. Include q2 hour's reorientation in the client's plan of care. d. Request immediate evaluation by Rapid Response Team e. Apply soft wrist restraints so that the operative site is protected. An older male comes to the clinic with a family member. When the nurse attempts to take the client's health history, he does not respond to questions in a clear manner. What action should the nurse implement first a. Ask the family member to answer the questions. b. Provide a printed health care assessment form c. Assess the surroundings for noise and distractions. d. Defer the health history until the client is less anxious. Assess the surroundings for noise and distractions. The nurse caring for a client with acute Large amounts of fluid and electrolyte replacement. renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Rationale: This client, whose output is significantly high will need fluids Based on this assessment, what should the and electrolyte replacement. The diuretic stage of ARF begins when nurse anticipate that client will need? the client has greater than 500 ml of urine in 24 hrs. A is associated with the oliguric and anuric stage of ARF. B and D should not occur a. Treatment for acute uremic symptoms until the client's BUN and electrolytes indicate a significant within 24 hours improvement that will allow for such changes. b. Change to a regular diet c. Large amounts of fluid and electrolyte replacement. d. Unrestricted sodium intake Which intervention should the nurse Minimize the amount of stimuli in the room include in the plan of care for a child with tetanus? Rationale: Tetanus is an acute, preventable, and often fatal disease caused by an exotoxin produces by the anaerobic spore forming a. Open window shades to provide natural gram positive bacillus clostridium tetani, which affect neuromuscular light junction and causes painful muscular rigidity. In planning caring for a b. Reposition side to side every hour. child with tetanus, any environmental stimulation should be minimized. c. Minimize the number of stimuli in the room. d. Encourage coughing and deep breathing Suicide precautions are initiated for a child Remove cigarettes for the client's room admitted to the mental health unit following an intentional narcotic overdose. Rationale: Safety is the priority, and any items that might cause self- After a visitor leaves, the nurse finds a harm, such as cigarettes should be removed immediately to create a package of cigarettes in the client's room. safe environment. Which intervention is most important for the nurse to implement? a. Assign a sitter for constant observation b. Screen future visitors for contraband c. Document suicide monitoring frequently d. Remove cigarettes for the client's room.