Flashcards Quiz on Nursing Part 2

After a third hospitalization 6 months ago, Capillary refill of 8 seconds a client is admitted to the hospital with ascites and malnutrition. The client is Rationale: The client is bleeding and hypovolemia is likely. Capillary drowsy but responding to verbal stimuli refill is greater than 3 to 5 seconds indicates poor perfusion and and reports recently spitting up blood. requires immediate attention What assessment finding warrants immediate intervention by the nurse? a. Bruises on arms and legs b. Round and tight abdomen c. Pitting edema in lower legs d. Capillary refill of 8 seconds After the nurse witnesses a preoperative a. The client voluntarily grants permission for the procedure to be client sign the surgical consent form, the done nurse signs the form as a witness. What are the legal implications of the nurse's c. The client is competent to sign the consent without impairment of signature on the client's surgical consent judgment form? (Select all that apply) d. The client understands the risks and benefits associated with the a. The client voluntarily grants permission procedure for the procedure to be done b. The surgeon has explained to the client why the surgery is necessary. Rationale: Inform consent is required for any invasive procedure. The c. The client is competent to sign the nurse's signature as a witness to the client's signature on surgical consent without impairment of judgment consent indicates that the client voluntary gives consent for the d. The client understands the risks and scheduled procedure. C is competent to give consent, and D and benefits associated with the procedure understand the risk and benefits of the procedure. e. After considering alternatives to surgery, the client elects to have the procedure. Following surgery, a male client with Advise the client that assignments are not based on clients requests antisocial personality disorder frequently requests that a specific nurse be assigned Rationale: Those with antisocial personality disorders are manipulative to his care and is belligerent when another in order to meet their own needs. The charge nurse must set limits on nurse is assigned. What action should the this behavior. The client's superficial charm and emotional maturity charge nurse implement? prevent effective therapeutic communication and (A and B) will be used to the client's advantage. C encourage further manipulative a. Ask the client to explain why he behavior. constantly request the nurse b. Encourage the client to verbalize his feelings about the nurse c. Reassure the client that his request will be met whenever possible. d. Advise the client that assignments are not based on client requests A client with cervical cancer is hospitalized Place the implant in a lead container using long-handled forceps for insertion of a sealed internal cervical radiation implant. While providing care, the Rationale: Solid or sealed radiation sources, such as Cesium which is nurse finds the radiation implant in the bed. removed after treatment, are inserted into an applicator or cervical What action should the nurse take? implant to emit continuous, low energy radiation for adjacent tumor tissues. If the radiation source or the applicator become dislodged a. Call the radiology department long-handled forceps should be used to retrieve the radiation implant b. Reinsert the implant into the vagina to prevent injury due to direct handling. The applicator is then placed c. Apply double gloves to retrieve the in the lead container. implant for disposal. d. Place the implant in a lead container using long-handled forceps The client with which type of wound is Laceration most likely to need immediate intervention Rationale: A laceration is a wound that is produced by the tearing of by the nurse? soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from a. Laceration b. Abrasion c. Contusion d. Ulceration whatever object caused the cut The nurse is planning care for a client Monitor blood pressure frequently admitted with a diagnosis of pheochromocytoma. Which intervention Rationale: A pheochromocytoma is a rare, catecholamine-secreting has the highest priority for inclusion in this tumor that may precipitate life-threatening hypertension client's plan of care? a. Record urine output every hour b. Monitor blood pressure frequently c. Evaluate neurological status d. Maintain seizure precautions When caring for a client who has acute To reduce abdominal pressure on the diaphragm respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 Rationale: a semi-sitting position is the best position for matching degrees. What is the reason for this ventilation and perfusion and for decreasing abdominal pressure on intervention? the diaphragm, so that the client can maximize breathing a. To reduce abdominal pressure on the diaphragm b. to promote retraction of the intercostal accessory muscle of respiration c. to promote bronchodilation and effective airway clearance d. to decrease pressure on the medullary center which stimulates breathing When assessing a mildly obese 35-year- The gallbladder is normal old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? a. The client is too obese b. Palpating in the wrong abdominal quadrant c. The gallbladder is normal d. Deeper palpation technique is needed Rationale: a normal healthy gallbladder is not palpable A woman with an anxiety disorder calls her Inform her that some antianxiety medications are safe to take while obstetrician's office and tells the nurse of breastfeeding increased anxiety since the normal vaginal delivery of her son three weeks ago. Since Rationale: There are several antianxiety medications that are not she is breastfeeding, she stopped taking contraindicated for breastfeeding mothers. The woman is apparently her antianxiety medications, but thinks she aware that drugs can be transmitted through breast milk, so A is not may need to start taking them again helpful. C might be helpful, but the client's history suggest that because of her increased anxiety. What nonpharmacological methods of anxiety management do not response is best for the nurse to provide produce the best outcome. (D) the mother's history places her at risk this woman? for severe anxiety. a. Describe the transmission of drugs to the infant through breast milk b. Encourage her to use stress relieving alternatives, such as deep breathing exercises c. Inform her that some antianxiety medications are safe to take while breastfeeding d. Explain that anxiety is a normal response for the mother of a 3-week-old. An older male client with a history of type 1 Start an intravenous (IV) infusion of normal saline diabetes has not felt well the past few days and arrives at the clinic with abdominal Rationale: the nurse should first start an intravenous infusion of normal cramping and vomiting. He is lethargic, saline to replace the fluids and electrolytes because the client has moderately, confused, and cannot been vomiting, and it is unclear when he last ate or took insulin. The remember when he took his last dose of symptoms of confusion, lethargy, vomiting, and abdominal cramping insulin or ate last. What action should the are all suggestive of hyperglycemia, which also contributes to diuresis nurse implement first? and fluid electrolyte imbalance. a. obtain a serum potassium level b. administer the client's usual dose of insulin c. assess pupillary response to light d. Start an intravenous (IV) infusion of normal saline A client who received multiple The additive effect of multiple medications has caused the blood antihypertensive medications experiences pressure to drop too low syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's Rationale: When medication with a similar action are administered, an scheduled antihypertensive medication? additive effect occurs that is the sum of the effects of each of the a. Increased urinary clearance of the pressure, when administer together, resulted in hypotension. medication. In this case, several medications that all lower the blood multiple medications has produced diuresis and lowered the blood pressure b. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness c. The additive effect of multiple medications has caused the blood pressure to drop too low. d. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension. Which client is at the greatest risk for An adult client who cannot sleep due to constant pain. developing delirium? Rationale: Client who are in constant pain ad have difficulty sleeping or resting are at high risk for delirium. Supplemental oxygen may a. An adult client who cannot sleep due to cause confusion. B is taking medication so is not at high risk of constant pain. delirium. b. an older client who attempted 1 month ago c. a young adult who takes antipsychotic medications twice a day d. a middle-aged woman who uses a tank for supplemental oxygen Which intervention should the nurse Reduce risks factors for infection include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Rationale: Interventions aimed at reducing the risk factors of Disease (COPD)? infections should be included in the plan of care COPD client are at particular risk for respiratory infection. Prevention and early detection a. Reduce risks factors for infection of infections are necessary. b. Administer high flow oxygen during sleep c. Limit fluid intake to reduce secretions d. Use diaphragmatic breathing to achieve better exhalation Which location should the nurse choose as A business and professional women's group the best for beginning a screening program for hypothyroidism? Rationale: The population at highest risk is A so this is the group that would benefit the most for a screening program of hypothyroidism and occurs between 35 and 60 years of age and is most common in a. A business and professional women's females. group. b. An African-American senior citizens center c. A daycare center in a Hispanic neighborhood d. An after-school center for NativeAmerican teens A female client has been taking a high Measure vital signs dose of prednisone, a corticosteroid, for several months. After stopping the Rationale: Abrupt withdrawal of an exogenous corticosteroids can medication abruptly, the client reports precipitate adrenal insufficiency and hypoglycemia, hypokalemia, and feeling "very tired". Which nursing circulatory collapse can occur. Is most important for the nurse to intervention is most important for the nurse assess vital sign to impending shock. to implement? a. Measure vital signs b. Auscultate breath sounds c. Palpate the abdomen d. Observe the skin for bruising A male client reports the onset of Serum calcium numbness and tingling in his fingers and around his mouth. Which lab is important Rationale: Numbness and tingling of the fingers and around the for the nurse to review before contacting mouth, along with muscle cramps are signs of hypocalcemia the health care provider? a. capillary glucose b. urine specific gravity c. Serum calcium d. white blood cell count What explanation is best for the nurse to The technique is intended to maintain straight spinal alignment. provide a client who asks the purpose of using the log-rolling technique for turning? Rationale: The main rationale for use of the long-rolling technique is to maintain the client's spine straight alignment. a. working together can decrease the risk for back injury b. The technique is intended to maintain straight spinal alignment. c. Using two or three people increases client safety. d. turning instead of pulling reduces the likelihood of skin damage A client receiving chemotherapy has Baked apples topped with dried raisins severe neutropenia. Which snack is best for the nurse to recommend to the client? Rationale: A patient with chemotherapy-induced severe neutropenia a. Plain yogurt with sweetened with raw healthy snack for a client receiving chemotherapy. A, B and C have a honey high bacterial count and should be avoided. is at high risk for infection. A low bacteria diet is required D is a b. Peanuts in the shell, roasted or unroasted. c. Aged farmer's cheese with celery sticks d. Baked apples topped with dried raisins Which action should the school nurse take Inspect for symmetrical shoulder height. first when conducting a screening for scoliosis? Rationale: Children between 9 and 15 years old should be screening for scoliosis, which is exhibited.... Vertebral column. Screening for a. Compare dorsal measurement of trunk scoliosis should begin with inspection of shoulder height b. Extend arms over head for visualization c. Inspect for symmetrical shoulder height. d. Observe weight-bearing on each leg. An unlicensed assistive personnel (UAP) Assign a practical nurse (LPN) to determine if an apical radial deficit is assigned to obtain client vital signs reports present to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement? a- Instruct the UAP to count the client apical pulse rate for sixty seconds b- Determine if the UAP also measured the client's capillary refill time. c- Assign a practical nurse (LPN) to determine if an apical radial deficit is present. d- Notify the health care provider of the abnormal pulse rate and pulse volume. After a sudden loss of consciousness, a Encourage a low-carbohydrate and high-protein diet female client is taken to the ED and initial assessment indicate that her blood glucose Rationale: A client with anorexia nervosa with long term starvation or level is critically low. Once her glucose who self-restrict intake can sign.... Reserves. Providing the client with level is stabilized, the client reports that dietary selections such as low-carbohydrate, high protein.... was recently diagnosed with anorexia Hypoglycemic episodes, which can become life-threating. nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan? a. Describe the signs and symptoms of hypoglycemia. b. Encourage a low-carbohydrate and high-protein diet c. Reinforce the need to continue outpatient treatment d. Suggest wearing a medical alert bracelet at all time. A client with a peripherally inserted central Observe the antecubital fossa for inflammation. catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform? The nurse administers an antibiotic to a -White blood cell (WBC) count client with respiratory tract infection. To -Sputum culture and sensitivity evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement? Negative pressure environment A school nurse is called to the soccer field Sitting up and leaning forward because a child has a nose bleed (epistaxis). In what position should the nurse place the child A female client with breast cancer who Rented movies and borrowed books to use while passing time at completed her first chemotherapy home treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs Which instruction should the nurse provide Eat small meal throughout the day to avoid a full stomach. a pregnant client who is complaining of heartburn? Rationale: Eating small frequent meals throughout the day decreases stomach fullness and helps decrease heartburn. Fluids should not be a. Limit fluids between meals to avoid over consumed with foods because they further distend the stomach, but distension of the stomach fluids not be limited between meals (A) because this puts the client at b. Take an antacid at bedtime and risk for dehydration. (B) is not recommended during pregnancy unless whenever symptoms worsen prescribed by the health provider because they place the client at risk c. Maintain a sitting position for two hours for electrolyte imbalance (sodium), constipation (aluminum, or after eating. diarrhea (magnesium) (C) is less effective than (D) preventing d. Eat small meal throughout the day to heartburn. avoid a full stomach. A client is admitted to the intensive care Hypokalemia unit with diabetes insipidus due to a pituitary gland tumor. Which potential Rational: pituitary tumors that suppress antidiuretic hormone (ADH) complication should the nurse monitor result in diabetes insipidus, which causes massive polyuria and serum closely? electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias a. Hypokalemia b. Ketonuria. c. Peripheral edema d. Elevated blood pressure A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement? Digitally check the client for a fecal impaction After changing to a new brand of laundry Bilateral Wheezing. detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse? The nurse should teach the parents of a 6 Inflammation of the mucous membrane & bronchospasm year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response? A 10 year old who has terminal brain "The heart will stop beating & you will stop breathing." cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond? a. "Your mother & father will be here soon. Talk to them about that." b. "Why do you want to know about what will happen to your body when you die?" c. "The heart will stop beating & you will stop breathing." d. "Are you concerned about where your spirit will go?" The nurse is assessing a 3-month-old infant a. Restlessness who had a pylorotomy yesterday. This child b. Clenched Fist should be medicated for pain based on c. Increased pulse rate which findings? Select all that apply: d. Increased respiratory rate. a. Restlessness b. Clenched Fist c. Increased pulse rate d. Increased respiratory rate. e. Increased temperature f. Peripheral pallor of the skin The nurse is preparing to administer an oral Determine which side of the body is weak. antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication a. Ask the client about soft foods preferences b. Auscultate the client's breath sounds c. Obtain and record the client's vital signs d. Determine which side of the body is weak. The nurse who is working on a surgical unit Abdominal-perineal resection 2 days ago with no drainage on receives change of shift report on a group dressing who has fever and chills. of clients for the upcoming shift. A client with which condition requires the most Rationale: the client with an abdominal- perineal resection is at risk for immediate attention by the nurse? peritonitis and needs to be immediately assessed for other signs and symptoms for sepsis. a. Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing. b. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-pratt drain. c. Collapsed lung after a fall 8h ago with 100 ml blood in the chest tube collection container d. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills.