Rapid Prep Worksheets 4

physician suspects asbestosis. Which nursing problem should the nurse prioritize in the client? a. Impaired gas exchange b. Imbalanced nutrition: Less than body requirements c. Fatigue d. Ineffective airway clearance Correct answer: A A is correct. In asbestosis, there is filling and inflammation of lung spaces with asbestos fibers. These fibers move into the alveolar space and cause fibrosis, leading to increased production in secretions impairing gas exchange. This should be a priority problem for the nurse. B is incorrect. There is imbalanced nutrition on the patient because of his difficulty of breathing and intolerance to activity. However, it should not be prioritized over the gas exchange. C is incorrect. Because of the client’s impaired oxygenation, there is not enough oxygen that reaches the muscles to sustain activity. However, this problem must not take priority over the gas exchange. D is incorrect. Due to the increased secretions brought about by the asbestos fibers, there is an ineffective airway clearance. Although equally crucial with gas exchange, the nurse should prioritize impaired gas exchange over airway clearance because treatment for asbestosis is focused on the relief of symptoms. Oxygen delivery to the cells holds more importance. 7. A nurse is reviewing the arterial blood gas results of a client and notes the following: pH 7.45, PCO2 of 30 mm Hg, and HCO3-of 22 mEq/L. Which of the following conditions do these results indicate? a. Metabolic acidosis, compensated b. Respiratory alkalosis, compensated c. Metabolic alkalosis, uncompensated d. Respiratory acidosis, uncompensated Correct answer: B The normal pH ranges between 7.35-7.45. A respiratory condition would show an inverse relationship between the PCO2and the pH, as seen in this case. In a metabolic state, the HCO3- would have direct contact with the pH. Because the pH is at 7.45, which is within the normal range, this is an indication that compensation has occurred. Therefore, option B is the correct answer, while options A, C, and D are incorrect. 8. A middle-aged African American is being treated in the emergency room for sickle cell crisis. Which position should the nurse place the patient? a. Side-lying with flexed knees b. Fetal position c. Semi-Fowler’s position with knees and hips bent d. Semi-Fowler’s with legs extended on the bed Correct answer: D A is incorrect. The nurse should facilitate oxygenation and adequate circulation for the client. Knee flexion impedes the flow of the client. B is incorrect. In a fetal position, the client’s knees and hips are flexed. Knee and hip flexion impede circulation in the patient. The nurse should ensure that flow is optimal when positioning the client. C is incorrect. Semi-Fowler’s position facilitates lung expansion; however, the bent knees and hips impede the client’s circulation. The nurse should not place the client in this position. D is correct. The client in sickle cell crisis should be positioned to optimize circulation and oxygenation. The nurse should place the client in Semi-Fowler’s position with his extremities relaxed and straightened. 9. The nurse is talking to a client that is being evaluated for possible acute leukemia. Which question by the nurse is most relevant? a. How has your sleep been recently? b. Did you have a respiratory infection recently? c. Did you lose weight the last couple of months? d. Have you noticed any changes in your bowels lately?” Correct answer: B A is incorrect. Leukemia may be associated with insomnia. However, it is not one of the primary clinical manifestations of the disease. B is correct. The client with leukemia is at risk for bleeding tendencies and infection due to pancytopenia. Therefore, the nurse should ask about recurrent infections and an abnormal bleeding tendency; the primary clinical manifestations of leukemia. This is due to the abnormal amount of blast cells accumulated and suppressing normal white blood cells, red blood cells, and platelets. The lack of normal WBCs is what leads to the client’s high risk of infection. C is incorrect. Weight loss may be associated with leukemia, but it is not a primary clinical manifestation of the disease. It is more closely associated with the treatment of cancer, namely chemotherapy, than the cancer itself. D is incorrect. A change in bowel habits is one warning sign of cancer. However, it is associated more with colon cancer rather than leukemia. 10. During handoff, the nurse was informed that a patient’s serum potassium is 2.8 mEq/L. During rounds, the first thing that the nurse should assess in this client should be: a. Ability to balance while walking b. Quality of peripheral pulses c. Respiratory status looking out for shallow respirations d. Frequency of bowel movement Correct answer: C Rationale: Hypokalemia affects the musculoskeletal, cardiovascular, neurologic, and respiratory systems. The skeletal muscles become weak, which may make ambulation difficult. The peripheral pulses may become weak and thready. One of the muscles that will become weak is the diaphragm, which can lead to weak and shallow respirations. There may be decreased peristalsis in the GI system leading to constipation. So, all of these assessment findings are possible with hypokalemia! However, it is the respiratory system that is the first thing that the nurse should assess. Remember, airway, breathing, circulation!! Hypokalemia causes weakness of the diaphragm muscle which may lead to shallow respirations and lead to respiratory insufficiency. This is the priority, therefore respiratory status should be assessed first in any client with hypokalemia, making option C the correct answer. Options A, B, and D should also be included in the assessment but are not the utmost priority and are, therefore, incorrect. 11. The infant just finished surgery for repair of a malfunctioning ventriculo-peritoneal shunt. Which symptom would indicate to the nurse that a problem could be arising? a. Increased urine output b. Depressed fontanelle c. A decreased heart rate d. Irritability Correct answer: D A is incorrect. Increased urine output is not related to problems with VP shunting. B is incorrect. Depressed fontanels are a sign that the VP shunt is draining the CSF from the child’s cranial cavity. A bulging fontanel is a sign of a problem. C is incorrect. Bradycardia is not an initial sign of increased ICP. Tachycardia should be observed in increased intracranial pressure. D is correct. Irritability in an infant is a sign of increased intracranial pressure. 12. A nurse is calling the physician regarding a new medication order because the dosage prescribed is higher than the usual recommended dosage. The nurse, however, is unable to locate the physician, and the medication is due to be administered. Which action should the nurse implement first? a. Contact the unit’s nursing supervisor b. Administer the dose as prescribed since the nurse is protected by a written order c. Hold the medication until the physician can be contacted and the order is clarified d. Administer what the nurse knows as the recommended dose until the physician can be located Correct answer: A The correct answer is A. If the physician writes a prescription that is questionable or requires clarification, the nurse's responsibility is to contact the physician. If there is no resolution regarding the order because the physician cannot be located or because the physician insists on keeping the medicine as it was written, the nurse should contact the nurse manager or nursing supervisor for further clarification as to the proper steps that should be taken. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification. 13. A nurse employed in an emergency department is doing triage on the evening shift. Which of the following clients should be assigned the highest priority? a. A client complaining of muscle aches, a headache, and malaise that has been on for 5 hours b. A client who twisted her ankle when she fell while skateboarding c. A client with a minor laceration on the index finger sustained while slicing vegetables d. A client with chest pain who claims that he just ate a very spicy pizza 2 hours ago Correct answer: D In the emergency department, triage involves brief client assessment to classify clients according to their need for care and includes prioritization of care. The type of illness or injury, the severity of the problem, and the resources available are considered in the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes are classified as emergent and are the number 1 or highest priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a second priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as non urgent and are the third priority. Thus, the correct answer is D, while options A, B, and C are incorrect. 14. A client has just been transferred back to his room following a below knee amputation of the right leg. The nurse is closely monitoring the client. Which sign would prompt the nurse to assess further as it could indicate a developing complication? a. The client is growing increasingly restless b. The client has a blood pressure of 127/78 mmHg c. The client has a pulse rate of 89 bpm d. Hypoactive bowel sounds were found upon auscultation of 4 quadrants Correct answer: A A postoperative client who is growing increasingly restless should prompt the nurse to monitor closely and assess further as it can indicate hemorrhage, shock, or pulmonary embolism. A blood pressure of 127/78mmHg is healthy as well as a pulse rate of 89 bpm. Hypoactive bowel sounds are expected postoperatively. The correct answer, therefore, is option A, while options B, C, and D are incorrect. 15. A nurse is conducting client teaching on a client receiving a monoamine oxidase inhibitor (MAOI) about his drug therapy. The client has demonstrated understanding by stating, I should avoid tyramine-containing foods, or I may go into a hypertensive crisis. When asked to list down specific tyramine-containing foods, the client would be correct by including which of the following foods? a. Cream cheese b. Swiss cheese c. Milk d. Ice cream Correct answer: B Fermented, aged, or smoked foods are high in tyramine and should be avoided; thus, Swiss cheese. Cream cheese, milk, and ice cream are unfermented milk products and may be taken by patients on MAOIs without incident. The correct answer, therefore, options B. Options A, C, and D are incorrect. 16. A client with thrombocytopenia is currently having epistaxis. The most appropriate nursing intervention should be: a. Instruct the client to lie flat with his neck suspended b. Ask client to sit upright, leaning slightly forward c. Ask client to blow his nose, then put lateral pressure on his nose d. Ask client to hold his nose while bending forward from the waist Correct answer: B In the event of epistaxis, the client should be instructed to assume an upright position, leaning slightly forward to help prevent an increase of vascular pressure in the nose and help prevent aspiration of blood. Option B is therefore the correct answer. Lying in the supine position would predispose the client to aspiration. Blowing the nose would risk dislodging any clotting that has occurred and promote further bleeding. Bending at the waist increases the vascular pressure in the nose that would lead to further bleeding instead of stopping it. Options A, C, and D are therefore incorrect. 17. A 16-year-old adolescent is brought to the ER following an accident at a skating rink. The adolescent’s left knee is bruised and swollen. Upon interview, the nurse finds out that the adolescent has Hemophilia A. Which medication would be most appropriate for the client? a. Oxycodone b. Aspirin c. Ibuprofen d. Oxycodone terephthalate/acetylsalicylate Correct Answer: A A is correct. Oxycodone is an opioid analgesic that has no aspirin components and is used for moderate to severe pain. Oxycodone does not prolong the bleeding time and is therefore appropriate in the patient with hemophilia. B is incorrect. Aspirin would aggravate the client's condition by inhibiting platelet aggregation, increasing bleeding. C is incorrect. Ibuprofen, a NSAID medication, prolongs the bleeding time andis contraindicated in clients with bleeding disorders. All NSAIDs must be avoided in the patient with hemophilia. D is incorrect. Oxycodone terephthalate/acetylsalicylate has aspirin components; aspirin is contraindicated in clients with bleeding disorders. You may not have recognized this medication at first glance, but when you read thoroughly you should notice it contains acetylsalicylate. That should tell you it contains aspirin, otherwise known as salicylate acid!! And you know that aspirin should be avoided in patients with bleeding disorders due to the fact that it decreases platelet aggregation! 18. The client in a psychiatric clinic tells the nurse, I want to kill my wife. The moment I see I am going to kill her. What should be the nurse's next action? a. Respect the client’s right to privacy and confidentiality. b. Document the client’s statements c. Notify the client’s psychiatrist of the comments. d. Explore the client’s feelings about his wife Correct answer: C A is incorrect. Although the nurse should respect the confidentiality of the subject, the nurse should make arrangements so that the wife is informed of the threat to her safety. B is incorrect. The nurse needs to document what the client said in the conversation; however, the nurse should implement measures to ensure the safety of the client’ s wife. C is correct. Mental health staff must report identifiable third parties of threats made by a person, even if these threats were discussed in a private therapy session. D is incorrect. Exploring the client’s feelings regarding his wife would further increase the client’s anger toward her. This is not an appropriate action for the nurse to take. 19. A nurse is assigned to care for a 2-year-old who is newly diagnosed with acute lymphocytic leukemia. Which action should be included in the client’s plan of care that is directed to facilitate growth and development in the acutely ill toddler? a. Focus on educating parents to minimize anxiety over parenting of the child b. Make sure that the toddler is informed in advance of what is to take place in a procedure c. Isolate the child from parents, especially if there are temper tantrums. d. Encourage regression to a previous developmental level for familiarity and comfort. Correct answer: A When a toddler is acutely ill, it is best to have parents who are not overly anxious and can work well with hospital personnel. It is, therefore, best to exert effort in educating the parents in this case. Option A is, therefore, the correct answer. Option B is not an appropriate action because a toddler’s thinking is concrete and tangible, and the toddler cannot think beyond the observable. Preparation should be done immediately before the procedure. Temper tantrums are a standard developmental characteristic of a 2-year-old, and the parents must hold her to alleviate fear. Isolating the toddler from her parents is not a therapeutic approach. Option C is, therefore, incorrect. A toddler may regress during hospitalization but will not facilitate comfort. Option D is an inappropriate action. 20. A nurse is taking care of a male client who has just been diagnosed with hepatitis C. Which statement about this condition is accurate? a. The potential for chronic liver disease is unlikely b. Symptoms set in abruptly c. The incubation period for hepatitis C is usually 2-26 weeks d. Vaccinations are available for hepatitis C Correct answer: C A is incorrect. Both hepatitis B and C may result in chronic liver disease. Hepatitis A is unlikely to end up in chronic liver disease. B is incorrect. Hepatitis C symptoms have insidious onsets. C is correct. Its incubation period is between 2-26 weeks. D is incorrect. Vaccinations are available for hepatitis A and B only. There is no vaccination for hepatitis C.