Exam Revision Guide Part 3 (53-74)

Question 53 A nurse has admitted a client to the hospital from home. During assessment the nurse notes a reddened, warm spot on the client’s coccyx. Choose an appropriate nursing action to address this finding. Massage the client’s coccyx twice a shift Reposition the client off their coccyx every two hours Order an off-loading mattress to relieve pressure on the coccyx Use a pillow as a cushion on the client’s bedside chair The nurse should turn and reposition the client off their coccyx at least every two hours. Massage could cause further tissue damage to the area. The provider must order a special mattress to relieve pressure. A pillow provides more pressure on the client’s coccyx. Question 54 A clinic nurse is assessing a client who complains of a large blister on their left heel following participation in a 5K race. Choose the best nursing action to treat this wound. Use a sterile needle to break the blister then apply a dry sterile dressing Instruct the client to leave the wound open to the air Protect the wound with a dry sterile gauze pad Carefully cut away the blistered skin and leave it open to the air Stage II pressure ulcers, which include blisters, should be protected from further injury by covering them with a dry sterile gauze and avoiding further pressure to the area. Question 55 A nurse is caring for a client with a Stage III pressure ulcer. The nurse will measure and record what data in the client’s medical record? Length, width and depth of the wound and any undermining or tunnelling Length and width of the wound with undermining noted Length, width and depth of the wound Length and width of the wound with tunnelling and undermining noted The nurse should measure the wound’s length, width, depth and note the measurement of any undermining or tunnelling. Question 56 A client asks the nurse about bilevel positive airway pressure (BiPap) devices as the provider just prescribed one for them. Choose the best explanation from the nurse. It provides negative pressure on inspiration and positive pressure on expiration BiPap provides both negative and positive pressure on inspiration It provides positive pressure on inspiration and expiration BiPap senses the client’s breathing and regulates it BiPap provides positive pressure on inspiration and expiration to prevent occlusion of the airway by tissue in the pharynx and throat. Question 57 The nurse is preparing to perform tracheal suctioning on a client. Select the best position in which to place this client. Lateral Semi-fowlers Supine Sims The client should be placed in the semi-fowlers position with the head and upper body elevated between 45 and 90 degrees to facilitate chest expansion. Question 58 The nurse is suctioning a client when the oxygen saturation drops below 90%. Select the action the nurse should perform next. Complete the suctioning as quickly as possible Increase oxygen flowing through the suction catheter Remove the suction catheter and hyperoxygenate the client Complete the suctioning and then hyperoxygenate the client It would be most appropriate for the nurse to stop suctioning the client, remove the suction catheter and hyperoxygenate them. Question 59 The nurse assesses a client having an anxiety attack who complains of numbness around the lips and tingling in the fingers. The nurse correctly recognizes these as signs of what? Hypoventilation Tachycardia Hypoglycemia Hyperventilation The client is displaying clinical signs of hyperventilation caused by blowing off too much carbon dioxide. Question 60 A nurse is teaching a group of post-operative clients how to correctly use the incentive spirometer. What does the nurse include in the teaching? Blow as hard as you can into the device Correct Answer Wash your hands before and after using the device Hold your breath for 10 seconds after taking a deep breath Use the device whenever you feel the need to cough The clients should be instructed to wash their hands before and after using the incentive spirometer. The client is instructed to inhale deeply on the device and hold their breath, if possible for 5 seconds before exhaling. The device is used once each hour while awake for 10 reps. Question 61 The nurse is preparing to discharge a client home who will be using an oxygen concentrator. The nurse teaches the client to do what to maintain safety while using oxygen? Always check the regulator before using oxygen Increase the liters per minute when you feel short of breath Only smoke in the room with oxygen if you use 2 liters or less per minute Wear synthetic clothing to prevent static electricity The client should always check the regulator before turning on the oxygen to make certain is is operational. The client should only increase the liters per minute if instructed to do so by the provider. The client and visitors should not smoke in the room where oxygen is being used. Synthetic clothing are more likely to cause static electricity than is natural fibers such as cotton and linen. Question 62 A nurse admits a client with bacterial pneumonia. The nurse recognizes the client is most at risk for this: Infection Correct Answer Hypoxia Hypovolemia Metabolic alkalosis The client with pneumonia has impaired gas exchange due to inflammation and infection of the alveoli. Therefore they are at risk for hypoxia. Question 63 The nurse is caring for several clients in the urgent care clinic. The nurse understands that this group is most likely to suffer oxygenation problems. Infants and toddlers Middle school children Teens and young adults Older adults Infants and toddlers have immature immune systems. When exposed to other children and adults with respiratory infections, they are more likely to develop infections. Also, teething may cause nasal congestion that can lead to respiratory infections. Finally, infants and toddlers exposed to second-hand smoke are more likely to suffer respiratory problems. Question 64 The nursing student is developing a plan of care for a client whose diagnosis is ineffective airway clearance related to retained pulmonary secretions as evidenced by the production of thick, yellow sputum. An appropriate nursing action for this client is what? Elevate the head of the bed 30º Restrict fluids to 1000 mL/day Encourage the client to cough and deep breathe Medicate the client with a cough suppressant The client should be placed in a semi-fowlers or fowlers position when in bed (at least 45 degrees). Fluids should be encouraged up to 2500 mL unless contraindicated by the client’s medical condition. The client should cough and deep breathe to encourage the movement of secretions, increase tidal volume and prevent atelectasis. The client should be encouraged to cough and the coughing should not be suppressed. Question 65 The nurse teaching a group of students explains the purpose of postural drainage for a client with oxygenation problems. The best explanation for the use of postural drainage is what? To provide a more comfortable position when sleeping To use gravity to pool secretions in the lower lobes To avoid suctioning the client Correct Answer To improve clearance of secretions Postural drainage improves clearance of secretions and therefore improves oxygenation. Postural drainage used gravity to move secretions from the lobes of the lungs into the trachea for suctioning or to enable efficient coughing. Question 66 The nurse is caring for a client who is able to cough productively, but unable to expectorate or swallow the sputum. Choose the appropriate nursing intervention and device. Correct Answer Oral Suctioning Oral Suctioning Oral Suctioning Tracheal Suctioning The nurse would use a yankaur suction to perform oral suctioning. Question 67 The nurse must select a prescribed oxygen delivery device that provides low flow oxygen at 60%. Select the correct device. The nurse will select a partial rebreather which can deliver 60% oxygen. A- is a venturi mask which is high flow and can deliver 24%-50%. B- is a nasal cannula that delivers 24%-44%. Cis a simple face mask that can deliver 35%-50%. Question 68 A nurse in a long-term care facility instructs nurses about using an assistive device during ambulation. Choose the correct way to instruct ambulating with a cane. Correct Answer The cane should move first, then the client The client should hold the can on the weaker side of the body The grip should be level with the client’s waist The client moves the strong leg first than the weak one When a client moves, the cane should move forward about 12 inches. Then, the client moves the weaker leg and finally brings the stronger leg forward. Question 69 A nurse is preparing to move a client who is only partially able to assist up in bed. Which method should the nurse plan to use? One nurse lifting as the client pushes with their feet Two nurses lifting the client under the shoulders One nurse lifting the client’s legs as the client uses a trapeze bar Two nurses use a friction-reducing device This method reduces the risk of injury to both the nurses and the client. The nurses can use a slider sheet, draw sheet or any other friction reducing aid. Question 70 Plantar flexion contractures can best be prevented through the use of this device. Trochanter roll Sheepskin heel pad Abduction pillow Footboard or plantar boot The use of a footboard can prevent plantar flexion also known as “foot drop”. Trochanter rolls prevent external rotation of the hip. Sheepskin heel pads prevent pressure ulcers from forming on the client’s heels. An abduction pillow keeps the client’s hips abducted to prevent dislocation following hip arthroplasty. Question 71 A nurse who is applying a gait belt before ambulating a client will correctly place the belt in this position: Tightly just below the ribs Snugly just above the client’s hips Loosely above the abdomen Tightly just below the client’s hips The correct placement of a gait belt is snugly just above the client’s hips. Question 72 A nurse is helping to ambulate a client who frequently loses balance while walking. Choose the best device to aid in safety for this client. Gait belt Jacket harness Four-wheel walker Cane The nurse should apply a gait belt to this client while ambulating to help the client maintain their balance. A jacket harness is used to prevent falling from a chair. A walker cannot support a client who loses their balance and may in fact cause an injury if the walker is pushed away from the client. Canes are not stable. If they are not perpendicular to the floor they may cause a fall for someone who loses their balance. Question 73 A client frequently attemps to remove his intravenous catheter. A family member asks the nurse to apply restraints. Choose the most appropriate response from the nurse. “I’ll provide more stimulation in the environment” “I will call the provider for an order” Correct Answer “I will cover the catheter to distract the client’s attention away from it” “I will wait and see if the behavior continues” The nurse should cover the catheter and place it out of sight of the client to draw attention away from it. Using stockinette or clothing to cover the IV site may distract the client and prevent them from trying to remove it. The nurse would reduce stimulation in the room to decrease confusion and agitation. The nurse should try other means to distract the client before calling and asking for a restraint order. Because of safety concerns the nurse needs to address the client’s behavior immediately. Question 74 A nurse is caring for a client who is postoperative and has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hours. Which action should the nurse take first? Check to determine if the catheter tubing is kinked Palpate the bladder Obtain a prescription to irrigate the catheter with 0.9% sodium chloride Encourage the client to drink more fluids Check the device first to make sure the tubing is not kinked and preventing free-flow of urine. The next step after that would be to palpate the bladder.