Exam Revision Guide Part 2 (29-52)

Question 29 A nurse is assessing a young woman diagnosed with anorexia nervosa. The nurse suspects the client is not eating all of the food on their prescribed diet when they observe this: a. They make frequent bathroom visits after meals b. Food waste is often found in the trash after family visits c. The client does not gain any weight between weigh-ins d. The client has very specific meal preferences The best way to determine a client with anorexia nervosa is not eating their prescribed diet is to check their weight. No weight gain, or weight loss indicates the client is not eating their prescribed diet. Bulemic clients will go to the bathroom to vomit or move their bowels immediately following meals. Food waste in the trash after family visits may have come from the visitors and not the client. A client with specific meal preferences can still maintain a therapeutic diet. Question 30 The nurse caring for a new mother is teaching about proper nutrition for the infant. Choose the best statement regarding infant nutrition. a. Infant formulas are the same as breast milk b. Breast milk is recommended for infants up to 12 months of age c. Solid foods may be introduced at 3 months d. Avoid using breast milk that has been pumped as it is not as nutritious Breast milk is recommended to feed infants through the first year of life. Infant formulas have the same calories and nutrients but lack the added benefit of immune factors passed from the mother to the infant. Also, infants may develop allergies to the formula. Solid foods should not be introduced until at least 4 months of age. Pumped breast milk is identical to breast milk fed on demand. Question 31 The nurse is performing a mini-nutritional assessment for a newly admitted client from a nursing home. The best description of this type of assessment is what? a. It helps the nurse identify the client’s favorite foods b. It is a quick method of identifying malnutrition and risks for malnutrition c. To identify caregivers in need of diet teaching d. To assist with food selection and meal planning Nutritional assessments are primarily ways to identify a client at risk for malnutrition or one who already is malnourished. Following review of this assessment the nurse can request a consultation with a nutritionist to plan a course of action to address the client’s specific needs. Question 32 The nurse is assessing a client’s peripheral circulation. Choose where the nurse will palpate a popliteal pulse. a. Top of the foot b. Behind the knee c. In the groin d. At the ankle The poplital pulse is located behind the knee. Dorsalis pedis pulse is at the top of the foot. The posterior tibeal pulse is at the ankle. The groin pulse is the femoral pulse. Question 33 The nursing assistant reports these vital signs to a nurse: tympanic temperature 98.8ºF, pulse 92 bpm, respiratory rate 18 breaths/min, blood pressure 98/58. What does the nurse do next? a. Retake Temperature b. Recheck Pulse c. Assess Respirations d. Retake Blood Pressure The blood pressure reading is out of normal range. The other signs reported are within the normal range. Question 34 A nurse instructs a group of new mothers to make sure the infant is covered up whenever in an air-conditioned space. Choose the best rationale for this action. a. Some infants get cold faster than others b. Covering the infant protects them against respiratory infection c. Newborns and infants have poor thermoregulation d. Newborns and infants have poor thermoregulation and must be kept covered in cooler environments. Question 35 The nurse is caring for a client with an irregular radial pulse. What action should the nurse take next? a. Assess the apical pulse for a full minute b. Use a doppler device on the radial pulse c. Assess the radial pulse for a full minute d. Ask another nurse to recheck the pulse When a client has an irregular radial pulse, the best action for a nurse to take next is to assess the apical pulse for a full minute. Question 36 A client is prescribed a medication that has adrenergic effects. Choose the effect on the vital signs that this drug can have. a. Decreased pulse b. Low blood pressure c. Increased temperature d. Increased heart rate Adrenergic effects include increased pulse, increased blood pressure and increased blood flow. Question 37 A nurse is preparing to administer a medication prescribed to treat the client’s tachycardia. The nurse should perform this action before giving the medication. a. Assess the blood pressure b. Assess the client for pain c. Assess the oxygen saturation d. Assess an apical pulse For medications that affect the pulse, the nurse should perform an apical pulse assessment for the most accurate reading of the heart rate. Unless the medication also can drop the blood pressure to dangerous levels, it is not necessary to assess BP. Question 38 A nurse assigns the nursing assistant the task of collecting vital signs on several clients. Select the client for whom the nurse should assess vital signs. a. A client being discharged from the hospital this morning b. A surgical client who is stable and 3 days post-op c. A maternity client who just delivered her infant d. A client who has just been transferred to the rehab unit for therapy A new mother must be closely assessed following delivery. The nurse should perform these vital signs at this time.The other clients are considered in stable condition and may be delegated to the nursing assistant for vital signs. Question 39 A group of student nurses is learning about adrenergic cardiovascular effects. Choose the chemicals most likely to cause these effects. epinepherine and norepinephrine serotonin and dopamine prostaglandins histamines Adrenergic effects are caused by epinephrine and norepinephrine. Bronchodilators, certain cardiac drugs and vasoconstrictors also have adrenergic effects. Cholinergic drugs such as acetylcholine cause the pulse to slow down. Serotonin, dopamine and prostaglandins are neurotransmitters. Histamines are part of the inflammation cascade. Question 40 A nurse caring for an older client who has been a smoker for several years can expect to assess this abnormal vital sign. Decreased respiratory rate Increased blood pressure Decreased pulse Increased oxygen saturation One of the factors that impact blood pressure is smoking which causes vasoconstriction and raises blood pressure. Question 41 A young teen is injured playing football when he is shoved into a goalpost and suffers a head injury. The nurse is concerned that this part of the brain may have suffered damage that can impact respirations. The frontal lobe The parietal lobe Correct Answer The medulla oblongata The meninges Head injury may damage the medulla oblongata and impact gas exchange, or the cerebral cortex and impact movement of the chest wall and diaphragm. Question 42 A nursing assistant has just taken a client’s blood pressure and suspects the reading is not accurate. Choose a valid reason for blood pressure error. Rechecking both arms to compare readings Smoothly deflating the cuff after taking the measurement Using a large cuff for a client who has large upper arms Reinflating the cuff before allowing it to complete deflate Common sources of blood pressure error are not rechecking both arms when a questionable reading is obtained; deflating the cuff in a jerky manner; using the wrong sized cuff; reinflating the cuff before allowing complete deflation; pushing too hard on the diaphragm and not calibrating the gauge to zero. Question 43 A nurse caring for a client who is short of breath places the client in this position to facilitate lung expansion. Prone Supine Lateral Correct Answer Fowlers The nurse places the client in Fowlers position to help expand the lungs and aid in respirations. The other choices are not appropriate as they do not allow for full lung expansion. Question 44 A nurse is caring for a client who is on fall precautions. An appropriate alternate solution to the use of restraints would be what? Turning on the TV so the client is distracted Using a bed or wheelchair alarm Assigning a double room so the other client can watch them Dimming the hall lights at night Use of a bed or wheelchair alarm for clients at risk to fall are good alternates to restraints. Turning on the TV would not prevent the client from falling. Assigning a double room might help the client socialize but it is the nurse’s responsibility check on him. Dimming hall lights would also not prevent falls. Question 45 A nurse is teaching other healthcare workers about the acronym for fire safety: R.A.C.E. The nurse explains that the letter “E” stand for what? Explain Eliminate Correct Answer Extinguish Evaluate R.A.C.E. stands for Rescue, Activate, Confine and Extinguish Question 46 A nurse witnesses a client having a seizure. What is the nurse’s priority action? Turn the client on their side Insert a mouth guard or bite-block Restrain the client to prevent injury Stay with the client and call for help A nurse who witnesses a seizure must remain with the client and call for help. They should then help the client to the floor, protect them from injury but not restrain them, turn them on their side if possible and reassure and reorient the client when they have regained consciousness. Question 47 The nurse prepares to help a client with crutch-walking. The nurse correctly places the crutches in this position: Directly in front of and parallel to the client 6 inches in front of and 6 inches to the side of each foot With the elbow straight Snug against each armpit Crutches are placed 6 inches in front of and 6 inches beside each foot. The elbow is bent about 20 degrees and the upper armrest is 2 inches below the axilla. Question 48 The nurse is caring for a client with a deep, infected wound. The provider has prescribed wound irrigations be performed with each dressing change. Choose the best nursing action. Flood the wound with warm tap water Use a sterile irrigation syringe to instill a solution of povidone iodine and water Use sterile saline to thoroughly flush the wound bed Wash the wound bed with soap and water and rinse well The wound should be irrigated with sterile saline using a sterile irrigation syringe to prevent cross-contamination. While closed surgical wounds may be washed with soap and water in the shower, deep wounds are irrigated with normal saline. Question 49 A nurse is preparing to discharge a client who has been hospitalized to treat a Stage IV decubitus ulcer. Select the best statement from the nurse regarding the client’s wound. Your wound was a Stage IV but now is has healed to a Stage III You will need to continue to keep pressure off the wound area Once the wound is completely healed the tissue will be stronger than ever It is normal to smell a foul odor from your dressing The client will need to continue to keep pressure off the wound area. It may be necessary for the client to use an offloading mattress or chair cushion, depending on the location of the pressure ulcer. Once a wound is staged it remains that stage. When healed it would be described as a healed Stage IV ulcer. Tissue regrowth over a wound is not as strong as uninjured tissue. A foul odor indicates a wound infection and the client should report this. Question 50 A nurse caring for a client with a Stage III pressure ulcer notes a foul odor coming from the room. What does the nurse do next? Notify the provider the wound is infected Perform a complete assessment including vital signs and lab values Consult with the wound care nurse for a change in wound care for the client Do a focused assessment of the wound The nurse should perform a complete assessment to determine the source of the odor. The client may have other skin breakdown, such as excoriation of the perineum or fungal growth causing the odor. The nurse cannot make the determination that a wound is infected, they can provide data for the provider. The nurse should not consult the wound care nurse until the assessment is complete. A focused wound assessment would miss other sources of the odor. Question 51 The nurse is preparing to teach a client how to do their own wound care once discharged home. Choose the best statement regarding wound packing. The wound should be packed with several dry sterile gauze pads Wound packing must be tightly compacted to facilitate healing Correct Answer Pack the wound loosely with saline moistened sterile gauze Avoid packing any tunnels or undermining To facilitate wound healing, the nurse will instruct the client to loosely pack the wound bed and any tunnelling or undermining with saline moistened sterile gauze and cover it with a dry sterile gauze. Avoid tight packing to prevent impairing tissue perfusion and delaying healing. Question 52 A nurse is discharging a client following surgical removal of the gall bladder. The nurse defines this type of wound healing as what? Primary intention Secondary intention Tertiary intention Preliminary intention Clean surgical wounds heal by primary intention. Secondary intention occurs when a deep wound heals from the tissue base to the surface. Tertiary intention is allowing a deep wound to heal by secondary intention till it is almost completely closed than using a surgical closure to join the skin edges.