(Test Bank) Exam (Elaborations) Nursing C475 (Nursingc475) Trainers 5-7

Kelly, 1

Nursing

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Author(s): Kelly

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TRAINER 5 The nurse prepares a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the following questions is MOST important for the nurse to ask? 1. "Did you have anything to eat or drink before you came in today?" 2. "Have you had any headaches since your last treatment?" 3. "Who came with you to the hospital today?" 4. "Have you had much memory loss since you began your treatments?" (1) correct —client given general anesthesia for ECT; NPO after midnight (2) not relevant to ECT (3) not most important (4) memory loss is an expected outcome A client is diagnosed with a flaccid bladder following a spinal cord injury. The nurse teaches the client about dietary changes. Which of the following beverages, if selected by the client, indicates to the nurse that teaching is effective? Select all that apply. 1. Lemonade. 2. Prune juice. 3. Milk. 4. Orange juice. 5. Cranberry juice. 6. Tomato juice. (1) promotes alkaline urine; should also avoid citrus juices, excessive amounts of milk, and carbonated beverages (2) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon (3) excessive amounts of milk promote alkaline urine (4) promotes alkaline urine; should also avoid citrus juices, excessive amounts of milk, and carbonated beverages (5) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon (6) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon The nurse cares for a client with a long history of alcohol and drug dependence. It is MOST important for the nurse to include which of the following as part of the discharge planning? 1. Refer to a social service agency for assistance with housing. 2. Refer to an aftercare center in the community. 3. Encourage participation in Alcoholics Anonymous (AA) meetings with a sponsor. 4. Ask the client to obtain a prescription for an antidepressant medication. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may be of some help, but will not directly provide support necessary to maintain sobriety (2) may be of some help, but will not directly provide support necessary to maintain sobriety (3) correct—self-help groups have greatest success rate as a sustained support system in the community (4) is information to indicate client depressed The client comes to the clinic for hepatitis B vaccine and asks if more than one injection is necessary. Which of the following responses by the nurse is BEST? 1. "A booster shot is required yearly." 2. "Additional injections are given at one and six months." 3. "Repeat doses are given at two and four months." 4. "Revaccination is not required." Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) yearly doses are given for flu shots, not for hepatitis B vaccine (2) correct—hepatitis B vaccine is repeated at 1 and 6 months (3) schedule for infant immunizations for IPV and DPT (4) inaccurate The nurse plans care for a client returning from surgery after a bowel resection with an IV of 0.9 % NaCl infusing at 100 mL/h into the left wrist. Which of the fol lowing actions, if performed by the nurse, is BEST? 1. Change the IV tubing each time a new IV solution is hung. 2. Cleanse the IV site with an alcohol swab using long strokes. 3. Limit manipulation of the cannula at the IV insertion site. 4. Adjust the drop rate to keep the total volume of IV fluids on schedule.Strategy: The topic of the question is unstated. Read the answer choices to determine the topic. "BEST" indicates that this is a priority question. All answers are implementations. Dete rmine the outcome of each answer choice. Is it desired? (1) unnecessary, changed every 48 to 72 h (2) should move swab in a circular motion outward (3) correct—will prevent dislodgment of needle (4) should give IV at rate ordered by physician, don't play "catch -up" with fluids The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST? 1. Send the staff member home. 2. Assess the staff member's compliance with standard precautions. 3. Assign the staff member only to clients with chronic diseases. 4. Reassign the staff member to clean the supply closet. (1) correct —extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis; highly contagious; infected employees cannot work until symptoms have resolved in 3 to 7 days (2) restrict from patient contact and the patient's environment (3) restrict from patient contact and the patient's environment (4) cannot work The nursing staff plans to use behavior modification techniques for an elderly woman who constantly screams. Which of the following nursing assessments is necessary to establish a successful program? 1. Monitor the client's ability to complete her activities of daily living (ADL). 2. Assess the client's levels of pain and correlate it with her response to analgesia. 3. Observe the client's behavior at regular intervals to obtain baseline information related to her screaming. 4. Ask the client why she is screaming and document it on her nursing assessment record. Strategy: Determine what is being assessed in each answer choice and how it relates to screaming. (1) important because activities of daily living can contribute to the targeted behavior of screaming; assessing only the area of ADLs does not provide comprehensive data for developing a behavior management program (2) important because activities of pain can contribute to the targeted behavior of screaming; assessing only the area of pain does not provide comprehensive data for developing a behavior management program (3) correct—to design an effective behavior modification program, accurate baseline data must first be collected about the target behavior in relation to frequency, amount, time, and precipitating factors (4) client may be unable to state why she is screaming; asking "why" questions is nontherapeutic The nurse observes a student nurse check the placement of a nasogastric (NG) tube prior to administering an intermittent feeding. Which of the following actions, if performed by the student nurse, requires an intervention by the nurse? Select all that apply. 1. The student nurse checks the pH of the contents aspirated from the NG tube. 2. The student nurse positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube. 3. The student nurse uses a large -barreled syringe to aspirate for stomach contents. 4. The student nurse flushes the NG tube with 30 ml of air before aspirating fluid. 5. The student nurse places the end of the NG tube in a cup of water and watches for bubble formation. (1) appropriate action; if client has for at least 4 hours, pH of gastric aspirate is 1 to 4 (2) correct—air injected to lungs, pharynx or esophagus may transmit similar sound (3) acceptable action (4) appropriate action; enables easier aspiration of fluid (5) correct—not considered acceptable procedure; if tube placed in lungs, may cause bubbling While scheduling the administration of bromocriptine (Parlodel), which nursing action has the HIGHEST priority? 1. The medication should be taken once a day for 6 weeks. 2. The medication should be taken with orange juice. 3. The medication should be taken in the morning and at bedtime. 4. The medication should be taken with meals. (1) is taken twice a day for 2 to 3 weeks (2) unnecessary (3) will cause GI upset unless taken with meals (4) correct—will decrease GI upset A brace is ordered for a young teen with scoliosis. The nurse determines teaching is effective if the client makes which of the following statements? 1. "I will have my parents put bed-boards on my bed." 2. "I should decrease my caloric intake." 3. "I should only take showers." 4. "I will hold on the rail when going down the stairs." (1) bed-boards maintain proper vertebral alignment but can't correct lateral curvature of scoliosis (2) diet should be high -calorie due to age of child and growth requirements; diet doesn't affect curvature of the spine (3) either tub bathing or a shower is permitted (4) correct—prevents falls, should also avoid slippery surfaces The nurse in a long -term care facility reviews the nurse's notes in a client's chart. The nurse is MOST concerned by which of the following entries? 1. "Foley catheter draining clear urine and the pH is 6.5." 2. "The client's skin is blanched over the scapular areas." 3. "Vital signs are within normal limits." 4. "The client drinks three glasses of orange juice every day." (1) appropriate charting of normal urine (2) correct—blanching or hyperemia that does not disappear in a short time is a warning sign of pressure ulcers (3) although the charting is not objective, blanching of the skin takes priority because it indicates a problem (4) appropriate charting The nurse cares for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. Which of the following messages should the nurse return FIRST? 1. A client with cold symptoms has an oral temperature of 103°F (39.4°C). 2. A client with stage II decubitus ulcer reports that the dressing has come off. 3. A client is nauseated and has vomited 6 times in the previous 24 hours. 4. A client complains of leg pain after walking half a mile. Strategy: Eliminate the two most stable clients. Use the ABCs to determine the most unstable client. (1) elevated temperature indicates infection; determine the underlying cause, encourage fluids (2) stable client (3) correct—assess amount, character, symptoms of fluid volume deficit (4) stable client, complaint indicates intermittent claudication A client has a bovine graft inserted into the left arm for hemodialysis. During the immediate postoperative period, which of the following actions, if performed by the nurse, is BEST? 1. Restart the IV above the level of the graft. 2. Take blood pressures on the right arm. 3. Elevate the left arm above the level of the heart. 4. Check the radial pulse on the left arm q4h. Strategy: Determine the outcome of each answer choice. (1) IVs should not be started in the grafted arm (2) correct—BP should always be taken on the opposite arm from the graft (3) unnecessary (4) important to assess circulation in extremity; priority is to prevent complication The nurse observes late deceleration of the fetal heart rate while the client is receiving oxytocin (Pitocin) IV to stimulate labor. Which of the following actions should the nurse take FIRST? 1. Discontinue the infusion. 2. Turn client to the left side. 3. Change the fluids to Ringers lactate. 4. Increase the IV flow rate. (1) correct—will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration (2) may help the deceleration, but is not a priority (3) will have no influence on the fetal heart rate (4) will have no influence on the fetal heart rate The nurse cares for a patient recovering from abdominal surgery. During ambulation, the patient complains about a dull ache in the left leg. Which of the following actions should the nurse take FIRST? 1. Place the patient on bedrest with extremity elevated. 2. Place a pillow under the patient's knee. 3. Encourage patient to ambulate more frequently. 4. Obtain thigh -high compression stockings. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—promotes venous return and decreases venous pressure, relieving pain and edema (2) obstructs venous flow, increasing chance for thrombus formation (3) can cause pulmonary emboli, should be on bedrest 5 to 7 days (4) used to prevent deep vein thrombosis, should be on bedrest initially A middle -aged female client begins outpatient therapy sessions for management of a phobic disorder. The nurse identifies which of the following interventions is MOST effective to reduce the client symptoms? 1. Antianxiety medication. 2. Group psychotherapy. 3. Systematic desensitization. 4. Biofeedback. (1) may be used for social phobia or social anxiety disorder (2) may benefit from cognitive -behavioral therapy (3) correct—phobic disorders are learned responses; learned responses can be unlearned through certain techniques, such as behavior modification; systematic desensitization is a form of behavior modifi cation; is a strategy used in conjunction with deep muscle relaxation to decrease the extreme response to anxiety -producing situations as they are gradually exposed; then exposure is increased; goal is to eradicate the phobic response by replacing it with the relaxation response (4) one learns to control the autonomic nervous system; is usually more useful for reducing stress associated with physiologically based disorders The nurse cares for a client diagnosed with Cushing's syndrome. Which of the following nursing actions is the priority? 1. Implement measures to prevent skin breakdown. 2. Plan measures to prevent infections. 3. Teach the client signs and symptoms of hyperglycemia. 4. Instigate measures to prevent fluid overload. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) clients are susceptible to skin breakdown and infections (2) clients are susceptible to skin breakdown and infections (3) impaired glucose tolerance often leads to hyperglycemia, but is not highest priority (4) correct—respirations are the first priority; clients with Cushing's syndrome are prone to fluid overload and CHF due to sodium and water retention The nurse assesses a client diagnosed with a detached retina. Which of the following observations supports this diagnosis? 1. Loss of acuity in the peripheral visual field. 2. Increased lacrimation, blurred vision. 3. Conjunctivitis, dilated pupils bilaterally. 4. Photophobia, loss of a portion of the visual field. (1) loss of peripheral vision occurs with glaucoma; loss of acuity occurs with cataracts (2) occurs with ocular infections (3) has no correlation with detached retina (4) correct—bright flashes of light and client stating that portion of visual field is dark are classic symptoms The physician orders indomethacin (Indocin) 25 mg PO bid for a client. It is MOST important for the nurse to make which of the following statements? 1. "Take this medication with food." 2. "Take this medication one hour before meals." 3. "Take this medication one hour after meals." 4. "Take this medication with orange juice." Strategy: "MOST important" indicates discrimination is required to answer the question. (1) correct—reduces GI upset (2) risk of GI upset (3) should be given with food (4) risk of GI upset A child comes to the school nurse with a honey -colored crusted lesion below the right nostril. Which of the following actions should the nurse take FIRST? 1. Remove the scab. 2. Apply a wet cloth to the lesion. 3. Notify the child's parents. 4. Contact the health department. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) notify parents first; loosen scab with Burrow's solution compress; gently remove, topical ointment (2) notify parents first; treated with systemic antibiotics, antibacterial soap (3) correct—describes impetigo, highly infectious superficial bacterial infection; notify parents so they can contact the physician (4) unnecessary to report impetig o to the health department Which of the following nursing actions is the priority for an infant admitted with a positive stool culture for Salmonella? 1. Change diet to clear liquids. 2. Initiate intravenous fluids. 3. Maintain contact precautions. 4. Apply cloth diapers. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may be appropriate, but is not a priority over answer choice 3, which will prevent transmission (2) may be appropriate, but is not a priority over answer choice 3, which will prevent transmission (3) correct—prevents transmission of this bacterium to other individuals (4) may be appropriate, but is not a priority over answer choice 3, which will prevent transmission The nurse cares for a client admitted 4 days ago for treatment of alcohol dependence. The nurse notes the client has slurred speech, ataxia, and uncoordinated movements, and complains of a headache. Which of the following actions should the nurse take FIRST? 1. Observe the client for 8 hours to collect additional data. 2. Perform a complete physical assessment. 3. Collect a urine specimen for a drug screen. 4. Encourage the client to talk about whatever is bothering him. Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires validation? Yes. (1) will not provide the data that a physical assessment would; may be a medical emergency requiring an immediate intervention (2) correct—best way to identify possible physical complications of alcohol dependence is through a complete physical assessment (3) should be done after the physical assessment is completed (4) inaccurate because the symptoms are most likely caused by physical and not psychological stressors The nurse identifies which of the following clients as being at HIGHEST risk of developing pulmonary embolus? 1. A 19-year -old 4 days' postpartum diagnosed with a placenta previa at 28 weeks' gestation. 2. A 22-year -old client diagnosed with leukemia with a platelet count of 120,000/mm3, hemoglobin 9.0 g/dL. 3. A 40-year -old man who is obese and diagnosed with multiple pelvic fractures due to a motor vehicle accident 2 days ago. 4. A 65 -year -old woman who had a fractured hip repaired 10 days ago and is currently receiving daily physical therapy. Strategy: Determine how each answer choice relates to pulmonary embolism. (1) not at risk for pulmonary embolism (2) at high risk for bleeding (3) correct—obesity, immobility, and pooling of blood in the pelvic cavity contribute to development of pulmonary emboli (4) client does not have a high risk for pulmonary emboli The nurse supervises a student nurse administer a tube feeding to a client via a Levin tube. Which of the following actions, if performed by the student nurse, indicates a proper understanding of the procedure? 1. The Levin tube remains unclamped for 30 min after the feeding. 2. Sterile equipment is used to administer the feeding. 3. The amount of the feeding is varied according to the patient's tolerance. 4. The tube feeding is given at room temperature. The nurse supervises a student nurse administer a tube feeding to a client via a Levin tube. Which of the following actions, if performed by the student nurse, indicates a proper understanding of the procedure? 1. The Levin tube remains unclamped for 30 min after the feeding. 2. Sterile equipment is used to administer the feeding. 3. The amount of the feeding is varied according to the patient's tolerance. 4. The tube feeding is given at room temperature. The nurse cares for a client diagnosed with deep vein thrombosis (thrombophlebitis) of the left leg. Which of the following is an appropriate nursing goal for the client? 1. Decrease inflammatory response in the affected extremity and prevent embolus formation. 2. Increase peripheral circulation and oxygenation of the affected extremity. 3. Prepare the client and family for anticipated vascular surgery on the affected extremity. 4. Prevent hypoxia associated with the development of a pulmonary embolus. Strategy: Think about each answer choice. (1) correct—important to prevent the complication of pulmonary embolism in clients at high risk (2) relates to arterial disease (3) surgery is not anticipated for this client (4) preventing embolism is the first priority The nurse is called to the room of a patient 4 days after abdominal surgery. The patient had been coughing and said he "felt something give." The nurse observes that the edges of the incision have separated, and a small loop of the bowel protrudes through the incision. The nurse should position the patient in which of the following positions? 1. Head of the bed elevated 30°. 2. Head of the bed tilted down. 3. Head of the bed elevated 15°. 4. Head of the bed elevated 90°. Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) semi -Fowler's; too high, puts pressure on abdominal area (2) Trendelenburg position; impedes respiratory excursion (3) correct—low Fowler's; reduces stress on suture line, may be placed supine with hips and knees bent (4) high Fowler's; too high, puts pressure on abdominal area On a home health visit, an elderly client tells the nurse, "This neighborhood has really gone down. I feel like a prisoner in my own home with all the trouble out there." Which of the following nursing responses by the nurse is BEST? 1. "Have you and your neighbors formed a Neighborhood Watch?" 2. "It must be very difficult for you to live in this neighborhood." 3. "I see a lot of police cars, so you should be pretty safe." 4. "Tell me what has happened to make you feel that you are not safe." (1) jumps ahead to solutions without adequately defining the problem (2) empathetic response, but does not obtain more information from the client or encourage the client to continue (3) false reassurance (4) correct—assessing the basis for client's fears and encouraging client to talk about them is the first positive step An intravenous pyelogram (IVP) is ordered for a client scheduled to have the left kidney removed due to renal disease and hypertension. Which of the following nursing actions has the highest priority the evening before the IVP?