Med-Surg
Which safety device is most restrictive for a client with dementia?
1. Walker
2. Childproof locks on cabinets and doors
3. Electronic monitoring system
4. Lap tray placed on a wheelchair
Correct Answer: 4
RATIONALES: The goal of care for clients with dementia is to maintain the highest level of functioning. When restraints must be used, the least restrictive type of restraint possible should be used. A lap tray over a wheelchair severely limits the client's mobility and can cause injury if the client tries to get out of the wheelchair. A walker can be very helpful to clients with dementia as they commonly have unsteady gaits. Childproof locks are helpful in preventing accidental contact with harmful substances. An electronic monitoring system is an effective way of managing a client who wanders.
One aspect of implementation related to drug therapy is:
1. developing a content outline.
2. documenting drugs given.
3. establishing outcome criteria.
4. setting realistic client goals.
Correct Answer: 2
RATIONALES: Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation.
You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP?
1. Assisting the patient with oral hygiene
2. Observing the patient's response to feedings
3. Facilitating expression of grief or anxiety
4. Initiating daily weighings
Ans: 1 Oral hygiene is within the scope of duties of the UAP. It is the responsibility of the nurse to observe response to treatments and to help the patient deal with loss or anxiety. The UAP can be directed to weigh the patient but should not be expected to know when to initiate that measurement. Focus: Delegation
The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter?
1. Family history of pressure ulcers
2. Presence of existing pressure ulcers
3. Potential areas of pressure ulcer development
4. Overall risk of developing pressure ulcers
Correct Answer: 4
RATIONALES: When assessing skin integrity, the overall risk potential for developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity.
A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing?
1. Planning
2. Data collection
3. Evaluation
4. Implementation
Correct Answer: 2
RATIONALES: During the data collection step of the nursing process, the nurse obtains the client's health history, measures vital signs, and performs a physical examination to gather data for use in formulating the nursing diagnoses. During the planning step, the nurse designs methods to help resolve client problems and meet client needs. During evaluation, the nurse determines the effectiveness of nursing interventions in achieving client goals. During implementation, the nurse takes actions to meet the client's needs.
Which nursing action is essential when providing continuous enteral feeding?
1. Elevating the head of the bed at least 30 degrees
2. Positioning the client on the left side
3. Warming the formula before administering it
4. Hanging a full day's worth of formula at one time
Correct Answer: 1
RATIONALES: Elevating the head of the bed at least 30 degrees during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. When such elevation is contraindicated, the client should be positioned on the right side. The nurse should give enteral feedings at room temperature to minimize GI distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused in 8 hours.
While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?
1. diphenhydramine hydrochloride (Benadryl)
2. pseudoephedrine hydrochloride (Sudafed
3. guaifenesin (Robitussin)
4. loperamide (Imodium)
Correct Answer: 1
RATIONALES: A client who is allergic to bee stings should keep diphenhydramine on hand because its antihistamine action can prevent a severe allergic reaction. Pseudoephedrine is a decongestant, which is used to treat cold symptoms. Guaifenesin is an expectorant, which is used for coughs. Loperamide is an antidiarrheal agent.
As the nurse manager in a public health department, you are implementing a plan to reduce the incidence of infection with human immunodeficiency virus (HIV) in the community. Which nursing action will you delegate to health assistants working for the agency?
1. Supplying injection drug users with sterile injection equipment such as needles and syringes
2. Interviewing patients about behaviors that indicate a need for annual HIV testing
3. Teaching high-risk community members about the use of condoms in preventing HIV infection
4. Assessing the community to determine which population groups to target for education
Ans: 1 Supplying sterile injection supplies to patients who are at risk for HIV infection can be done by staff members with health assistant education. Assessing for high-risk behaviors, education, and community assessment are RN-level skills. Focus: Delegation
An adolescent with type 1 diabetes mellitus is experiencing a growth spurt. Which treatment approach would be most effective for this client?
1. Administering insulin once per day
2. Administering multiple doses of insulin
3. Limiting dietary fat intake
4. Substituting an oral antidiabetic agent for insulin
Correct Answer: 2
RATIONALES: During an adolescent growth spurt, a regimen of multiple insulin doses achieves better control of the blood glucose level because it more closely simulates endogenous insulin release. A single daily dose of insulin wouldn't control this client's blood glucose level as effectively. Limiting dietary fat intake wouldn't help the body use glucose at the cellular level. An adolescent with type 1 diabetes mellitus doesn't produce insulin and therefore can't receive an oral antidiabetic agent instead of insulin.
The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should the nurse proceed?
1. Irrigate continuously until the solution becomes clear or all of the solution has been used.
2. Moisten the area around the wound with normal saline after the irrigation.
3. Apply a wet-to-dry dressing to the wound after the irrigation.
4. Rapidly instill a stream of irrigating solution into the wound.
Correct Answer: 1
RATIONALES: To wash away tissue debris and drainage effectively, the nurse should irrigate the wound until the solution becomes clear or all of the solution has been used. After the irrigation, the nurse should dry the area around the wound; moistening it promotes microorganism growth and skin irritation. When the area is dry, the nurse should apply a sterile dressing, rather than awet-to-dry dressing. The nurse always should instill the irrigating solution gently; rapid or forceful instillation can damage tissues.
A 76-year-old client is admitted to a long-term care facility with Alzheimer's-type dementia. The client has been wearing the same dirty clothes for several days. The nurse contacts the family and asks them to bring in clean clothing. Which intervention would bestprevent further regression in the client's personal hygiene?
1. Encouraging the client to perform as much self-care as possible
2. Making the client assume responsibility for physical care
3. Assigning a staff member to take over the client's physical care
4. Accepting the client's desire to go without bathing
Correct Answer: 1
RATIONALES: Clients with Alzheimer's-type dementia tend to fluctuate in their capabilities. Encouraging self-care to the extent possible helps increase the client's orientation and promotes a trusting relationship with the nurse. Making the client assume responsibility for physical care is unreasonable. Assigning a staff member to take over the client's physical care restricts the client's independence. Accepting the client's desire to go without bathing promotes poor hygiene.
A nurse's neighbor complains of severe right flank pain. She explains that it began during the night, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke, the pain increased in intensity. How should the nurse intervene?
1. Explain that she can't give medical advice.
2. Inform the neighbor that she might require surgery.
3. Advise the neighbor to seek medical attention.
4. Tell the neighbor that she'll be fine because she was able to get through the night.
Correct Answer: 3
RATIONALES: The nurse should advise the neighbor to seek medical attention. Explaining that she can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope of practice to suggest that the neighbor might need surgery. Telling the neighbor she'll be fine might also delay treatment, and it isn't a professional response.
After a client has a seizure, which action can you delegate to the UAP?
1. Documenting the seizure
2. Performing neurologic checks
3. Taking the client's vital signs
4. Restraining the client for protection
Ans: 3 Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements if necessary. Focus: Delegation, supervision
As an adolescent is receiving care, he's inadvertently injured with a warm compress. The nurse completes an incident report based on the knowledge that identification of which of the following is a goal of the report?
1. To reprimand the involved staff members for their actions
2. To identify the learning needs of staff to prevent incident recurrences
3. To reprimand the nurse-manager responsible for the unit
4. To hold people accountable for their actions
Correct Answer: 2
RATIONALES: The purpose of an incident report is threefold: to identify ways to prevent incident recurrences, to identify patterns of care problems, and to identify facts surrounding each incident. Incident reports aren't used to hold people accountable for their actions, to punish those involved in the incident, or to punish the nurse-manager responsible for the unit.
Which detail of a client's drug therapy is the nurse legally responsible for documenting?
1. Peak concentration time of the drug
2. Safe ranges of the drug
3. Client's socioeconomic data
4. Client's reaction to the drug
Correct Answer: 4
RATIONALES: The nurse legally must document the client's reaction to the drug in addition to the time the drug was administered and the dosage given. The nurse isn't legally responsible for documenting the peak concentration time of the drug, safe drug ranges, or the client's socioeconomic data.
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first?
1. Blood pressure
2. Respirations
3. Temperature
4. Cardiac rhythm
Correct Answer: 4
RATIONALES: The nurse should assess the client's cardiac rhythm using electrocardiography because an elevated serum potassium level may lead to a life-threatening cardiac arrhythmia. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also can delay assessing respirations and temperature because these aren't affected by the serum potassium level.
The parent of a preschooler with chickenpox asks the nurse about measures to make the child comfortable. The nurse instructs the parent to avoid administering aspirin or any other product that contains salicylates. When given to children with chickenpox, aspirin has been linked to which disorder?
1. Guillain-Barré syndrome
2. Rheumatic fever
3. Reye's syndrome
4. Scarlet fever
Correct Answer: 3
RATIONALES: Research shows a correlation between the use of aspirin during chickenpox and the development of Reye's syndrome (a disorder characterized by brain and liver toxicity). Therefore, the nurse should instruct the parents to avoid administering aspirin or other products that contain salicylates and to consult the physician or pharmacist before administering any medication to a child with chickenpox. No research has found a link between aspirin use, chickenpox, and the development of Guillain-Barré syndrome, rheumatic fever, or scarlet fever.
A newly hired licensed practical nurse (LPN) is helping the charge nurse admit a client. The charge nurse asks the LPN if she understands the facility's rules of ethical conduct. Which statement by the LPN indicates the need for further teaching?
1. "I make sure that I do everything in my client's best interest."
2. "I maintain client confidentiality at all times."
3. "I always support the Patient's Bill of Rights."
4. "I don't discuss advance directives unless the client initiates the conversation."
Correct Answer: 4
RATIONALES: The law mandates that health care agencies ask all clients if they have an advance directive. Therefore, the LPN must address this question regardless of whether the client initiates a conversation about it. Nurses must always act in the best interest of their clients, maintain confidentiality, and support the Patient's Bill of Rights.
The nurse is preparing to boost a client up in bed. She instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?
1. Friction
2. Impaired circulation
3. Localized pressure
4. Shearing forces
Correct Answer: 4
RATIONALES: Using a trapeze reduces shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis), which increase the risk of pressure ulcer development. They can occur as clients slide down in bed or when they're pulled up in bed. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move the client up in bed, and keep the head of the bed no higher than 30 degrees. The risks of friction, impaired circulation, and localized pressure aren't decreased with trapeze use.
The nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal age-related change is:
1. cloudy vision.
2. incontinence.
3. diminished reflexes.
4. tremors.
Correct Answer: 3
RATIONALES: Degenerative changes can lead to decreased reflexes, which is a normal result of aging. Cloudy vision, incontinence, and tremors may be signs and symptoms of underlying pathology and shouldn't be considered normal results of aging.
In a client who's predisposed to bipolar disorder, a bipolar episode might be triggered by:
1. hypothyroidism.
2. hyperglycemia.
3. hypertension.
4. antiseizure medication.
Correct Answer: 1
RATIONALES: Hypothyroidism might trigger a bipolar episode in a client predisposed to bipolar disorder. Episodes aren't known to be triggered by hyperglycemia, hypertension, or antiseizure medications.
A 43-year-old man was transferring a load of firewood from his front driveway to his backyard woodpile at 10 a.m. when he experienced a heaviness in his chest and dyspnea. He stopped working and rested, and the pain subsided. At noon, the pain returned. At 1:30 p.m., his wife took him to the emergency department. Around 2 p.m., the emergency department physician diagnoses an anterior myocardial infarction (MI). The nurse should anticipate which immediate order by the physician?
1. Lidocaine administration
2. Cardiac stress test
3. Serial liver enzyme testing
4. Tissue plasminogen activator (tPA)
Correct Answer: 4
RATIONALES: If 6 hours or less have passed since the onset of symptoms related to MI, thrombolytic therapy is indicated. (The client's chest pain began 4 hours before diagnosis.) The preferred choice is tPA. The client doesn't exhibit symptoms that indicate the use of lidocaine. Stress testing shouldn't be performed during the acute phase of an MI, but it may be ordered before discharge. Serial cardiac biomarkers, not serial liver enzymes, would be ordered for this client.
You are supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause you to intervene?
1. Suctioning the tracheostomy tube before performing tracheostomy care
2. Removing old dressings and cleaning off excess secretions
3. Removing the inner cannula and cleaning using standard precautions
4. Replacing the inner cannula and cleaning the stoma site
Ans: 3 When tracheostomy care is performed, a sterile field is set up and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate. Focus: Delegation, supervision
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding signals a significant problem during this procedure?
1. Blood glucose level of 200 mg/dl
2. White blood cell (WBC) count of 20,000/mm3
3. Potassium level of 3.8 mEq/L
4. Hematocrit (HCT) of 35%
Correct Answer: 2
RATIONALES: An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.8 mEq/L is an acceptable value. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.
The nurse collects data on a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
1. Serum potassium level of 4.9 mEq/L
2. Serum sodium level of 135 mEq/L
3. Temperature of 99.2° F (37.3° C)
4. Urine output of 20 ml/hour
Correct Answer: 4
RATIONALES: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. The other options are normal data collection findings.