A
A client with diabetic ketoacidosis is admitted to the intensive care unit and is manifesting respirations that are rapid and deep. Which descriptive term should the nurse use to document the client's breathing pattern?
A. Kussmaul respirations.
B. Cheyne stokes respirations.
C. Apnea.
D. Orthopnea.
A. Kussmaul respirators
Metabolic acidosis in DKA causes compensatory responses to increase the blood pH which results in Kussmaul respiration in a effort to blow off CO2 and adjust blood pH. The nurse should document the client's respiratory rate and Kussmaul respiratory pattern.
The nurse is caring for a client with advanced metastatic cancer that has not responded to treatment. The healthcare provider prescribes palliative care only. Which intervention should the nurse withhold?
A. Intubation with mechanical ventilation.
B. Around-the-clock pain medication.
C. Regular diet as tolerated.
D. Bronchodilators for shortness of breath.
A. Intubation with mechanical ventilation.
Palliative care provides clients with comfort measures as they near the end of life. When the healthcare provider prescribes palliative care only, the nurse should withhold life-saving interventions, such as intubation with mechanical ventilation.
A preschool-aged child who speaks Spanish is starting kindergarten in an English-speaking school. The child cries most of the time, appears helpless, and is unable to function in the new situation. What nursing diagnosis should the nurse include in the plan of care for this child?
A. Culture shock secondary to unfamiliar environment.
B. Growth and development, impaired.
C. Cultural incompetence due to inability to adjust.
D. Defiance behavior as evidenced by outbursts of crying.
A. Culture shock secondary to unfamiliar environment
A child who experiences a language barrier is unable to communicate in the spoken language in school and may lack the skills necessary to participate. Culture shock describes feelings of discomfort, disorientation, fears, and stress when adapting to new cultural settings.
The nurse is caring for a client who has recently immigrated into the country. Which factor should the nurse consider when providing care?
A. Cultural changes may be difficult for the client.
B. The client desires to adapt to the new culture.
C. The client views their cultural differences as abnormal.
D. Information may be given to help the client adapt to the new culture.
A. Cultural changes may be difficult for the client.
Providing culturally competent care includes the understanding of the characteristics of culture. It is important for the nurse to recognize that cultural changes may be difficult for the client to make. Care should be designed around the client's culture as long as it is not detrimental to the client's health.
The nurse is visiting a client at home and recognizes that the client's cultural background is different than the nurse's cultural practices. Which action should the nurse prioritize when demonstrating cultural competence?
A. Accept an invitation to eat a cultural meal with the client's family.
B. Participate in cultural healing rituals with the client and family.
C. Ask the client how culture plays a role in their health care preferences.
D. Read articles about the specific culture to increase client communication.
C. Ask the client how culture plays a role in their health care preferences.
Cultural competence means the nurse incorporates the client's culture into the health care plan. Asking the client about cultural beliefs and how they impact healthcare preferences demonstrates cultural competence.
A client is admitted to the intensive care unit with asthma and an upper respiratory infection. The client is experiencing severe bronchospasms and develops status asthmaticus. Which prescription should the nurse administer first?
A. Beta 2-antagonist.
B. Antihistamine.
C. Decongestant.
D. IV antibiotics.
A. Beta 2-antagonist.
Beta2-antagonists and corticosteroids are used to treat status asthmaticus. Beta2-antagonists facilitate smooth muscle relaxation, while steroids decrease inflammation of the airways and enhance the effects of beta2-antagonists.
The home health nurse is teaching the family of a hospice client about pain control. Which information should the nurse include?
A. Too much pain medication will cause the client to become dependent upon it.
B. Pain medication should be given at regular intervals throughout a 24-hour period.
C. Too much pain medication can affect the client's family about the quality of care.
D. Wait to administer pain medication to the client until breakthrough pain occurs.
B. Pain medication should be given at regular intervals throughout a 24-hour period.
Pain control is one of the primary goals of hospice care. Clients and their families should be taught that pain medication needs to be given at regularly scheduled intervals to maintain a therapeutic dose and to prevent breakthrough pain from occurring
The nurse is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the nurse instruct the client to use at home?
A. Exercise bicycle.
B. Sphygmomanometer.
C. Blood glucose monitor.
D. Weekly medication box.
B. Sphygmomanometer
Self-awareness is the best way for a client to manage chronic hypertension, so the client should obtain a sphygmomanometer and learn how to monitor blood pressure daily and maintain a record.
The school nurse is teaching a group of male adolescent clients about testicular self-examination. Which teaching aid should the school nurse use?
A. Written instructions.
B. Audio instructions.
C. Illustrated pamphlet.
D. Plastic model of testicles.
D. Plastic model of testicles.
Teaching aids for adolescents should promote student engagement. A plastic model is something the adolescents can touch and use to practice return demonstrations.
Which social detriment has shown to increase the rate of teen pregnancies in a community?
A. Poverty.
B. Age.
C. Culture.
D. Ethnicity.
A. Poverty
A social detriment of health that influences the teen pregnancy rate is poverty. One-third of pregnant teenagers come from a low socioeconomic background regardless of ethnicity. Other risk factors for teen pregnancy rates include education, social support systems, and living environment.
The nurse reports findings to the healthcare provider for a client who is admitted to the intensive care unit today with chronic obstructive pulmonary disease (COPD). When the nurse completes the report using the SBAR format, which statement best supports the nurse's reason for calling the healthcare provider?
A. Prescription for an additional respiratory treatment.
B. Admission today with difficulty breathing.
C. History of COPD.
D. Presence of expiratory wheezes in the lower lobes.
A. Prescription for an additional respiratory treatment.
The SBAR reporting format uses client information that includes the Situation, Background, Assessment, Recommendation. The nurse should complete the report with a recommendation, such as a prescription for an additional breathing treatment.
The nurse is preparing an orientation class for new employees at an inner city clinic that serves a low-income population. Which information should the nurse include in the presentation to these new employees?
A. A lack of transportation is the major impediment for the clinic's clients.
B. Basic physiologic needs are likely to be unmet in this clinic's client population.
C. Printed material is less effective for this population that has limited reading skills.
D. A group education class is often poorly attended by non-compliant clients.
B. Basic physiologic needs are likely to be unmet in this clinic's client population
Low-income clients are at risk for basic physiologic needs being unmet because they do not have the funds to pay for healthcare services, whether preventive or acute.
Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan about the risk for cervical cancer?
A. Neisseria gonorrhoea.
B. Chlamydia trachomatis.
C. Herpes simplex virus.
D. Human papillomavirus.
D. Human papillomavirus
According to the CDC (2017), it is estimated at least 80% of all women who are sexually active will contract the Human papillomavirus (HPV) in their lifetime. Certain types of HPV have been suspected to cause cervical cancer and HPV strain 16 and 18 have been identified to cause 70% of cervical cancers.
Which client has the greatest risk for developing community-acquired pneumonia?
A. A 40-year-old first-grade teacher who works with underprivileged children.
B. A 75-year-old retired secretary with exercise-induced wheezing.
C. A 60-year-old homeless person who is an alcoholic and smokes.
D. A 35-year-old aerobics instructor who skips meals and eats only vegetables.
C. A 60-year-old homeless person who is an alcoholic and smokes
Although age is a factor in the development of community-acquired pneumonia, other lifestyle behaviors, such as smoking, alcoholism, and exposure factors related to homelessness increase one's risk due to impaired nutrition and immune function.
The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs at what time?
A. Two weeks before menstruation.
B. Immediately after menstruation.
C. Immediately before menstruation.
D. Three weeks before menstruation.
A. Two weeks before menstruation.
Because menstruation varies for many women, the nurse should explain that ovulation occurs 14 days before the first day of the menstrual period.
A client is brought to the Emergency Center after a snow-skiing accident. Which intervention is most important for the nurse to implement?
A. Review the electrocardiogram tracing.
B. Obtain blood for coagulation studies.
C. Apply a warming blanket.
D. Provide heated PO fluids.
A. Review the electrocardiogram tracing.
While airway, breathing, and circulation are priorities in client assessment and treatment, continuous cardiac monitoring is also indicated because hypothermic clients have an increased risk for dysrhythmias.
A male client who is in the terminal stage of cancer is cared for at home by his family and receives a prescription for morphine at a rate to control intractable pain. When the hospice nurse visits, the client awakens, moans in severe pain, and asks for an increase in the morphine dosage. After determining the client's respirations are 10 breaths per minute, what is the best action for the nurse to implement?
A. Titrate the morphine dose upward until the client has adequate pain relief.
B. Suggest to the family that they can also give the client ibuprofen, a non-narcotic analgesic.
C. Hold additional morphine until the client's respirations are at least 16 per minute.
D. Inform the client that an increased dose of morphine increases side effects without additional pain control.
A. Titrate the morphine dose upward until the client has adequate pain relief
Tolerance can occur in a client who requires large doses of opioids for intractable pain management, and an increased titration of the analgesic or an additional drug in the same or a different classification may provide more effective pain management. The client's basic need for comfort during the last stages of a terminal malignancy is the main priority for this hospice client.
The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?
A. Between the time the temperature falls and rises.
B. Between 36 and 48 hours after the temperature rises.
C. When the temperature falls and remains low for 36 hours.
D. Within 72 hours before the temperature falls.
A. Between the time the temperature falls and rises.
In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone making between the time of the temperature fall and rise is the best time to try to conceive.
A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge?
A. Supplementary iron is more efficiently utilized during pregnancy.
B. It is difficult to consume 18 mg of additional iron by diet alone.
C. Iron absorption is decreased in the GI tract during pregnancy.
D. Iron is needed to prevent megaloblastic anemia in the last trimester.
B. It is difficult to consume 18 mg of additional iron by diet alone.
Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and to meet the demands of pregnancy is difficult so iron supplements are often recommended.
The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of 20. Which of the following nursing diagnosis is most appropriate based upon this assessment?
A. Hyperthermia related to infectious illness
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions
A. Hyperthermia related to infectious illness
Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths per minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.
The nurse is admitting a client diagnosed with hyperosmolar hyperglycemic state (HHS) who is severely dehydrated. The client's vital signs are blood pressure 78/46 mmHg, pulse 130 beats/minute, respirations 22 breaths/minute, CVP 6, and MAP 58. Which intravenous solution should the nurse expect to administer to this client?
A. 0.9% sodium chloride (normal saline).
B. 0.45% sodium chloride (1/2 normal saline).
C. 5% dextrose in lactated ringers (D5LR).
D. 5% dextrose in 0.45% sodium chloride (D5 ½NS).
A. 0.9% sodium chloride (normal saline).
The client is demonstrating a sign of hypovolemic shock, the fluid of choice for fluid replacement is 0.9% sodium chloride (normal saline) with an initial bolus of one (1) liter of normal saline to replace the extracellular fluid volume deficit.
During a home health visit, a male client reports to the nurse that he felt a solid testicular mass during self-exam, but that it wasn't painful. What instruction should the nurse provide the client?
A. Continue to monitor the mass until the next scheduled annual medical exam.
B. Notify the healthcare provider if the mass becomes soft, painful, or starts to drain.
C. Schedule an appointment with the healthcare provider for prompt evaluation.
D. Testicular nodules are of concern only if they feel matted or are not easily movable.
C. Schedule an appointment with the healthcare provider for prompt evaluation.
A painless testicular mass is an abnormal finding, and the nurse should instruct the client to obtain prompt medical evaluation. The other options place the client at risk, since they do not emphasize prompt medical evaluation.
The nurse is preparing to teach a community prenatal class about transplacental infections. Which infection should the nurse include in the presentation?
A. Toxoplasmosis.
B. Group B streptococcus.
C. Chlamydia.
D. Herpes simplex virus.
A. Toxoplasmosis
Toxoplasmosis is a vertically transmitted infection that passes from the mother to the fetus through the placenta.
A client with diabetes mellitus asks the nurse how many grams of carbohydrates can be consumed each day if the healthcare provider prescribes a 2000 calorie diet. What answer should the nurse provide?
A. 250 grams.
B. 300 grams.
C. 350 grams.
D. 200 grams.
A. 250 grams
According to the American Diabetes Association, carbohydrates should be 50% of daily intake. Carbohydrates provide 4 calories/gram, so a 2000 calorie per day diet should include 1000 calories from carbohydrates, or 250 grams (1000 calories :: 4 calories/1 gram = 250 grams).
The nurse is caring for a patient with COPD and pneumonia who has an order for arterial blood gases to be drawn. Which of the following is the minimum length of time the nurse should plan to hold pressure on the puncture site?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes
B. 5 minutes Following obtaining an arterial blood gas, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.