Fundamentals
The nursing care plan is:
A. A written guideline for implementation and evaluation.
B. A documentation of client care.
C. A projection of potential alterations in client behaviors
D. A tool to set goals and project outcomes.
A. A written guideline for implementation and evaluation.
Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply.
1. Auscultation of breath sounds
2. Auscultation of bowel sounds
3. Presence of chest pain.
4. Presence of peripheral edema
5. Color of nail beds
1, 3, 5.
A respiratory assessment, which includes auscultation of breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.
High-pitched gurgles heard over the right lower quadrant are:
A. A sign of increased bowel motility
B. A sign of decreased bowel motility
C. Normal bowel sounds
D. A sign of abdominal cramping
C. Normal bowel sounds
Option C: High-pitched gurgles head over the right lower quadrant are normal bowel sounds.
Option A: Hyperactive sounds indicate increased bowel motility.
Option B: Two or three sounds per minute indicate decreased bowel motility.
Option D: Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction.
A nurse is teaching a client with pancreatitis about following a low-fat diet. The nurse develops a list of high-fat foods to avoid and includes which food on the item list?
A. Chocolate milk.
B. Broccoli.
C. Apple.
D. Salmon.
A. Chocolate milk.
Chocolate milk is a high-fat food.
Options B and C: Fruits and vegetables are low in fat because they do not come from animal sources.
Option D: Salmon is naturally lower in fat.
Mrs. Johanson’s physician has prescribed tetracycline 500 mg po q6h. While assessing Mrs. Johanson’s nursing history for allergies, the nurse notes that Mrs. Johanson’s is also taking oral contraceptives. What is the most appropriate initial nursing intervention?
A. Administer the dose of tetracycline.
B. Notify the physician that Mrs. Johanson is taking oral contraceptives.
C. Tell Mrs. Johanson, she should stop taking oral contraceptives since they are inactivated by tetracycline.
D. Tell Mrs. Johanson, to use another form of birth control for at least two months.
B. Notify the physician that Mrs. Johanson is taking oral contraceptives.
The nurse should be aware that tetracyclines decrease the effectiveness of oral contraceptives. The physician should be notified. The physician should be notified. Tetracycline decreases the effectiveness of oral contraceptives. There may be an equally effective antibiotic available that can be prescribed. Note on the client’s chart that the physician was notified. The nurse should be aware that tetracyclines decrease the effectiveness of oral contraceptives. The nurse should not tell the client to stop taking oral contraceptives unless the physician orders this. The nurse should be aware that tetracyclines decrease the effectiveness of oral contraceptives. If the physician chooses to keep the client on tetracycline, the client should be encouraged to use another form of birth control. The first intervention is to notify the physician.
When establishing realistic goals, the nurse:
A. Bases the goals on the nurse’s personal knowledge.
B. Knows the resources of the health care facility, family, and the client.
C. Must have a client who is physically and emotionally stable.
D. Must have the client’s cooperation.
B. Knows the resources of the health care facility, family, and the client.
When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply.
1. Increased heart rate
2. Decline in visual acuity
3. Decreased respiratory rate
4. Decline in long-term memory
5. Increased susceptibility to urinary tract infections
6. Increased incidence of awakening after sleep onset
2, 5, and 6.
Anatomical changes to the eye affect the individual’s visual ability, which leads to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Respiratory rates are usually unchanged. The heart rate decreases, and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client’s susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Changes in sleep patterns are consistent, age-related changes. Older persons experience an increased incidence of awakening after sleep onset.
Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place?
A. Maintain the drainage tubing and collection bag level with the patient’s bladder
B. Irrigate the patient with 1% Neosporin solution three times a daily
C. Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
D. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity
D. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity
Option D: Maintaining the drainage tubing and collection bag level with the patient’s bladder could result in reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician.
The nurse is giving dietary instructions on a client who is on a vegan diet. The nurse provides dietary teaching focus on foods high in which vitamin that may be lacking in a vegan diet?
A. Vitamin A.
B. Vitamin D.
C. Vitamin E.
D. Vitamin C.
B. Vitamin D.
Deficiencies in vegetarian diets include vitamin B12 which are found in animal products and vitamin D (if limited exposure to sunlight).
Options A, C, and D are found in fruits and vegetables, which are eaten by a vegetarian.
A two-year-old child with congestive heart failure has been receiving digoxin for one week. The nurse needs to recognize that an early sign of digitalis toxicity is:
A. bradypnea.
B. failure to thrive.
C. tachycardia.
D. vomiting.
D. vomiting.
Bradypnea (slow breathing) is not associated with digitalis toxicity. Bradycardia is associated with digitalis toxicity. Although children with congestive heart failure often have a related condition of failure to thrive, it is not directly related to digitalis administration. It is more related to chronic hypoxia. Tachycardia is not a sign of digitalis toxicity. Bradycardia is a sign of digitalis toxicity. The earliest sign of digitalis toxicity is vomiting, although one episode does not warrant discontinuing medication.
Which organization’s standards require that all patients be assessed specifically for pain?
A. American Nurses Association (ANA)
B. State nurse practice acts
C. National Council of State Boards of Nursing (NCSBN)
D. The Joint Commission
D. The Joint Commission
The Joint Commission has developed assessment standards, including that all clients be assessed for pain. The ANA has developed standards for clinical practice, including those for assessment, but not specifically for pain. State nurse practice acts regulate nursing practice in individual states. The NCSBN asserts that the scope of nursing includes a comprehensive assessment but does not specifically include pain.
A 16-year-old child is brought to the emergency department by his mother with a complaint that the child just experienced a tonic-clonic seizure. On arrival in the emergency department no apparent seizures were occurring. The mother states that her son is taking medication for the seizure disorder. The nurse plans care, knowing that which of the following medications are used for long-term control of tonic-clonic seizures? Select all that apply.
1. Diazepam (Valium)
2. Alprazolam (Xanax)
3. Gabapentin (Neurontin)
4. Ethosuximide (Zarontin)
5. Carbamazepine (Tegretol)
6. Methylphenidate (Ritalin)
3, 4, and 5.
Medications that are prescribed for long-term control of tonic-clonic seizures are gabapentin, ethosuximide, and carbamazepine. Diazepam is a medication that is prescribed to halt tonic-clonic episodes, and methylphenidate is a medication used to treat attention deficit hyperactivity disorder. Both of these medications are not suitable for long-term control of a seizure condition. Alprazolam is a medication used to treat anxiety.
A nurse is caring for a client who has diarrhea for the past four days. When assessing a client, the nurse should expect which of the following findings? Select all that apply.
A. Bradycardia
B. Hypotension
C. Fever
D. Poor skin turgor
E. Peripheral edema
B, C and D
Prolonged diarrhea lead to dehydration, which causes a decrease in blood pressure. Prolonged diarrhea leads to dehydration, which causes fever. Prolonged diarrhea is more likely to cause take a tachycardia than bradycardia. Peripheral edema results from a fluid overload. Prolonged diarrhea is more likely to cause a fluid deficit.
The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary instructions if she selects which of the following from her menu?
A. Nuts and fish.
B. Oranges and dark green leafy vegetables.
C. Butter and margarine.
D. Sugar and candy.
B. Oranges and dark green leafy vegetables.
Dark green leafy vegetables are rich in iron while oranges are a good source of vitamin C, which enhances iron absorption.
Nurse Celine is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, the nurse should instruct the client to:
A. Avoid chocolate and cheese
B. Take frequent naps
C. Take the medication with milk
D. Avoid walking without assistance
A. Avoid chocolate and cheese
Foods high in tryptophan, tyramine and caffeine, such as chocolate and cheese may precipitate hypertensive crisis.
The appropriate needle size for insulin injection is:
A. 18G, 1 ½” long
B. 22G, 1” long
C. 22G, 1 ½” long
D. 25G, 5/8” long
D. 25G, 5/8” long
Option D: A 25G, 5/8” needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route.
Option A: An 18G, 1 ½” needle is usually used for I.M. injections in children, typically in the vastus lateralis.
Option C: A 22G, 1 ½” needle is usually used for adult I.M. injections, which are typically administered in the vastus lateralis or ventrogluteal site.
The nurse would anticipate the use of which medications in the treatment of the client with heart failure? Select all that apply.
1. Diuretics
2. Anticoagulants
3. Anticholinergics
4. Cardiac glycosides
5. Phosphodiesterase (PDE) inhibitors
6. Angiotensin-converting enzyme (ACE) inhibitors
1, 4, 5, and 6.
Medications recommended for treatment of heart failure include diuretics, cardiac glycosides such as digoxin (Lanoxin), PDE inhibitors, and ACE inhibitors. Clients in heart failure do not need anticoagulants or anticholinergics.
A client with Congestive heart failure is about to take a dose of furosemide (Lasix). Which of the following potassium level, if noted in the client’s record, should be reported before giving the due medication?
A. 5.1 mEq/L.
B. 4.9 mEq/L.
C. 3.9 mEq/L.
D. 3.3 mEq/L.
D. 3.3 mEq/L.
The normal potassium level is 3.5 to 5.5 mEq/L. Low potassium levels can be dangerous, especially for people with CHF. Low potassium can cause fatal heart arrhythmias.
The nurse instructs a client with renal failure who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu?
A. Mushroom and blueberry.
B. Beans and banana.
C. Fish and tomato juice.
D. Potato and spinach.
A renal diet is one that is low in sodium, phosphorous, potassium and protein.
Options B, C, and D are high in sodium, phosphorus, and potassium.
A client with an acute exacerbation of rheumatoid arthritis is admitted to the hospital for treatment. Which drug, used to treat clients with rheumatoid arthritis, has both an anti-inflammatory and immunosuppressive effect?
A. Gold sodium thiomalate (Myochrysine)
B. Azathioprine (Imuran)
C. Prednisone (Deltasone)
D. Naproxen (Naprosyn)
C. Prednisone (Deltasone)
Gold sodium thiomalate is usually used in combination with aspirin and nonsteroidal anti-inflammatory drugs to relieve pain. Gold has an immunosuppressive affect. Azathioprine is used for clients with life-threatening rheumatoid arthritis for its immunosuppressive effects. Prednisone is used to treat persons with acute exacerbations of rheumatoid arthritis. This medication is given for its anti-inflammatory and immunosuppressive effects. Naproxen is a nonsteroidal anti-inflammatory drug. Immunosuppression does not occur.
A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action?
A. Prepare to irrigate the colostomy.
B. After assessing the stoma and surrounding skin, notify the surgeon.
C. Assess bowel sounds and administer antiemetic.
D. Administer a bulk forming laxative, and encourage increased fluids and exercise.
B. After assessing the stoma and surrounding skin, notify the surgeon.
The client has assessment findings consistent with complications of surgery. Option A: irrigating the stoma is a dependent nursing action, and is also intervention without appropriate assessment. Option C: assessing the peristomal skin area is an independent action, but administering an antiemetic is an intervention without appropriate assessment. antiemetics are generally ordered to treat immediate postoperative nausea, not several days postoperative. Option D: administering a bulk forming laxative to a nauseated postoperative client is contraindicated
A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.
1. Severely anxious client
2. Pneumonia client
3. Diabetic mellitus client
4. Malnourished client
5. Asthma client
6. Renal failure client
3, 4, and 6.
Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis because of the increasing acids in the body. Options 1, 2, and 5 are respiratory problems, not metabolic, and result in either respiratory acidosis or respiratory alkalosis.
The nurse is reviewing the laboratory result of a client receiving digoxin (Lanoxin) and notes that the result is 2.5 ng/mL. The nurse plans to do which of the following?
A. Give the next dose.
B. Notify the physician.
C. Check the client’s pulse rate.
D. Increase the next dose as ordered.
B. Notify the physician.
The normal value therapeutic range for digoxin is 0.5 to 2 ng/mL. A level of 2.5 ng/mL indicates a toxicity. The nurse should immediately inform the physician, who may give further instructions about holding the next doses of digoxin.
The nurse is instructing a client with hyperkalemia on the importance of choosing foods low in potassium. The nurse should teach the client to limit which of the following foods?
A. Grapes.
B. Carrot.
C. Green beans.
D. Lettuce.
B. Carrot.
Carrots has 320 mg of potassium per 100 mg serving; green beans give 209 mg of potassium, 194 mg for lettuce, and 191 mg for grapes all in 100 mg serving. Other foods that are low in potassium include: applesauce, blueberries, pineapple, and cabbage.
Mr. Bates is admitted to the surgical ICU following a left adrenalectomy. He is sleepy but easily aroused. An IV containing hydrocortisone is running. The nurse planning care for Mr. Bates knows it is essential to include which of the following nursing interventions at this time?
A. Monitor blood glucose levels every shift to detect development of hypo- or hyperglycemia.
B. Keep flat on back with minimal movement to reduce risk of hemorrhage following surgery.
C. Administer hydrocortisone until vital signs stabilize, then discontinue the IV.
D. Teach Mr. Bates how to care for his wound since he is at high risk for developing postoperative infection.
A. Monitor blood glucose levels every shift to detect development of hypo- or hyperglycemia.
Hydrocortisone promotes gluconeogenesis and elevates blood glucose levels. Following adrenalectomy the normal supply of hydrocortisone is interrupted and must be replaced to maintain the blood glucose at normal levels. Care for the client following adrenalectomy is similar to that for any abdominal operation. The client is encouraged to change position, cough, and deep breathe to prevent postoperative complications such as pneumonia or thrombophlebitis. Maintenance doses of hydrocortisone will be administered IV until the client is able to take it by mouth and will be necessary for six months to two years or until the remaining gland recovers. The client undergoing an adrenalectomy is at increased risk for infection and delayed wound healing and will need to learn about wound care, but not at this time while he is in the ICU.