Tissue Integrity
Which nursing intervention should be implemented after a femoral angiogram procedure?
Provide passive range of motion (ROM) to all extremities.
Elevate the foot of the bed for 36 hours.
Assist the client to stand if unable to void.
Apply pressure to the catheter insertion site.
What is Apply pressure to the catheter insertion site?
Rationale
Pressure promotes coagulation and prevents the complication of bleeding. Bending the operative leg may cause decreased perfusion to the leg or bleeding at the catheter insertion site. Elevation will resist the gravity flow of arterial blood, reducing oxygen to distal tissue. The client should remain in the supine position for 4 to 6 hours to prevent bleeding at the insertion site.
A 14-year-old with diabetes has been self-administering insulin twice a day. This morning, the parents found their child lethargic and confused. After the adolescents admission to the emergency department, laboratory testing reveals a hemoglobin Alc level of 14% and the UAP reports to the nurse, a blood glucose level of 300 mg/dL. Which condition is the nurse concerned about?
Hypoglycemia
Somogyi effect
Uncontrolled blood glucose level
Noncompliance with the prescribed insulin regimen
What is uncontrolled blood glucose level?
Rationale
Lethargy, confusion, thirst, nausea, flushed face, and abdominal pain are associated with hyperglycemia, not with hypoglycemia. The blood glucose level is above the expected range of 90 to 130 mg/dL for adolescents older than 12 years of age from the American Diabetes Association, and the hemoglobin Alc is above the expected range. The plasma blood glucose would be less than 60 mg/dL with hypoglycemia. Periodic blood glucose monitoring, including at night, must be performed to document the Somogyi effect, which is hypoglycemia followed by a rebound increase in the morning. Suggesting that the prescribed regimen was not followed is a judgmental assumption, and there is insufficient information to justify this conclusion.
A nurse administers an intramuscular injection of vitamin K to a newborn. What is the purpose of the injection?
It promotes formation of red blood cells.
It prevents destruction of red blood cells.
It promotes conjugation of bilirubin.
It provides protection from hemorrhage.
Double Jeopardy: What medication is given to newborns to protect their eyes?
What is It provides protection from hemorrhage?
Rationale
Vitamin K prevents hemorrhagic disease of the newborn because it activates coagulation factors in the liver. The mechanism by which vitamin K prevents hemorrhage is unrelated to formation or destruction of red blood cells, for which vitamin K does not have a role. Its role in the liver is to activate blood coagulation, not bilirubin conjugation.
DJ: Erythromycin ointment
Fluid replacement of 7200 mL during the first 24 hours has been prescribed for a burn client. What does the nurse calculate the hourly intravenous (IV) fluid to be?
Record your answer using a whole number.
What is 300 mL/hour?
Rationale
The total volume to be infused is 7200 mL. The total time of infusion is 24 hours. 7200 mL รท 24 hours = 300 mL/hr.
A child with acute poststreptococcal glomerulonephritis requests a snack. Which selection of food would the nurse provide?
Peanuts
Pretzels
Bananas
Applesauce
DOUBLE JEOPARDY: Which two electrolytes do we need to watch closely with this diagnosis?
What is applesauce?
DJ: Sodium and potassium
Rationale
Applesauce provides nutrition without large additional amounts of potassium and sodium.
Peanuts and pretzels are high in sodium, which increases fluid retention. Bananas are high in potassium, which is contraindicated.
Which advice regarding foot care would the nurse give to a client diagnosed with diabetes?
Remove corns on the feet.
Wear shoes that are larger than the feet.
Examine the feet weekly for potential sores.
Wear synthetic fiber socks when exercising.
***DOUBLE JEOPARDY: What is the patho behind why we are worried about diabetics feet?
What is wear synthetic fiber socks when exercising?
Rationale
Research demonstrates that socks with synthetic fibers wick away moisture better than other fabrics when participating in vigorous activities. Self-removal of corns can result in injury to the feet. Shoes that do not fit appropriately will create friction, causing sores, blisters, and calluses.
The feet should be examined daily (not weekly).
DJ: neuropathies from PVD/some lose all feeling in their feet
The nurse would teach the UAP that direct pressure during active and passive range-of-motion exercises on a client with a subsiding acute episode of rheumatoid arthritis would not be applied to the clients joints because this may precipitate what?
Pain
Swelling
Nodule formation
Tophaceous deposits
What is pain?
Rationale
Palpation will elicit tenderness because pressure stimulates nerve endings and causes pain.
Pressure will not increase the swelling of already swollen joints. Nodules associated with rheumatoid arthritis are not caused by pressure; they occur spontaneously in about 25% of individuals with rheumatoid arthritis and are composed of collagen fibers, exudate, and cellular debris. Tophaceous deposits are present in gout, not rheumatoid arthritis; they are composed of sodium urate.
A nurse is caring for four pediatric clients. Which client needs to be assessed first?
A- A 16-year-old with an exacerbation of rheumatoid arthritis (RA) due to infection
B- A 2-year-old with sickle cell anemia receiving PO folic acid
C- A 4-year-old to be given digoxin with a pulse rate of 70 beats per minute
D- A 1-year-old with croup with a respiratory rate of 35 breaths per minute
What is C?
Rationale
The normal pulse for a 4-year-old is 90 to 110 beats per minute. The pulse rate of 70 beats per minute is low, and digoxin should be held and the health care provider notified. The adolescent with an exacerbation of RA due to infection needs to be assessed but not first. The pediatric client with sickle cell anemia does not need to be assessed first, as he or she is not in sickle cell crisis.
Folic acid stimulates red blood cell (RBC) production. A child with croup needs to be assessed for respiratory depression but has a normal respiratory rate and does not need to be seen first.
A nurse is caring for a client with preeclampsia who is receiving intravenous magnesium sulfate. For which assessment would the nurse need to call the health care provider:
Respiratory rate of 18 breaths per minute
Patellar reflex response of +2
Blood pressure of 112/76 mm Hg
Urine output of less than 100 mL in 4 hours
Double Jeopardy: What is the antidote for magnesium sulfate?
What is Urine output of less than 100mL in 4 hours?
Rationale
A decreased urine output of less than 25 mL per hour may be indicative of kidney damage, a result of the preeclampsia, and impending renal failure. Magnesium sulfate is excreted by the kidneys, and magnesium toxicity may occur. Respirations at this rate are within the expected range; a rate of at least 12 breaths per minute should be present during magnesium sulfate therapy. Loss of the patellar reflex is suggestive of magnesium sulfate toxicity; a +2 reflex is within the expected range. A blood pressure of 112/76 mm Hg is within normal limits.
DJ: Calcium Gluconate
Which diet would the nurse expect to be prescribed to best meet the immediate nutritional needs of an obese client with wound healing after surgery?
Low in fat and vitamin D
High in calories and fiber
Low in residue and bland
High in protein and vitamin C
What is High in protein and vitamin C?
Rationale
Protein and vitamin C promote wound healing; this is a postoperative priority. Although a low-fat diet is preferred for an obese client, vitamin D, as well as other vitamins, should not be limited. A high-calorie diet can increase obesity, and there is no indication that this client is at risk for constipation requiring a high-fiber diet. A low-residue bland diet can cause constipation; the priority is for nutrients to promote healing.
A child who has cerebral palsy and scoliosis also is mentally challenged, incontinent, has contractures of the elbows and wrists, and sits in a customized wheelchair most of the day. Which nursing action will best achieve the goal for the child's skin integrity to remain intact?
Padding the child's lower extremities
Repositioning the child every 4 hours
Replacing the bed linens with sterile linens
Changing disposable diapers every 2 to 3 hours
What is changing disposable diapers every 2 to 3 hours?
Rationale
The buttocks are at greatest risk for excoriation because the child sits in a wheelchair most of the day; for skin integrity to be maintained, the diaper area must be kept dry; disposable diapers keep moisture away from the skin. Because the child is in a wheelchair, there is no pressure on the child's legs. The child should be repositioned every 1 to 2 hours. Replacing the bed linens is unnecessary; freshly laundered linens will not prevent the development of a pressure ulcer.
Which task can be delegated to an unlicensed assistive personnel (UAP) working on a cardiac unit? Select all that apply. One, some, or all responses may be correct.
A-Checking vital signs
B-Providing mouth care
C-Helping feed clients
D-Recording intake and output
E-Assisting clients with ambulating
F-Performing simple dressing changes
What is all the above?
Rationale
These are all tasks that can be delegated to a UAP. Checking vital signs, providing mouth care, helping feed clients, recording intake and output, assisting clients with ambulating, and performing simple dressing changes that do not require debridement or packing are things that a UAP can do under the supervision of a nurse.
After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. Which is the priority nursing care for this newborn?
Protecting the sac with moist sterile gauze
Dry and swaddling the infant in a warm blanket
Placing name bracelets on both the mother and infant
Transferring the infant to the neonatal intensive care unit
What is protecting the sac with moist sterile gauze?
Rationale
Preventing infection and trauma is the priority; rupture of the sac may lead to meningitis. The Apgar scores are 9 and 10 at 1 and 5 minutes, respectively; the infant should be dried off after the sac has been protected. The child will be placed on a radiant warmer bed and will not need to be swaddled. Placement of name bracelets on both mother and infant may be done before the infant leaves the birthing room; the priority is care of the infant's sac. The infant's sac must be protected before the infant is transferred to the neonatal intensive care unit.
A client who is receiving a cardiac glycoside, a diuretic, an antibiotic, and a vasodilator has been placed on bed rest for an apical pulse rate of 44 beats per minute. The nurse concludes that the decreased heart rate is most likely a result of which medication?
Diuretic
Vasodilator
Antibiotic
Cardiac glycoside
DOUBLE JEOPARDY: If a patient is taking a diuretic such as furosemide, and a cardiac glycoside such as Digoxin, what are they at greatest risk for besides hypotension?
What is a cardiac glycoside?
Rationale
A cardiac glycoside such as digoxin decreases the conduction speed within the myocardium and slows the heart rate. The primary effect of a diuretic is on the kidneys, not the heart; it may reduce the blood pressure, not the heart rate. A vasodilator can cause tachycardia, not bradycardia, which is an adverse effect. An antibiotic does not reduce the heart rate.
DJ: HYPOkalemia
Which food selection would indicate to the nurse that a client with full-thickness burns understands the teaching on how to best meet nutritional needs?
Cheeseburger and a malted milk
Beef barley soup and orange juice
Bacon and tomato sandwich and tea
Chicken salad sandwich and soft drink
What is Cheeseburger and a malted milk
Rationale
Of the selections offered, a cheeseburger and a malted have the highest calories and protein, which are needed for the increased basal metabolic rate associated with burns and for tissue repair. Although orange juice provides vitamin C, beef barley soup does not provide adequate protein or calories. Bacon and tomato sandwich and tea do not provide an adequate amount of calories and protein. A chicken salad sandwich and a soft drink do not provide an adequate amount of calories and protein.
Which process is an example of third spacing in a burn injury?
Blister formation
Edema formation
Fluid mobilization
Fluid accumulation
What is blister formation?
Rationale
Blister formation is an example of third spacing in burn injuries. Edema formation and fluid mobilization generally happen in every burn injury. Fluid accumulation is formed by second spacing in a burn injury.
A charge nurse is assigning tasks to the healthcare team on a busy medical-surgical unit. Which of the following delegation decisions is most appropriate?
A) Assigning an LPN to independently assess a newly admitted patient with unstable vital signs
B) Delegating the task of patient education about a new medication to a nursing assistant
C) Asking an experienced RN to supervise an LPN providing care to a patient with a deteriorating condition
D) Instructing a nursing assistant to reposition a patient with a pressure ulcer and document any changes in wound appearance
What is C: Asking an experienced RN to supervise an LPN providing care to a patient with a deteriorating condition
Rationale:
This question tests understanding of complex delegation scenarios, considering the scope of practice for different healthcare team members and the acuity of patient conditions.
C is correct because:
A is incorrect because LPNs should not independently assess newly admitted patients with unstable vital signs. This requires RN-level clinical judgment.
B is inappropriate as patient education, especially regarding new medications, requires nursing knowledge and cannot be delegated to nursing assistants.
D is partially correct but not the best answer. While nursing assistants can reposition patients, assessing and documenting changes in wound appearance requires nursing judgment and should not be delegated.
Which part of a newborns body is usually affected by the rash erythema toxicum neonatorum? Select all that apply. One, some, or all responses may be correct.
A- Face
B- Palms
C- Soles
D- Trunk
E- Buttocks
DOUBLE JEOPARDY: WHAT IS THE CAUSE?
What is A, D, E?
Rationale
Erythema toxicum neonatorum is a type of skin eruption noted during the first 2 days after birth.
The rashes are most prominent on the face, trunk, and buttocks. The palms and soles are unaffected by the eruptions.
DJ: Its cause is unknown.
Which complication would the nurse monitor for development in a client receiving total parenteral nutrition (TPN)? Select all that apply. One, some, or all responses may be correct.
A- Phlebitis
B- Infection
C- Hepatitis
D- Anorexia
E- Dysrhythmias
What is A and B?
Rationale
Phlebitis may occur because the hypertonic nature of the infusion is irritating to the vein. The concentration of glucose in the solution is a culture medium that supports the growth of microorganisms. Hepatitis usually is not associated with TPN. Anorexia often is present before the medical decision is made to begin TPN. Dysrhythmias are not related to TPN but may be a sign of hyperkalemia or hypokalemia.
The nurse would teach a client with calcium oxalate renal calculi to avoid which food? Select all that apply. One, some, or all responses may be correct.
Milk
Nuts
Liver
Spinach
Rhubarb
What is nuts, spinach, and rhubarb?
Rationale
Nuts, especially peanuts, almonds, and pecans, should be avoided. Clients with struvite stones (staghorn stones) also should avoid nuts. Spinach and rhubarb are high in calcium oxalate. Other examples include beets, wheat bran, tea, chocolate, and coffee. Limiting oxalate-rich foods limits oxalate absorption and the formation of calcium oxalate calculi. Milk is an acceptable calcium-rich protein. Research indicates that it reduces oxalate absorption. Liver is a purine-rich food that may be eaten. All meats, especially organ meats, anchovies, sardines, fish roes, herring, meat extracts, and broths, are purine-rich foods.
Which clinical indicator of postoperative thrombophlebitis would the nurse expect to identify when assessing a surgical client? ***Select all that apply. One, some, or all responses may be correct.
A-Pain in the calf
B-Intermittent claudication
C-Redness in the affected area
D-Pitting edema of the lower leg
E-Ecchymotic areas around the ankle
F-Localized warmth in the lower extremity
What is A, C, F
Rationale
Pain is related to the edema associated with the inflammatory response. Redness is related to vasodilation and the inflammatory response. Thrombophlebitis is inflammation of a vein that occurs with the formation of a clot. Warmth is related to vasodilation. Intermittent claudication (pain when walking, resulting from tissue ischemia) may occur with peripheral arterial disease.
Although some localized edema occurs, pitting edema does not occur in thrombophlebitis.
Ecchymosis is a sign of bleeding; thrombophlebitis is caused by a clot.
When the nurse assigns the unlicensed assistive personnel (UAP) to obtain and record routine vital signs on all clients on the unit, which action would the nurse take? Select all that apply.
A- Validate willingness to accept the delegated task.
B- Convey unique client requirements, characteristics, or concerns.
C- State the exact task, how it is to be accomplished, and expected outcomes.
D- Specify concerns or emergency conditions that warrant prompt reporting.
E- Allow UAPs to make decisions regarding times in which vital signs should be performed.
what is A, B, C, D?
Rationale
The nurse would validate the UAP's willingness to accept the delegated task. The nurse would also convey unique client requirements, characteristics, or concerns (i.e., the client will only drink with a straw); communicate to the UAPs the exact task to be done, how the task will be accomplished, and the expected outcomes; and specify any specific concerns or emergency conditions that warrant prompt reporting. The nurse would specific the time and frequency of the task to be performed.
A toddler receives a gastrostomy tube feeding every 4 hours. Which is the priority nursing intervention for this child?
Opening the tube 1 hour before feeding
Keeping the child lying flat during the feeding
Flushing the tube with normal saline after the feeding
Positioning the child on the right side after the feeding
What is Positioning the child on the right side after the feeding?
Rationale
Positioning the child on the right side after feeding facilitates digestion because the pyloric sphincter is on this side and gravity aids emptying of the stomach. The feeding may be started immediately after the tube is opened. Keeping the child lying flat during the feeding may result in aspiration; the child's head and torso should be elevated. If the gastrostomy tube is flushed before or after a feeding, water, not normal saline, is used.
A 2-year-old child is receiving intravenous fluid. A 500 mL bag of D5% in normal saline is hung at 1:00 am and is to infuse at 45 mL/hr. At 6:00 am the nurse notes that there is 125 mL left in the bag. Which would the nurse conclude regarding the fluids that have infused?
It should be recalculated in an hour.
It is more than the child should have received.
It is less than the amount prescribed for the child.
It remained at the prescribed rate through the night.
What is It is more than the child should have received?
Rationale
An excessive amount of fluid has infused. The intravenous (IV) medicine should be delivered at 45 mL/hr and should be checked on a regular schedule. If the IV had infused at the prescribed rate of 45 mL/hr for 5 hours, 225 mL should have infused, leaving 275 mL in the bottle. An excessive, not less-than-prescribed, amount of fluid has infused. It would not be appropriate to wait another hour to calculate the amount of fluid infused.
A client weighed 210 pounds on admission and after two days of diuretic therapy, the client weighs 205.5 pounds. Which numerical value represents the amount of fluid in liters that the client excreted? Record your answer using a whole number.
What is 2 liters?
Rationale
One liter of fluid weighs approximately 2.2 pounds. A 4.5-pound weight loss equals approximately 2 liters.