Fundamentals
The nurse is caring for assigned clients. Which essential infection control measure should the nurse take?
A. Perform hand hygiene before, after, and between providing direct client care
B. Wear gloves while providing client care
C. Cleanse equipment such as thermometers or stethoscopes between client care
D. Maintain a distance of 3 feet away from clients who are coughing
A. Perform hand hygiene before, after, and between providing direct client care
Choice A is correct. Appropriate hand hygiene is the most effective measure the nurse can take to reduce the transmission of disease-causing pathogens. The nurse should perform hand hygiene after toileting, before, during, and after preparing food, before and after client care, and if the hands are visibly soiled. Alcohol-based hand rubs (ABHRs) may be used as long as the hands are not visibly soiled and if the client does not have conditions that resist ABHRs, such as C. diff, norovirus, or rotavirus.
The nurse assesses a client three hours following cardiac surgery. Assessment findings were a blood pressure of 88/52 mm Hg, jugular venous distention, and muffled heart sounds. The nurse anticipates that this client will need an immediate
A. thoracentesis.
B. pericardiocentesis.
C. arthrocentesis.
D. paracentesis.
B. pericardiocentesis.
Choice B is correct. The client is exhibiting signs and symptoms of cardiac tamponade following surgical trauma. Cardiac tamponade is a medical emergency where an accumulation of blood or fluid in the pericardial sac of sufficient volume and pressure occurs to the point of impairing cardiac filling. As a result, obstructive shock occurs. Clients with cardiac tamponade typically exhibit Beck's triad, consisting of hypotension, muffled heart tones, and neck vein distention. Treatment of cardiac tamponade includes immediate pericardiocentesis (inserting a needle into the pericardial cavity to drain the fluid or blood).
The nurse is assessing a client suspected of having the early stages of dementia. Which defense mechanism would the nurse expect?
A. Identification
B. Projection
C. Denial
D. Conversion
C. Denial
Choice C is correct. In the early stages of dementia, it is quite common for family members and the client to exhibit denial. Denial is utilized to avert the unpleasant emotions surrounding the diagnosis of dementia which is progressive in terms of its symptom intensity. Typically, symptoms that may be concerning for dementia are noticed by family or friends. This individual (an informant) usually brings this concern forward to the primary healthcare provider (PHCP).
The nurse is assessing a child in the emergency department with a fractured tibia. The medical record shows the client was recently discharged for a fracture to the radius and clavicle. The nurse is suspicious for
A. neglect.
B. psychological abuse.
C. physical abuse.
D. osteoscarcoma.
C. physical abuse.
Choice C is correct. Physical abuse is any intentional act causing injury or trauma to another person. In the child, who was recently seen for another fracture, this would be concerning. The nurse should perform a child abuse assessment and share the results with the physician.
The primary healthcare provider (PHCP) is preparing to intubate a client. The PHCP prescribes succinylcholine. The nurse understands that this medication is intended to
A. sedate the client during the procedure.
B. decrease oral and airway secretions.
C. increase heart rate in case of a vagal response.
D. cause skeletal muscle paralysis.
D. cause skeletal muscle paralysis.
Choice D is correct. Skeletal muscle paralysis is the intent of this medication. Succinylcholine is a neuromuscular blocking medication typically given immediately prior to intubation to assist with the procedure.
The nurse supervises a student nurse assisting a client with left-sided weakness in performing activities of daily living. Which action by the student nurse requires the nurse to intervene? The student nurse
A. puts the client's affected (weaker) arm in the shirt's sleeve first.
B. places shoes with velcro straps on the client's feet.
C. places the wheelchair as close to the bed as possible on the client's affected (weaker) side.
D. places the hairbrush in the client's unaffected (stronger) hand.
C. places the wheelchair as close to the bed as possible on the client's affected (weaker) side.
Choice C is correct. Placing the wheelchair as close to the bed as possible on the client's affected (weaker) side requires follow-up because the client should be mobilized by having the wheelchair on their unaffected (stronger) side. This requires follow-up because the client is at risk of falling and injury.
The nurse is caring for a client six hours postoperative following a below-knee amputation (BKA). Which of the following assessment findings requires follow-up?
A. Restlessness
B. Blood pressure of 140/78 mmHg
C. Pulse rate of 89 bpm
D. Hypoactive bowel sounds in all four quadrants
A. Restlessness
Choice A is correct. A nurse who observes a postoperative client with restlessness should be prompted to closely monitor and further assess the client, as this may be an early indicator of hemorrhage, shock, or pulmonary embolism. The client is six hours postoperative, and the risk of shock is high, especially from a vascular surgery such as an amputation.
The nurse is assessing a client with intermittent explosive disorder (IED). Which of the following findings would support a diagnosis of IED?
A. predatory violence
B. inattention
C. impulsivity
D. deceptive behavior
C. impulsivity
Choice C is correct. IED is characterized by exhibiting episodic aggressiveness grossly disproportionate to any stressors that may have helped elicit the episodes. The symptoms, which may be spells or attacks, appear within minutes or hours and remit spontaneously and quickly regardless of duration. After each episode, the client may express remorse. The client with IED often resorts to physical or verbal assault during the episodes and may damage property, people, or animals.
The nurse is planning a series of classes for young pregnant women. Which of the following discussion topics should the nurse include in a class related to nutrition during pregnancy?
A. The need to increase caloric intake by about 350 calories during the second trimester of gestation
B. The need to increase caloric intake by about 450 calories during the second trimester of gestation
C. The need to increase caloric intake by about 350 calories during the third trimester of gestation
D. The need to increase caloric intake by about 400 calories during the third trimester of gestation
A. The need to increase caloric intake by about 350 calories during the second trimester of gestation
Choice A is correct. Young pregnant women should be taught that most women (carrying one fetus) with a healthy pre-pregnancy weight require an additional 350 extra calories per day beginning in the second trimester of pregnancy (i.e., weeks 13 to 26). Similarly, an increase of approximately 450 calories per day is indicated during the third trimester (i.e., after 26 weeks) and continuing throughout the pregnancy (following birth, nutritional requirements vary based on whether the client is breastfeeding).
The nurse reviews newly prescribed laboratory tests and medications for the following clients. Which of the laboratory tests and prescriptions should the nurse question?
A. Liver function tests (LFTs) for a client prescribed atorvastatin
B. International normalized ratio (INR) for a client prescribed rivaroxaban
C. Serum creatinine level for a client prescribed lisinopril
D. Glycosylated hemoglobin (HgbA1C) level for a client prescribed olanzapine
B. International normalized ratio (INR) for a client prescribed rivaroxaban
Choice B is correct. Rivaroxaban is advantageous because it does not require frequent laboratory monitoring. International Normalized ratio (INR) monitoring is required for a client receiving selected anticoagulants such as warfarin. Rivaroxaban and apixaban (direct factor Xa inhibitors) may increase prothrombin time (PT) and INR. However, these tests are not reliable in assessing the anticoagulation effects of these agents. Therefore, INR monitoring is not recommended for clients on prescribed rivaroxaban. The nurse should question this because it is unnecessary.
A nurse is conducting infection control assessments on the nursing unit. Which client is at the greatest risk for infection? A client
A. withdrawing from alcohol and is malnourished.
B. receiving methylprednisolone for an asthma exacerbation.
C. has an external urinary catheter device for urinary incontinence.
D. receiving total parenteral nutrition (TPN) via a central line.
D. receiving total parenteral nutrition (TPN) via a central line.
Choice D is correct. A central line is a significant risk factor for a client to develop a central line-associated bloodstream infection (CLABSI). This occurs because of suboptimal sterile technique during insertion and/or inappropriate dressing changes. Additionally, TPN is a risk factor as the high glucose content makes the client more likely to develop a bacterial or fungal infection. TPN increases the risk for a CLABSI compared to solutions such as 0.9% saline.
The nurse is caring for a client with a breast tumor. The client reports trouble breathing, a puffy face/neck, nasal congestion, and a raspy voice. The nurse would suspect which of the following?
A. Spinal cord compression
B. Non-Hodgkin’s Lymphoma (NHL)
C. Superior vena cava syndrome
D. Shock
C. Superior vena cava syndrome
Choice C is correct. This patient’s tumor originates in the breast. Breast cancer may spread locally into the chest wall and lymph nodes. Due to its proximity to the superior vena cava (SVC), a locally advanced tumor or metastatic lymph node enlargement in the chest may obstruct blood flow to and from the superior vena cava. Such an obstruction results in venous congestion (puffiness in the face/ neck) and jugular-venous distension. Frequent clinical features of venous congestion in superior vena cava syndrome include blurred vision, hoarse voice, stridor, dyspnea, and nasal congestion.
The nurse is assessing a client with a binge eating disorder. The nurse understands which other comorbidity is commonly found with this disorder?
A. Disorganized behavior
B. Depression
C. Fear of abandonment
D. Perfectionism
B. Depression
Choice B is correct. Individuals who binge eat are more likely to have depression (and/or anxiety) than those who do not. Therefore, following this client admitting to binge eating, the nurse should screen this client for depression and suicidal ideation. Depression associated with the binge-eating disorder could be linked to their body image; however, other causes may be evident.
The nurse cares for a child admitted with severe dehydration secondary to gastroenteritis. Which assessment data would be most reliable in determining the client's response to the prescribed intravenous fluid replacement?
A. The number of stools in the past shift
B. The current weight compared to the admission weight
C. Mucous membrane assessment
D. The 24-hour urinary output
B. The current weight compared to the admission weight
Choice B is correct. Weight is the gold standard in determining fluid status. It provides an objective assessment of the client's overall fluid status. As a reminder, One kilogram equals 2.2 pounds, equivalent to one liter of fluid. If the client has an increase in one kilogram, compared to their admission weight, they have responded favorably to the fluid replacement.
The nurse is caring for a client receiving bupropion. Which of the following findings would indicate a therapeutic response?
A. A decrease in depressive symptoms
B. A decrease in manic symptoms
C. A decrease in delusions
D. A decrease in alcohol cravings
A. A decrease in depressive symptoms
Choice A is correct. Bupropion is an antidepressant medication that may be used for clients with major depressive disorder (MDD).
The charge nurse is reviewing room assignments and recognizes that only one private room is left. It would be appropriate to assign this room to the client with
A. human immunodeficiency virus (HIV).
B. delirium tremens who is agitated.
C. disseminated herpes zoster.
D. an implantable port that is accessed.
C. disseminated herpes zoster.
Choice C is correct. Disseminated herpes zoster requires airborne and contact precautions until lesions are dry and crusted. This client requires a private room because negative airflow is necessary, and thus, the door must be kept closed. The client should not be placed in a room with another client because of the high risk of disease transmission.
The nurse is assessing a client with hyperparathyroidism. Which of the following findings would support a diagnosis of hyperparathyroidism?
A. nephrolithiasis
B. hyperphosphatemia
C. diarrhea
D. halitosis
A. nephrolithiasis
Choice A is correct. Hyperparathyroidism causes a client to develop hypercalcemia. While most clients are asymptomatic, clients may go on to develop manifestations such as nephrolithiasis, polyuria, confusion, constipation, and shortened QT interval. The client with hyperparathyroidism would cause the client to develop hypercalcemia, which increases the client's proclivity to develop nephrolithiasis. The reason for nephrolithiasis is that the urinary calcium levels are high, which makes conditions favorable for stone formation.
The nurse in the emergency department (ED) is caring for a client experiencing agitation, anxiety, and hypertension. On assessment, the client has mydriasis and diaphoresis. The nurse suspects that this client may be intoxicated with which substance?
A. Opioids
B. Barbiturates
C. Amphetamines
D. Cannabis
C. Amphetamines
Choice C is correct. Fever, mydriasis, agitation, paranoia, hypertension, and tachycardia are all manifestations of amphetamine intoxication. Substances producing this type of intoxication include amphetamines, methamphetamines, and cocaine, a central nervous stimulant. When a client experiences amphetamine withdrawal, they are likely to experience hypersomnia, fatigue, increased appetite, and dysphoria.
The nurse is preparing to assess a child with cystic fibrosis at the outpatient clinic. The nurse anticipates that the primary healthcare provider (PHCP) will order which routine laboratory test?
A. Blood glucose
B. Total cholesterol
C. 24-hour urine
D. Blood cultures
A. Blood glucose
Choice A is correct. Diabetes mellitus is a common co-morbidity associated with cystic fibrosis (CF). The damage that CF may cause to the pancreas may induce diabetes. Thus, random blood glucose levels and quarterly hemoglobin A1C levels are commonly ordered throughout the course of the illness. A random blood glucose level greater than 200 mg/dL (11.1 mmol/L) [70-110 mg/dL, 4.0–11.0 mmol/L]may suggest the presence of diabetes.
The nurse is teaching a client who has hypertension about the newly prescribed medication, diltiazem. Which of the following should the nurse include in the teaching?
A. "A nagging cough can occur as a side effect of the medication."
B. "This medication may cause you to go to the bathroom more often."
C. "Avoid taking the medication with grapefruit juice."
D. "You will need to increase your dietary intake of potassium-rich foods."
C. "Avoid taking the medication with grapefruit juice."
Choice C is correct. Diltiazem is a calcium channel blocker indicated in the treatment of atrial fibrillation, hypertension, and peripheral arterial disease. Diltiazem and other calcium channel blockers should not be taken with grapefruit because of the risk of serious potentiation of the drug, leading the client to develop profound bradycardia and hypotension.