F & E
The nurse is caring for a client who has been treated with gastric suctioning for 4 days. The nurse notes an increase in nasal gastric drainage. Which of the following acid-base imbalances is the client experiencing? pH: 7.50; PaCO2: 45mmHg; HCO3: 32 mEq/L
a.) Metabolic Alkalosis
b.) Metabolic Acidosis
c.) Respiratory Alkalosis
d.) Respiratory Acidosis
a.) Metabolic Alkalosis
Rationale: The client's ABG shows metabolic alkalosis. The most likely cause of this alkalosis is the loss of acidic gastric contents from prolonged gastric suctioning.
Client's ABG is high in pH (alkalosis) and bicarbonate. Bicarbonate (HCO3) is basic; therefore, an elevated bicarb level indicates a more basic (alkalotic) state due to a metabolic cause.
The nurse is teaching a patient how to use a cane. Which information will the nurse include in the teaching session?
a.) Place the cane at the top of the hip bone.
b.) Place the cane on the stronger side of the body.
c.) Place the cane 10 to 15 inches in front of the body when walking.
d.) Place the cane in front of the body and then move the good leg.
b.) Place the cane on the stronger side of the body.
Rationale:
Cane should be placed at the hip level. Cane length is measured at the greater trochanter to the floor.
•FIRST: move cane forward 6-10 inches.
•NEXT: move weak (affected) leg forward toward the cane.
•LAST: move stronger (unaffected) leg past the cane. While you are doing this, the weight is divided between the cane and weaker leg. – REPEAT.
Contact precautions are initiated for a client with a health care–associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?
a.) Gloves and gown
b.) Gloves and goggles
c.) Gloves, gown, and shoe protectors
d.) Gloves, gown, goggles, and face shield
d.) Gloves, gown, goggles, and face shield
Splashes of body secretions can occur when providing colostomy care. Goggles and a face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.
A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply.
a.) Broth
b.) Coffee
c.) Gelatin
d.) Pudding
e.) Vegetable juice
f.) Pureed vegetables
a.) Broth
b.) Coffee
c.) Gelatin
Rationale:
A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet.
A patient with a tracheostomy has developed thick secretions that are obstructing the airway. What is the most appropriate nursing action to manage this issue?
a.) Increase the patient's oral fluid intake to thin the secretions.
b.) Perform tracheostomy suctioning using sterile technique.
c.) Change the tracheostomy tube to a larger size to improve airflow.
d.) Administer a saline nebulizer to the patient.
b.) Perform tracheostomy suctioning using sterile technique.
Rationale:
When a patient with a tracheostomy develops thick secretions that obstruct the airway, the most appropriate immediate action is to perform tracheostomy suctioning. This procedure helps clear the secretions and maintain a patent airway. While increasing fluid intake and using a saline nebulizer can help thin secretions over time, suctioning is the direct and effective intervention for clearing an obstructed airway. Changing the tracheostomy tube should only be considered if there are specific indications for it, such as a malfunctioning or improperly sized tube.
The nurse is assessing a client with hypocalcemia. Which of the following findings would be consistent with condition? Select All That Apply.
a.) Muscle cramps
b.) Increased urination
c.) Tingling around the mouth
d.) Cardiac dysrhythmias
e.) Headache
a.) Muscle cramps
c). Tingling around the mouth
d.) Cardiac dysrhythmias
Rationale: Hypocalcemia results in increased neuromuscular excitability, which can lead to smooth, cardiac, and skeletal muscle dysfunction.
Signs & Symptoms include:
Muscle cramps, seizures, paresthesia, hyperactive DTR's, cardiac dysrhythmias
Which health problem would place a patient at the greatest risk for complications associated with immobility?
a.) Quadriplegia
b.) Incontinence
c.) Hemiparesis
d.) Confusion
a.) Quadriplegia
Rationale:
(a) Quadriplegia, the paralysis of all four extremities, places the patient at greatest risk for pressure ulcers because the patient has no ability to shift the body weight off of bony prominences or change position without total assistance
(b) Bladder and bowel retraining, incontinence devices, and meticulous skin care limit the potential for skin breakdown when patients are incontinent
(c) Hemiparesis, muscle weakness on one side of the body, does not prevent a person from shifting or changing position to relieve pressure on the skin
(d) Confused patients can move independently when uncomfortable or when encouraged and assisted to move by the nurse.
The nurse is caring for a client with meningococcal pneumonia and implements which transmission-based precautions for this client?
a.) Private room or cohort client
b.) Personal respiratory protection device
c.) Private room with negative airflow pressure
d.) Mask worn by staff when the client needs to leave the room
a.) Private room or cohort client
Rationale:
Meningococcal pneumonia is transmitted by droplet infection. Precautions for this disease include a private room or cohort client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis. When appropriate, a mask must be worn by the client and not the staff when the client leaves the room.
The nurse is preparing a plan of care for a client receiving enteral feedings via a gastrostomy tube (G-tube). The nurse should plan to include which intervention in the plan of care?
a.) Provide oral fluids three times per day.
b.) Check around the stoma site for skin irritation.
c.) Medicate with antidiarrheal medications every day.
d.) Use sterile technique when administering the tube feedings.
b.) Check around the stoma site for skin irritation.
Rationale:
A G-tube is a tube inserted directly into the stomach for the purpose of providing direct enteral nutrition. Generally, G-tubes are well tolerated and beneficial to clients on long-term enteral nutrition. Aspiration of stomach contents into the lungs can occur, and the client's head of the bed must be kept elevated. Because of the surgical incision, occasionally gastric contents leak out onto the client's skin. Gastric contents are highly acidic and can cause skin irritation. The skin irritation may lead to infection. The nurse must monitor the insertion site for skin irritation. Oral fluids are not generally a component of the plan of care because the client with a G-tube normally does not have the capability of swallowing. Although diarrhea may be a complication of the feedings, antidiarrheals are not administered daily. Aseptic, not sterile, technique is necessary when administering feedings.
The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical manifestations are the direct result of altered perfusion? Select all that apply.
a.) Bounding pulse
b.) Pink nail beds
c.) Cyanosis
d.) Confusion
e.) Respiratory Rate 13
c.) Cyanosis
d.) Confusion
Rationale: A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include cyanosis and confusion. A weak pulse and blue nail beds would also indicate poor perfusion. Respiratory rate of 13 is within normal range.
The nurse is caring for a client with coronary artery disease and heart failure. Which of the following findings would require immediate follow-up?
a.) Bruises easily on the arms
b.) Reports chronic fatigue
c.) Muscle cramps in the legs
d.) Reports feeling depressed
c.) Muscle cramps in the legs
Rationale: Hypokalemia is a common adverse effect of potassium-wasting diuretics (furosemide) that may cause leg cramps, muscle weakness, or cardiac changes. Unmanaged hypokalemia can lead to lethal cardiac dysrhythmias. Nurse should immediately notify the HCP of symptoms of hypokalemia.
To combat hypokalemia, supplemental potassium and/or a high-potassium diet may be required for clients receiving potassium-wasting diuretics.
The nurse is observing a client who sustained a left ankle sprain ascending the stairs using a modified 3-point gait. The nurse should intervene if the client is observed
a.) bearing weight on the right leg
b.) realigning the crutches between each step
c.) assuming the tripod position before ascending the stairs
d.) Using the right crutch to support the weight while advancing the left leg onto the next step
d.) Using the right crutch to support the weight while advancing the left leg onto the next step
A registered nurse (RN) is providing instructions to an unlicensed assistive personnel (UAP) assigned to give a bed bath to a client who is on contact precautions. The RN instructs the UAP to use which protective item when giving the bed bath?
a.) A gown and gloves
b.) Gloves and goggles.
c.) A gown and goggles
d.) Gloves and shoe protectors
a.) A gown and gloves
Rationale:
Contact precautions require the use of gloves and a gown if direct client contact is anticipated. Goggles are not necessary unless it is anticipated that splashes of blood, bodily fluids, secretions, or excretions may occur. Shoe protectors are not necessary.
The nurse is formulating a plan of care for a client receiving enteral feedings. Which client problem is the highest priority?
a.) Diarrhea
b.) Nutrition
c.) Aspiration
d.) Deficient fluid volume
c.) Aspiration
Rationale:
Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places the client at risk for aspiration. Diarrhea and nutrition may be appropriate problems, but are not of highest priority. Deficient fluid volume is not likely to occur in this client.
The nurse is conducting an assessment for a client on a medical-surgical unit. Which findings are indicative of a client who is experiencing tachypnea? Select all that apply.
A) Excessive rapid breathing
B) Chest pain
C) Rapid breathing at rest
D) Shallow breathing
E) Cyanosis
A) Excessive rapid breathing
C) Rapid breathing at rest
D) Shallow breathing
Rationale: Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations of tachypnea. Chest pain is a manifestation of a pneumothorax. Cyanosis is a late manifestation of hypoxemia.
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present?
a.) Weight loss
b.) Flat neck and hand veins
c.) An increase in blood pressure
d.) Decreased central venous pressure (CVP)
c.) An increase in blood pressure
Rationale:
A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit.
A nurse is preparing to help a patient with ambulation. Which action is most important to ensure safety during the process?
a.) Ensure the patient’s feet are off the floor before standing.
b.) Lock the wheels on the bed and assistive devices.
c.) Instruct the patient to hold onto the nurse’s shoulders.
d.) Have the patient pivot quickly to avoid straining muscles.
b.) Lock the wheels on the bed and assistive devices.
Rationale:
Ensuring that wheels on the bed and assistive devices are locked is crucial for safety to prevent any unintended movement that could lead to falls or injuries.
A registered nurse (RN) is providing instructions to an unlicensed assistive personnel (UAP) assigned to give a bed bath to a client who is on contact precautions. The RN instructs the UAP to use which protective item when giving the bed bath?
a.) A gown and gloves
b.) Gloves and goggles
c.) A gown and goggles
d.) Gloves and shoe protectors
a.) A gown and gloves
Rationale:
Contact precautions require the use of gloves and a gown if direct client contact is anticipated. Goggles are not necessary unless it is anticipated that splashes of blood, bodily fluids, secretions, or excretions may occur. Shoe protectors are not necessary.
A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?
a.) Creatine kinase
b.) Troponin
c.) Total bilirubin
d.) Albumin
d.) Albumin
Rationale:
A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time.
A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?
a.) Encourage the client to ambulate frequently.
b.) Encourage coughing and deep breathing.
c.) Encourage the client to increase fluid intake.
d.) Encourage regular use of the incentive spirometer.
c.) Encourage the client to increase fluid intake.
Rationale:
Increasing fluid intake to 1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client’s ability to cough and remove the secretions.
The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?
a.) The client who is taking diuretics
b.) The client with hyperaldosteronism
c.) The client with Cushing's syndrome
d.) The client who is taking corticosteroids
a.) The client who is taking diuretics
Rationale:
Hyponatremia is evidenced by a serum sodium level less than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.
A nurse is assisting a patient who has had a stroke and now has limited mobility on one side. Which intervention will help the patient maintain independence while promoting mobility?
a.) Assist with all activities of daily living (ADLs)
b.) Provide a walker and supervise the patient during ambulation.
c.) Encourage bed rest to prevent falls.
d.) Limit physical therapy sessions to twice a week.
b.) Provide a walker and supervise the patient during ambulation
Rationale: Providing a walker and supervision promotes mobility while maintaining safety. Assisting with all activities, limiting physical therapy sessions, and encouraging bed rest would hinder the patient's independence.
The nursing student is following standard precautions to prevent a hospital-acquired infection in a client. The student understands that which applies to the use of standard precautions? Select all that apply.
a.) Used when working with all clients
b.) Used only when specifically indicated
c.) Does not apply to those who do not have any open wounds
d.) Applies to blood, all body fluids, secretions, and excretions
e.) Is designed to prevent the risk of spreading microorganisms
a.) Used when working with all clients
d.) Applies to blood, all body fluids, secretions, and excretions
e.) Is designed to prevent the risk of spreading microorganisms
Rationale:
Standard precautions are to be used on all clients and are designed to prevent the risk of spreading microorganisms. It applies to contact with blood, body fluids, secretions, and excretions.
A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a intestinal obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching?
a.) Determine the pH of the gastric secretions.
b.) Supply nutrients via tube feedings.
c.) Decompress the stomach.
d.) Administer medications.
c.) Decompress the stomach.
Rationale: A pyloric obstruction, also called gastric outlet obstruction, is caused by edema, scarring, or spasm, often the result of gastritis or peptic ulcer disease. The nurse should inform the client that because the stomach is dilated and may contain undigested food, it must be decompressed, necessitating the placement of an NG tube.
A nurse is assessing a patient for signs of adequate perfusion. Which of the following findings would indicate poor perfusion?
a.) Warm, dry skin with a capillary refill time of 2 seconds
b.) Clear urine output of 50 mL per hour
c.) Cool, pale skin with a capillary refill time of 4 seconds
d.) Normal blood pressure and regular heart rate
c.) Cool, pale skin with a capillary refill time of 4 seconds
Rationale:
Cool, pale skin and a prolonged capillary refill time (greater than 2 seconds) are signs of poor perfusion. These findings suggest that blood flow to the skin is reduced, which can be indicative of issues such as shock or impaired circulation. The other options (warm, dry skin; clear urine output; normal blood pressure and heart rate) are generally signs of adequate perfusion.