Basic Care & Comfort
The nurse is caring for a 48-year-old executive on the cardiac unit who has just been diagnosed with primary hypertension. Which teaching strategy implemented by the nurse is most likely to be effective for this client?
1. Leave diet pamphlets for the client to review later
2. Refer the client to the nurse case manager to follow up with diet instructions
3. Sit with the client during meal selections and assist with identification of low sodium options
4. Turn the TV on in the client's room to the patient education channel to watch
3. Sit with the client during meal selections and assist with identification of low sodium options
Explanation: the nurse should actively engage the client in teachings that the client is ready to receive and perceives as an immediate need.
The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?
1. Drops sterile gauze on the sterile field from 6 inches (15 cm) above
2. Keeps the sterile field and sterile gloved hands within view at all times
3. Places sterile gauze 2 inches (5 cm) inside the outer edge of the sterile
drape
4. Pours sterile saline solution from a recapped bottle opened 30 hours ago
4. Pours sterile saline solution from a recapped bottle opened 30 hours ago
Explanation: When performing a sterile dressing change, the nurse should use concepts of sterile technique to reduce the client's risk for infection, including discarding any sterile items that have been open for more than 24 hours.
A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action?
1. Auscultate the client's breath sounds
2. Encourage the client to increase fluid intake
3. Report the findings to the health care provider
4. Start an intravenous line for diuretic administration
1. Auscultate the client's breath sounds
Explanation: Decreased urine output of <30 mL/hr could be due to low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter). Always assess the client first, and then report to the HCP.
The nurse is talking with a staff member about reconstituting medications. Which of the following information should the nurse include?
1. "A total of 10 mL of air should be injected into the vial that contains the medication powder before reconstituting it."
2. "Powdered medications should be reconstituted using 10mL of 0.9% sodium chloride."
3. "The medication should be drawn up in a syringe after the powder is dissolved."
4. "The medication should be mixed by shaking the medication vial."
3. "The medication should be drawn up in a syringe after the powder is dissolved."
Explanation: Some medications come in a powdered form that requires reconstitution with a liquid diluent prior to administration. The nurse should ensure that all the powder is dissolved within the diluent before drawing up the medication into a syringe for administration.
The nurse is caring for a client who had a right modified radical mastectomy 4 hours ago. The nurse should place the client in the:
1. High Fowler position with the right arm resting on the bed
2. Supine position with the right arm elevated on several pillows
3. Semi-Fowler position with the right arm elevated on several pillows
4. Supine position with the right arm resting on the bed
3. Semi-Fowler position with the right arm elevated on several pillows
Explanation: promotes drainage and prevents venous and lymphatic pooling
A client is scheduled for an elective laparoscopic prostatectomy in the morning. The nurs should notify the health care provider about which assessment data as soon as possible before surgery?
1. Hemoglobin 15.0 g/dL (150 g/L), hematocrit 45% (0.45)
2. INR 1.3
3. Platelet count 295,000/mm (295×10/)
4. Temperature 100.4 F (38 C) with cough
4. Temperature 100.4 F (38 C) with cough
Explanation: The health care provider (HCP) should be notified as soon as possible if a client scheduled for surgery develops manifestations that could indicate a possible infection. Anesthesia and the physiologic stress of surgery in the presence of fever and cough can cause potential intraoperative and postoperative complications.
The nurse in the emergency department is caring for a client who is experiencing torsades de pointes. Which of the following medications should the nurse recognize is used to treat this cardiac dysrhythmia?
1. Adenosine
2. Dopamine
3. Magnesium
4. Propranolol
3. Magnesium
Explanation: Torsades de pointes results from a prolonged QT interval, which is caused by electrolyte imbalances (eg, hypomagnesemia) or some medications (eg, amiodarone, amitriptyline, ondansetron). IV magnesium is the first-line treatment for torsades de pointes.
The nurse is caring for 4 clients requiring IV fluid therapy. For which client should the nurse anticipate the need for isotonic crystalloid administration? Click the exhibit button for additional client information.
1. 25-year-old with a closed-head injury and signs of increasing intracranial pressure
2. 45-year-old with acute gastroenteritis and dehydration
3. 60-year-old with seizures and serum sodium of 112 mEq/L (112 mmol/L)
4. 68-year-old with chronic renal failure and hypertensive crisis
2. 45-year-old with acute gastroenteritis and dehydration
Explanation: Isotonic fluid therapy is used to treat clients with extracellular fluid deficits (eg, dehydration). Clients at risk for cerebral swelling (eg, increased intracranial pressure, hyponatremia) require hypertonic fluid administration to decrease cellular swelling. Isotonic fluid administration may cause fluid overload in clients with renal failure.
The nurse has taught a client who is using a pick-up walker to ambulate. Which of the following statements by the client would require follow-up?
1. "I will ensure the legs of the walker are on the floor before bearing weight on the handgrips."
2. "I should advance my foot past the front bar of the walker when I take a step forward."
3. "I will maintain my elbows at a 15-to 30-degree angle when holding the
handgrips."
4. "I should move the walker forward first, then step forward with my weaker
leg."
2. "I should advance my foot past the front bar of the walker when I take a step forward."
Explanation: to reduce the risk for falls, clients should avoid advancing the foot beyond the front bar of the walker during ambulation.
The male client had a hemicolectomy. The client is refusing to wear the prescribed sequential compression devices (SCDs). What is most important for the nurse to communicate to the client?
1. An appropriate form must be signed, verifying refusal
2. Complications, including death, could result
3. The client will be billed for the equipment regardless
4. The surgeon will be informed of the refusal
2. Complications, including death, could result
Explanation: The most important aspect of a client's refusal for treatment is to make sure that the client is informed of the potential results of the refusal.
The nurse is caring for assigned clients with central venous access devices (CVADs). The nurse should recognize that the client at highest risk for developing a central line-associated bloodstream infection is the client with a CVAD in the:
1. basilic vein, inserted at the bedside 2 weeks ago
2. internal jugular vein, inserted in the operating room 2 days ago
3. subclavian vein, inserted in the intensive care unit 72 hours ago
4. femoral vein, inserted in the emergency department 24 hours ago
4. femoral vein, inserted in the emergency department 24 hours ago
Explanation: Femoral CVADs bring a high risk for infection due to their strong susceptibility to contamination by urine or feces; in addition, they are difficult to cover with an occlusive dressing.
The nurse has received a new order to discontinue IV fluids for a client who is receiving bolus doses of morphine via an IV patient-controlled analgesia (PCA) device. Which of the following actions should the nurse take?
1. Change the settings on the PCA device to deliver a continuous infusion.
2. Clarify the order with the health care provider.
3. Connect the PCA tubing directly to the client's peripheral venous access device.
4. Discontinue operation of the PCA device.
2. Clarify the order with the health care provider.
Explanation: Continuous IV fluids are often necessary with the use of a patient-controlled analgesia (PCA) device. The fluids maintain an open vein and provide a vehicle for PCA medication delivery.
The nurse begins to assist with ambulation of a 9-year-old client who is 1 day postoperative appendectomy when the child cries out, "It hurts too much. I can't do it." Which action should the nurse complete first?
1. Administer a PRN analgesic and monitor for adverse effects
2. Ask the client to point to a numeric scale to indicate pain level
3. Come back later in the day to attempt ambulation again
4. Encourage the client to walk to promote blood circulation
2. Ask the client to point to a numeric scale to indicate pain level
Explanation: when a client is in pain, assessment is the first necessary nursing action. Pain assessments help determine the appropriate relief measure and serve as a baseline for evaluating the effectiveness of the chosen pharmacologic or nonpharmacologic measure.
A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety. Which prescription should the nurse question before administering?
1. Haloperidol for a client with a fall history who keeps getting out of bed without assistance
2. Lorazepam for a client who is in alcohol withdrawal and is extremely
agitated
3. Olanzapine for a client with schizophrenia who is exhibiting violent behavior
4. Proofol for a client who is intubated and receiving mechanical ventilation
1. Haloperidol for a client with a fall history who keeps getting out of bed without assistance
Explanation: Medications that are standard treatments for specific conditions (eg, alcohol withdrawal, schizophrenia, mechanical ventilation) are not considered chemical restraints. The nurse should question a chemical restraint prescription that may not be medically necessary for a client's safety.
A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse explains that the pain will improve with which of the following?
1. Coughing and deep breathing
2. Left lateral position
3. Pursed-lip breathing
4. Sitting up and leaning forward
4. Sitting up and leaning forward
Explanation: Pericarditis is characterized by typical pleuritic chest pain that is sharp. It is aggravated during inspiration and coughing. Pain is typically relieved by sitting up and leaning forward. Treatment includes a combination of NSAIDs or aspirin plus colchicine.
A new graduate nurse is preparing to administer the following analgesics to clients with postoperative pain. Which situation would require intervention by the precepting nurse?
1. Chooses to administer 50 mcg of the prescribed 50-100 mcg of IV fentanyl (6%) for the first dose
2. Dilutes hydromorphone with 5mL of normal saline and injects IV push over 2 minutes
3. Injects 1 mg of morphine sulfate undiluted via IV push over 5 minutes
4. Selects a 25-gauge ½-inch (1.3-cm) needle to injact ketorolac intramuscularly
4. Selects a 25-gauge ½-inch (1.3-cm) needle to injact ketorolac intramuscularly
Explanation: Ketorolac, a nonsteroidal anti-inflammatory drug, is used for short-term (≤5 days) pain relief due to risk of bleeding, gastrointestinal ulcers, and kidney injury. Intramuscular (IM) injections (using Z-track method) should be given deep into a large muscle due to burning and discomfort. A 1- to 1½-in (2.5- to 3.8-cm) needle is used to reach the proper muscle space.
The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time?
1. Call emergency medical services and place ice packs on the client's axilla
and groin
2. Encourage the client to leave the venue to visit a health care provider
3. Evaluate whether the client may be intoxicated
4. Move the client to an air-conditioned booth and provide a cool sports drink
4. Move the client to an air-conditioned booth and provide a cool sports drink
Explanation: Initial management of heat exhaustion includes moving the client from the heat to a cooler area and providing a cool, electrolyte-containing sports drink or water. Early intervention in heat exhaustion can prevent the development of heat stroke, a potentially fatal condition leading to brain and additional organ damage.
A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor?
1. Step behind client with arms around waist, squat using the quadriceps, and lower client to the floor
2. Step in front of client, brace knees and feet against the client's, and assist to the floor gently
3. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor
4. Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor
3. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor
Explanation: These nursing actions can help prevent injury if a client is falling while the nurse is assisting with ambulation: step slightly behind the client with feet wide apart and knees bent, place arms under the axillae or around the client's waist, place one leg behind the other and extend the front leg, and let the client slide down the extended leg to the floor.
The nurse is caring for a client who has a single-chamber atrial pacemaker. Which of the following findings would the nurse expect to observe on the client's electrocardiogram strip?
1. pacemaker spike on the T wave
2. pacemaker spike before the Pwave
3. occasional wide and distorted QRS complex
4. prolonged PR interval with normal QRS complex
2. pacemaker spike before the Pwave
Explanation: The cardiac conduction cycle can be visualized on an electrocardiogram (ECG). The P wave represents atrial depolarization and the QRS complex represents ventricular depolarization. Therefore, the ECG of a client with a single-chamber atrial pacemaker should display a pacemaker spike before the P wave, indicating electrical stimulation of the atria by the pacemaker lead. The P wave may appear normal or somewhat distorted following the spike.
A nurse is reviewing prescriptions for assigned clients. Which of the following prescriptions should the nurse clarify? Click the exhibit button for additional client information.
1. 0.45% sodium chloride for a client with gastroenteritis who had 12 episodes of diarrhea in the past 4 hours
2. 0.9% sodium chloride for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL (36.1 mmol/L)
3. lactated Ringer solution for a client with multiple food allergies who is experiencing hives and generalized itching
4. 3% sedium chloride for a client with a closed head injury who is exhibiting (11%) symptoms of increased intracranial pressure
1. 0.45% sodium chloride for a client with gastroenteritis who had 12 episodes of diarrhea in the past 4 hours
Explanation: Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer solution) have the same osmolality as plasma, meaning they do not promote shifting of fluid in or out of the intravacular system. Isotonic IV solutions are administered to expand intravascular fluid volume, replacing fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury. The nurse should question the prescription of a hypotonic IV solution (ie, 0.45% sodium chloride) for a client with fluid loss (eg, diarrhea, vomiting) as this would create a concentration gradient and shift fluid out of the intravascular compartment into the interstitial tissue and cells, worsening the client's fluid volume deficit.