Bullets for Nursing Basic Concepts Part 15
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Transcript of Bullets for Nursing Basic Concepts Part 15
Bullets for Nursing Basic Concepts Part 15
If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops. If bruising occurs, the nurse should monitor the site for an enlarging hematoma. When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head. The frequency of patient hair care depends on the length and texture of the hair, the duration of hospitalization, and the patients condition. Proper function of a hearing aid requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries. The hearing aid thats marked with a blue dot is for the left ear; the one with a red dot is for the right ear. A hearing aid shouldnt be exposed to heat or humidity and shouldnt be immersed in water. The nurse should instruct the patient to avoid using hair spray while wearing a hearing aid. The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy. The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown. Heat is applied to promote vasodilation, which reduces pain caused by inflammation. A sutured surgical incision is an example of healing by first intention (healing directly, without granulation). Healing by secondary intention (healing by granulation) is closure of the wound when granulation tissue fills the defect and allows reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered. Keloid formation is an abnormality in healing thats characterized by overgrowth of scar tissue at the wound site. The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldnt massage the injection site.
An ascending colostomy drains fluid feces. A descending colostomy drains solid fecal matter. A folded towel (scrotal bridge) can provide scrotal support for thev patient with scrotal edema caused by vasectomy, epididymitis, or orchitis. When giving an injection to a patient who has a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection. Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation. To insert a nasogastric tube, the nurse instructs the patient to tilt the head back slightly and then inserts the tube. When the nurse feels the tube curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.) Families with loved ones in intensive care units report that their four most important needs are to have their questions answered honestly, to be assured that the best possible care is being provided, to know the patients prognosis, and to feel that there is hope of recovery. Double-bind communication occurs when the verbal message contradictsv the nonverbal message and the receiver is unsure of which message to respond to. Bullets for Nursing Basic Concepts Part 16
A nonjudgmental attitude displayed by a nurse shows that she neither approves nor disapproves of the patient. Target symptoms are those that the patient finds most distressing. A patient should be advised to take aspirin on an empty stomach, with a full glass of water, and should avoid acidic foods such as coffee, citrus fruits, and cola. For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient. Administering an I.M. injection against the patients will and without legal authority is battery. An example of a third-party payer is an insurance company.
The formula for calculating the drops per minute for an I.V. infusion is as follows: (volume to be infused drip factor) time in minutes = drops/minute On-call medication should be given within 5 minutes of the call. Usually, the best method to determine a patients cultural or spiritual needs is to ask him. An incident report or unusual occurrence report isnt part of a patients record, but is an in-house document thats used for the purpose of correcting the problem. Critical pathways are a multidisciplinary guideline for patient care. When prioritizing nursing diagnoses, the following hierarchy should be used: Problems associated with the airway, those concerning breathing, and those related to circulation. The two nursing diagnoses that have the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern. A subjective sign that a sitz bath has been effective is the patients expression of decreased pain or discomfort. For the nursing diagnosis Deficient diversional activity to be valid,the patient must state that hes bored, that he has nothing to do, or words to that effect. The most appropriate nursing diagnosis for an individual who doesnt speak English is Impaired verbal communication related to inability to speak dominant language (English). The family of a patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him. Before instilling medication into the ear of a patient who is up to age 3, the nurse should pull the pinna down and back to straighten the eustachian tube. To prevent injury to the cornea when administering eyedrops, the nurse should waste the first drop and instill the drug in the lower conjunctival sac. Bullets for Nursing Basic Concepts Part 17
The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for the problem, and selecting the intervention from the choices provided that will enable the patient to reach that goal.
After administering eye ointment, the nurse should twist the medication tube to detach the ointment. When the nurse removes gloves and a mask, she should remove the gloves first. They are soiled and are likely to contain pathogens. Crutches should be placed 6 (15.2 cm) in front of the patient and 6 to the side to form a tripod arrangement. Listening is the most effective communication technique. Before teaching any procedure to a patient, the nurse must assess the patients current knowledge and willingness to learn. Process recording is a method of evaluating ones communication effectiveness. When feeding an elderly patient, the nurse should limit high-carbohydrate foods because of the risk of glucose intolerance. When feeding an elderly patient, essential foods should be given first. Passive range of motion maintains joint mobility. Resistive exercises increase muscle mass. Isometric exercises are performed on an extremity thats in a cast. A back rub is an example of the gate-control theory of pain. Anything thats located below the waist is considered unsterile; a sterile field becomes unsterile when it comes in contact with any unsterile item; a sterile field must be monitored continuously; and a border of 1 (2.5 cm) around a sterile field is considered unsterile. A shift to the left is evident when the number of immature cells (bands) in the blood increases to fight an infection. A shift to the right is evident when the number of mature cells in the blood increases, as seen in advanced liver disease and pernicious anemia. Before administering preoperative medication, the nurse should ensure that an informed consent form has been signed and attached to the patients record. A nurse should spend no more than 30 minutes per 8-hour shift providing care to a patient who has a radiation implant.
A nurse shouldnt be assigned to care for more than one patient who has a radiation implant. Long-handled forceps and a lead-lined container should be available in the room of a patient who has a radiation implant. Usually, patients who have the same infection and are in strict isolation can share a room. Bullets for Nursing Basic Concepts Part 18
Diseases that require strict isolation include chickenpox, diphtheria, and viral hemorrhagic fevers such as Marburg disease. For the patient who abides by Jewish custom, milk and meat shouldnt be served at the same meal. Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps involved in the procedure (cognitive domain of learning). According to Erik Erikson, developmental stages are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to age 3), initiative versus guilt (ages 3 to 5), industry versus inferiority (ages 5 to 12), identity versus identity diffusion (ages 12 to 18), intimacy versus isolation (ages 18 to 25), generativity versus stagnation (ages 25 to 60), and ego integrity versus despair (older than age 60). When communicating with a hearing impaired patient, the nurse should face him. An appropriate nursing intervention for the spouse of a patient who has a serious incapacitating disease is to help him to mobilize a support system. Hyperpyrexia is extreme elevation in temperature above 106 F (41.1 C). Milk is high in sodium and low in iron. When a patient expresses concern about a health-related issue, before addressing the concern, the nurse should assess the patients level of knowledge. The most effective way to reduce a fever is to administer an antipyretic, which lowers the temperature set point. When a patient is ill, its essential for the members of his family to maintain communication about his health needs. Ethnocentrism is the universal belief that ones way of life is superior to others.
When a nurse is communicating with a patient through an interpreter, the nurse should speak to the patient and the interpreter. In accordance with the hot-cold system used by some Mexicans, Puerto Ricans, and other Hispanic and Latino groups, most foods, beverages, herbs, and drugs are described as cold. Prejudice is a hostile attitude toward individuals of a particular group. Discrimination is preferential treatment of individuals of a particular group. Its usually discussed in a negative sense. Increased gastric motility interferes with the absorption of oral drugs. The three phases of the therapeutic relationship are orientation, working, and termination. Patients often exhibit resistive and challenging behaviors in the orientation phase of the therapeutic relationship. Bullets for Nursing Basic Concepts Part 19
Abdominal assessment is performed in the following order: inspection, auscultation, palpation, and percussion. When measuring blood pressure in a neonate, the nurse should select a cuff thats no less than one-half and no more than two-thirds the length of the extremity thats used. When administering a drug by Z-track, the nurse shouldnt use the same needle that was used to draw the drug into the syringe because doing so could stain the skin. Sites for intradermal injection include the inner arm, the upper chest, and on the back, under the scapula. When evaluating whether an answer on an examination is correct, the nurse should consider whether the action thats described promotes autonomy (independence), safety, self-esteem, and a sense of belonging. Veracity is truth and is an essential component of a therapeutic relationship between a health care provider and his patient. Beneficence is the duty to do no harm and the duty to do good. Theres an obligation in patient care to do no harm and an equal obligation to assist the patient. Nonmaleficence is the duty to do no harm.
Fryes ABCDE cascade provides a framework for prioritizing care by identifying the most important treatment concerns. A = Airway. This category includes everything that affects a patentv airway, including a foreign object, fluid from an upper respiratory infection, and edema from trauma or an allergic reaction. B = Breathing. This category includes everything that affects the breathing pattern, including hyperventilation or hypoventilation and abnormal breathing patterns, such as Korsakoffs, Biots, or Cheyne-Stokes respiration. C = Circulation. This category includes everything that affects the circulation, including fluid and electrolyte disturbances and disease processes that affect cardiac output. D = Disease processes. If the patient has no problem with the airway, breathing, or circulation, then the nurse should evaluate the disease processes, giving priority to the disease process that poses the greatest immediate risk. For example, if a patient has terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern. E = Everything else. This category includes such issues as writing an incident report and completing the patient chart. When evaluating needs, this category is never the highest priority. Rule utilitarianism is known as the greatest good for the greatest number of people theory. Egalitarian theory emphasizes that equal access to goods and services must be provided to the less fortunate by an affluent society. Active euthanasia is actively helping a person to die. Brain death is irreversible cessation of all brain function. Passive euthanasia is stopping the therapy thats sustaining life. A third-party payer is an insurance company. Bullets for Nursing Basic Concepts Part 20
Utilization review is performed to determine whether the care provided to a patient was appropriate and cost-effective. A value cohort is a group of people who experienced an out-of-the-ordinary event that shaped their values. Voluntary euthanasia is actively helping a patient to die at the patients request.
Bananas, citrus fruits, and potatoes are good sources of potassium. Good sources of magnesium include fish, nuts, and grains. Beef, oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron. Intrathecal injection is administering a drug through the spine. When a patient asks a question or makes a statement thats emotionally charged, the nurse should respond to the emotion behind the statement or question rather than to whats being said or asked. The steps of the trajectory-nursing model are as follows: Step 1: Identifying the trajectory phase Step 2: Identifying the problems and establishing goals Step 3: Establishing a plan to meet the goals Step 4: Identifying factors that facilitate or hinder attainment of the goals Step 5: Implementing interventions Step 6: Evaluating the effectiveness of the interventions A Hindu patient is likely to request a vegetarian diet. Pain threshold, or pain sensation, is the initial point at which a patient feels pain. The difference between acute pain and chronic pain is its duration. Referred pain is pain thats felt at a site other than its origin. Alleviating pain by performing a back massage is consistent with the gate control theory. Rombergs test is a test for balance or gait. Pain seems more intense at night because the patient isnt distracted by daily activities. Older patients commonly dont report pain because of fear of treatment, lifestyle changes, or dependency. No pork or pork products are allowed in a Muslim diet. Two goals of Healthy People 2010 are: 1. Help individuals of all ages to increase the quality of life and the number of years of optimal health 2. Eliminate health disparities among different segments of the population. A community nurse is serving as a patients advocate if she tells av malnourished patient to go to a meal program at a local park. Bullets for Nursing Basic Concepts Part 21
If a patient isnt following his treatment plan, the nurse should first ask why. Falls are the leading cause of injury in elderly people. Primary prevention is true prevention. Examples are immunizations, weight control, and smoking cessation. Secondary prevention is early detection. Examples include purified protein derivative (PPD), breast self-examination, testicular self-examination, and chest X-ray. Tertiary prevention is treatment to prevent long-term complications. A patient indicates that hes coming to terms with having a chronic disease when he says, Im never going to get any better. On noticing religious artifacts and literature on a patients night stand, a culturally aware nurse would ask the patient the meaning of the items. A Mexican patient may request the intervention of a curandero, or faith healer, who involves the family in healing the patient. In an infant, the normal hemoglobin value is 12 g/dl. The nitrogen balance estimates the difference between the intake and use of protein. Most of the absorption of water occurs in the large intestine. Most nutrients are absorbed in the small intestine. When assessing a patients eating habits, the nurse should ask, What have you eaten in the last 24 hours? A vegan diet should include an abundant supply of fiber. A hypotonic enema softens the feces, distends the colon, and stimulates peristalsis. First-morning urine provides the best sample to measure glucose, ketone, pH, and specific gravity values. To induce sleep, the first step is to minimize environmental stimuli. Before moving a patient, the nurse should assess the patients physical abilities and ability to understand instructions as well as the amount of strength required to move the patient.
To lose 1 lb (0.5 kg) in 1 week, the patient must decrease his weekly intake by 3,500 calories (approximately 500 calories daily). To lose 2 lb (1 kg) in 1 week, the patient must decrease his weekly caloric intake by 7,000 calories (approximately 1,000 calories daily). To avoid shearing force injury, a patient who is completely immobile is lifted on a sheet. Bullets for Nursing Basic Concepts Part 22
To insert a catheter from the nose through the trachea for suction, the nurse should ask the patient to swallow. Vitamin C is needed for collagen production. Only the patient can describe his pain accurately. Cutaneous stimulation creates the release of endorphins that block the transmission of pain stimuli. Patient-controlled analgesia is a safe method to relieve acute pain caused by surgical incision, traumatic injury, labor and delivery, or cancer. An Asian American or European American typically places distance between himself and others when communicating. The patient who believes in a scientific, or biomedical approach to health is likely to expect a drug, treatment, or surgery to cure illness. Chronic illnesses occur in very young as well as middle-aged and very old people. The trajectory framework for chronic illness states that preferences about daily life activities affect treatment decisions. Exacerbations of chronic disease usually cause the patient to seek treatment and may lead to hospitalization. School health programs provide cost-effective health care for low-income families and those who have no health insurance. Collegiality is the promotion of collaboration, development, and interdependence among members of a profession. A change agent is an individual who recognizes a need for change or is selected to make a change within an established entity, such as a hospital.
The patients bill of rights was introduced by the American Hospital Association. Abandonment is premature termination of treatment without the patients permission and without appropriate relief of symptoms. Values clarification is a process that individuals use to prioritize their personal values. Distributive justice is a principle that promotes equal treatment for all. Milk and milk products, poultry, grains, and fish are good sources of phosphate. The best way to prevent falls at night in an oriented, but restless, elderly patient is to raise the side rails. By the end of the orientation phase, the patient should begin to trust the nurse. Bullets for Nursing Basic Concepts Part 23
In a patient with hypokalemia (serum potassium level below 3.5 mEq/L), presenting signs and symptoms include muscle weakness and cardiac arrhythmias. During cardiac arrest, if an I.V. route is unavailable, epinephrine can be administered endotracheally. Pernicious anemia results from the failure to absorb vitamin B12 in the GI tract and causes primarily GI and neurologic signs and symptoms. A patient who has a pressure ulcer should consume a high-protein, high-calorie diet, unless contraindicated. The CK-MB isoenzyme level is used to assess tissue damage in myocardial infarction After a 12-hour fast, the normal fasting blood glucose level is 80 to 120 mg/dl. A patient who is experiencing digoxin toxicity may report nausea, vomiting, diplopia, blurred vision, light flashes, and yellow-green halos around images. Anuria is daily urine output of less than 100 ml. In remittent fever, the body temperature varies over a 24-hour period, but remains elevated. Risk of a fat embolism is greatest in the first 48 hours after the fracture of a long bone. Its manifested by respiratory distress.
To help venous blood return in a patient who is in shock, the nurse should elevate the patients legs no more than 45 degrees. This procedure is contraindicated in a patient with a head injury. The pulse deficit is the difference between the apical and radial pulse rates, when taken simultaneously by two nurses. To reduce the patients risk of vomiting and aspiration, the nurse should schedule postural drainage before meals or 2 to 4 hours after meals. Blood pressure can be measured directly by intra-arterial insertion of a catheter connected to a pressure-monitoring device. A positive Kernigs sign, seen in meningitis, occurs when an attempt to flex the hip of a recumbent patient causes painful spasms of the hamstring muscle and resistance to further extension of the leg at the knee. In a patient with a fractured, dislocated femur, treatment begins with reduction and immobilization of the affected leg Herniated nucleus pulposus (intervertebral disk) most commonly occurs in the lumbar and lumbosacral regions. Laminectomy is surgical removal of the herniated portion of an intervertebral disk. Surgical treatment of a gastric ulcer includes severing the vagus nerve (vagotomy) to reduce the amount of gastric acid secreted by the gastric cells. Valsalvas maneuver is forced exhalation against a closed glottis, as when taking a deep breath, blowing air out, or bearing down.
Bullets for Nursing Basic Concepts Part 24
When mean arterial pressure falls below 60 mm Hg and systolic blood pressure falls below 80 mm Hg, vital organ perfusion is seriously compromised. Lidocaine (Xylocaine) is the drug of choice for reducing premature ventricular contractions. A patient is at greatest risk of dying during the first 24 to 48 hours after a myocardial infarction. During a myocardial infarction, the left ventricle usually sustains the greatest damage.
The pain of a myocardial infarction results from myocardial ischemia caused by anoxia. For a patient in cardiac arrest, the first priority is to establish an airway. The universal sign for choking is clutching the hand to the throat. For a patient who has heart failure or cardiogenic pulmonary edema, nursing interventions focus on decreasing venous return to the heart and increasing left ventricular output. These interventions include placing the patient in high Fowlers position and administering oxygen, diuretics, and positive inotropic drugs as prescribed. A positive tuberculin skin test is an induration of 10 mm or greater at the injection site. The signs and symptoms of histoplasmosis, a chronic systemic fungal infection, resemble those of tuberculosis. In burn victims, the leading cause of death is respiratory compromise. The second leading cause is infection. The exocrine function of the pancreas is the secretion of enzymes used to digest carbohydrates, fats, and proteins. A patient who has hepatitis A (infectious hepatitis) should consume a diet thats moderately high in fat and high in carbohydrate and protein, and should eat the largest meal in the morning. Esophageal balloon tamponade shouldnt be inflated greater than 20 mm Hg. Overproduction of prolactin by the pituitary gland can cause galactorrhea (excessive or abnormal lactation) and amenorrhea (absence of menstruation). Intermittent claudication (pain during ambulation or other movement thats relieved with rest) is a classic symptom of arterial insufficiency in the leg. In bladder carcinoma, the most common finding is gross, painless hematuria. Parenteral administration of heparin sodium is contraindicated in patients with renal or liver disease, GI bleeding, or recent surgery or trauma; in pregnant patients; and in women older than age 60. Drugs that potentiate the effects of anticoagulants include aspirin, chloral hydrate, glucagon, anabolic steroids, and chloramphenicol. For a burn patient, care priorities include maintaining a patent airway, preventing or correcting fluid and electrolyte imbalances, controlling pain, and preventing infection.
Medical and Surgical Nursing Review Questions 1 1. Which nursing intervention would be most appropriate for promoting the environmental safety of a client with a cognitive disorder? A. Applying an identification bracelet on the client B. Maintaining daily routine care for the client C. Placing a clock and a daily schedule in the clients room D. Using short sentences with simple words when speaking with the client Correct Answer: A Rationale: Applying an identification bracelet on the client would be most effective in helping to ensure environmental and client safety should the client wander. Other measures include installing alarms; instituting injury, fire, and poisoning precautions; providing adequate lighting; and keeping the bed in a low position. Maintaining a daily routine would be helpful for ensuring consistency and promoting optimal functioning. Clocks and daily schedules would be helpful for reorienting the client and promoting optimal cognitive function. Using short sentences with simple words would be appropriate for maximizing effective communication. 2. Which client complaint would lead the nurse to suspect premenstrual syndrome A. Fatigue and weight gain on the day prior to B. Headache and mood swings occurring about 10 days prior to C. Mood swings and breast tenderness with the onset of D. Painful menstruation and large menstrual flow (PMS)? menses menses menses
Correct Answer: B Rationale: Typically, PMS is manifested by complaints of headache, mood swings, irritability, weight gain, fatigue, and full, tender breasts, occurring approximately 10 days before menses in each cycle. Painful menstruation and a large menstrual flow are not associated with PMS. 3. When disposing of the plastic bags, tubing, syringes, and gloves used to administer antineoplastic drugs, the nurse should implement which nursing intervention? A. Avoiding contact with the equipment by allowing housekeeping to remove it B. Discarding all used equipment in a container marked isolation C. Disposing of all equipment in a container marked bio-health hazard D. Disposing of all used equipment in the regular trash receptacles Correct Answer: C Rationale: Any disposable equipment and supplies used for chemotherapy must be disposed of in a manner that protects the environment; placing the items in a container marked bio-health hazard is appropriate because these containers can be incinerated at a temperature of 2,200 to 2,500 F so that there is no residue. Only personnel trained in the proper handling of antineoplastic agents should handle the wastes. Infectious waste is incinerated at 1,700 to
1,800 F; residue is possible after incineration at these temperatures, making it an inappropriate method for the disposal of antineoplastic equipment and supplies. Because the equipment has been contaminated with material that is carcinogenic, special precautions are required. 4. Which assessment data for a client who is 1 day postabdominal surgery would warrant immediate nursing intervention? A. Blood pressure of 110/70 mm Hg and hematocrit of 42% B. Complaints of abdominal pain as an C. Hypoactive bowel sounds and a serum potassium of 3.7 mEq/L D. Rigid, hard, boardlike abdomen and a white blood cell (WBC) count of 20,000 mm Correct Answer: D Rationale: One day after abdominal surgery, the clients abdomen should be soft, not rigid or hard. Also, the WBC count may be slightly elevated in response to the surgery, but an elevation of 20,000 mmis highly suggestive of an infectious process. A rigid, boardlike abdomen in conjunction with a seriously elevated WBC count suggests peritonitis and requires immediate intervention. The clients blood pressure and hematocrit are within normal limits. One day after surgery, abdominal incisional pain would be expected and often is rated as high when using a scale from 1 to 10. The clients hemoglobin level is within normal limits. Hypoactive bowel sounds would be expected 1 day after abdominal surgery. The clients potassium level is within normal limits. 5. The nurse would include which nursing intervention for a client diagnosed with acute diverticulitis? A. Administration of stimulant laxatives B. Increased fluid intake C. Continuation of clients nothing-by-mouth status D. High-fiber diet Correct Answer: C Rationale: During an acute episode of diverticulitis, measures focus on resting the colon, such as keeping the client on nothing-by-mouth status, administering I.V. fluids, and maintaining nasogastric suctioning and bedrest. Administering stimulant laxatives may be appropriate for restoring the clients normal bowel elimination, but their use during an acute attack would only serve to irritate the bowel further. Increased fluid intake would be appropriate for diverticulosis. A high-fiber diet would be indicated for diverticulosis, but this type of diet would not be appropriate during an acute attack. 6. The nurse would include which nursing intervention in the care plan for a client with an L5-S1 intervertebral disc herniation? A. Assessing the skeletal traction insertion sites for infection B. Encouraging the client to ambulate as much as possible C. Positioning the client with his knees slightly flexed and the head of bed elevated D. Preparing the client for lumbar puncture
Correct Answer: C Rationale: Positioning the client with the head of the bed elevated and his knees slightly flexed increases the disc space and may help to decrease the clients pain. Skeletal traction is not a treatment of choice for a herniated disc. The client with an intervertebral disc herniation should be kept on bedrest. A lumbar puncture is not a diagnostic procedure for intervertebral disc herniation. 7. A 16-year-old client asks the nurse, What caused me to have acne? Which statement would be the nurses best response? A. Acne is caused by an excess production of sebum. B. Acne is caused by not cleaning your face thoroughly every day. C. Eating lots of chocolate and candy causes you to have acne. D. The exact cause of acne is not really known. Correct Answer: D Rationale: The exact cause of acne is not known, but evidence has shown that acne involves multiple factors, such as genetics, hormonal factors, and bacterial infections. Excess production of sebum results in seborrhea. Uncleanliness and dietary indiscretions, such as eating chocolate and candy, do not cause acne. 8. Which intervention would most important in the prevention of pressure ulcers? A. Applying external urine collection devices B. Helping the client to maintain appropriate body position C. Massaging reddened areas as soon as they are noted D. Turning the client every 2 hours Correct Answer: D Rationale: Turning the client frequently, such as every 2 hours, is one of the single most important interventions in preventing pressure ulcers because it helps to minimize the effects of pressure on the skin, allowing pressure to be redistributed with each turn. Applying an external urine collection device would be appropriate if the client is incontinent, but this action is not always relevant for every client and thus is not the most important. Helping the client to maintain appropriate body position is important, but it must be done in conjunction with frequent turning; maintaining body position without frequent turning would not be beneficial. Reddened areas should never be massaged because this increases tissue damage. 9. The client with a rectovaginal fistula is at high risk for infection. Which intervention would be the most important aspect of preventative nursing care? A. Administering antibiotics B. Ensuring adequate rest to enhance healing C. Monitoring temperature and white blood cell (WBC) count D. Performing perineal hygiene, including irrigations Correct Answer: D Rationale: The client with a rectovaginal fistula may experience fecal drainage via the vagina; preventing infection by keeping the vaginal area clean with irrigation, douches, and sitz baths
would be most important. Administering antibiotics and ensuring adequate rest may be useful in promoting healing, but they are not preventative measures. Monitoring for symptoms of infection is important, but perineal hygiene is more effective as a preventative measure. 10. The client with a head injury is experiencing increased intracranial pressure (ICP). Which medication would the nurse anticipate administering? A. B. C. D. Osmotic diuretics Anticholinesterase Loop agents Anticonvulsants diuretics
Correct Answer: D Rationale: Osmotic diuretics such as mannitol are the preferred diuretic in the management of increased ICP to decrease cerebral edema and, therefore, decrease ICP. Anticholinesterase agents are used in the management of myasthenia gravis and are not helpful in decreasing ICP. Anticonvulsant medications would be used to treat seizure activity and are not helpful in decreasing ICP. Loop diuretics can be given in cases of increased ICP, but they are not a firstline agent.
1. When removing a contaminated gown, the nurse should be careful that the first thing she touches is the: 1. Waist tie and neck tie at the back of the gown 2. Waist tie in front of the gown 3. Cuffs of the gown 4. Inside of the gown Correct Answer: A. The back of the gown is considered clean, the front is contaminated. So, after removing gloves and washing hands, the nurse should untie the back of the gown; slowly move backward away from the gown, holding the inside of the gown and keeping the edges off the floor; turn and fold the gown inside out; discard it in a contaminated linen container; then wash her hands again. 2. Which of the following nursing interventions is considered the most effective form or universal precautions? 1. Cap all used needles before removing them from their syringes 2. Discard all used uncapped needles and syringes in an impenetrable protective container 3. Wear gloves when administering IM injections
4. Follow enteric precautions Correct Answer: B. According to the Centers for Disease Control (CDC), blood-to-blood contact occurs most commonly when a health care worker attempts to cap a used needle. Therefore, used needles should never be recapped; instead they should be inserted in a specially designed puncture resistant, labeled container. Wearing gloves is not always necessary when administering an I.M. injection. Enteric precautions prevent the transfer of pathogens via feces. 3. All of the following measures are recommended to prevent pressure ulcers except: 1. Massaging the reddened are with lotion 2. Using a water or air mattress 3. Adhering to a schedule for positioning and turning 4. Providing meticulous skin care Correct Answer: A. Nurses and other health care professionals previously believed that massaging a reddened area with lotion would promote venous return and reduce edema to the area. However, research has shown that massage only increases the likelihood of cellular ischemia and necrosis to the area. 4. Which of the following blood tests should be performed before a blood transfusion? 1. Prothrombin and coagulation time 2. Blood typing and cross-matching 3. Bleeding and clotting time 4. Complete blood count (CBC) and electrolyte levels. Correct Answer: B. Before a blood transfusion is performed, the blood of the donor and recipient must be checked for compatibility. This is done by blood typing (a test that determines a persons blood type) and cross-matching (a procedure that determines the compatibility of the donors and recipients blood after the blood types has been matched). If the blood specimens are incompatible, hemolysis and antigen-antibody reactions will occur. 5. The primary purpose of a platelet count is to evaluate the: 1. Potential for clot formation 2. Potential for bleeding 3. Presence of an antigen-antibody response 4. Presence of cardiac enzymes Correct Answer: A. Platelets are disk-shaped cells that are essential for blood coagulation. A platelet count determines the number of thrombocytes in blood available for promoting hemostasis and assisting with blood coagulation after injury. It also is used to evaluate the patients potential for bleeding; however, this is not its primary purpose. The normal count ranges from 150,000 to 350,000/mm3. A count of 100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is associated with spontaneous bleeding.
6. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis? 1. 4,500/mm 2. 7,000/mm 3. 10,000/mm 4. 25,000/mm Correct Answer: D. Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. Normal WBC counts range from 5,000 to 100,000/mm3. Thus, a count of 25,000/mm3 indicates leukocytosis. 7. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is experiencing: 1. Hypokalemia 2. Hyperkalemia 3. Anorexia 4. Dysphagia Correct Answer: A. Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. Anorexia is another symptom of hypokalemia. Dysphagia means difficulty swallowing. 8. Which of the following statements about chest X-ray is false? 1. No contradictions exist for this test 2. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist 3. A signed consent is not required 4. Eating, drinking, and medications are allowed before this test Correct Answer: A. Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. However, if a chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from radiation. Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should not be worn above the waist. A signed consent is not required because a chest X-ray is not an invasive examination. Eating, drinking and medications are allowed because the X-ray is of the chest, not the abdominal region. 9. The most appropriate time for the nurse to obtain a sputum specimen for culture is: 1. Early in the morning 2. After the patient eats a light breakfast 3. After aerosol therapy 4. After chest physiotherapy
Correct Answer: A. Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for culturing and decreases the risk of contamination from food or medication 10. A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patients skin. The most appropriate nursing action would be to: 1. Withhold the moderation and notify the physician 2. Administer the medication and notify the physician 3. Administer the medication with an antihistamine 4. Apply corn starch soaks to the rash Correct Answer: A. Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who have not been allergic to it previously. Because of the danger of anaphylactic shock, he nurse should withhold the drug and notify the physician, who may choose to substitute another drug. Administering an antihistamine is a dependent nursing intervention that requires a written physicians order. Although applying corn starch to the rash may relieve discomfort, it is not the nurses top priority in such a potentially life-threatening situation. Sample Nursing Board Exam Review Questions 3
1. All of the following nursing interventions are correct when using the Z-track method of drug injection except: 1. Prepare the injection site with alcohol 2. Use a needle thats a least 1 long 3. Aspirate for blood before injection 4. Rub the site vigorously after the injection to promote absorption Correct Answer: D. The Z-track method is an I.M. injection technique in which the patients skin is pulled in such a way that the needle track is sealed off after the injection. This procedure seals medication deep into the muscle, thereby minimizing skin staining and irritation. Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin. 2. The correct method for determining the vastus lateralis site for I.M. injection is to: 1. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest 2. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm 3. Palpate a 1 circular area anterior to the umbilicus 4. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh
Correct Answer: D. The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by many clinicians as the site of choice for I.M. injections because it has relatively few major nerves and blood vessels. The middle third of the muscle is recommended as the injection site. The patient can be in a supine or sitting position for an injection into this site. 3. The mid-deltoid injection site is seldom used for I.M. injections because it: 1. Can accommodate only 1 ml or less of medication 2. Bruises too easily 3. Can be used only when the patient is lying down 4. Does not readily parenteral medication Correct Answer: A. The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size and location (on the deltoid muscle of the arm, close to the brachial artery and radial nerve). 4. The appropriate needle size for insulin injection is: 1. 18G, 1 long 2. 22G, 1 long 3. 22G, 1 long 4. 25G, 5/8 long Correct Answer: D. A 25G, 5/8 needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route. An 18G, 1 needle is usually used for I.M. injections in children, typically in the vastus lateralis. A 22G, 1 needle is usually used for adult I.M. injections, which are typically administered in the vastus lateralis or ventrogluteal site. 5. The appropriate needle gauge for intradermal injection is: 1. 20G 2. 22G 3. 25G 4. 26G Correct Answer: D. Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G needle is recommended. This type of injection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. A 20G needle is usually used for I.M. injections of oil-based medications; a 22G needle for I.M. injections; and a 25G needle, for I.M. injections; and a 25G needle, for subcutaneous insulin injections. 6. Parenteral penicillin can be administered as an: 1. IM injection or an IV solution 2. IV or an intradermal injection 3. Intradermal or subcutaneous injection 4. IM or a subcutaneous injection
Correct Answer: A. Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot be administered subcutaneously or intradermally. 7. The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is: 1. 0.6 mg 2. 10 mg 3. 60 mg 4. 600 mg Correct Answer: D. gr 10 x 60mg/gr 1 = 600 mg 8. The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml? 1. 5 gtt/minute 2. 13 gtt/minute 3. 25 gtt/minute 4. 50 gtt/minute Correct Answer: C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute 9. Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion? 1. Hemoglobinuria 2. Chest pain 3. Urticaria 4. Distended neck veins Correct Answer: A. Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic reaction (incompatibility of the donors and recipients blood). In this reaction, antibodies in the recipients plasma combine rapidly with donor RBCs; the cells are hemolyzed in either circulatory or reticuloendothelial system. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh incompatibilities. Chest pain and urticaria may be symptoms of impending anaphylaxis. Distended neck veins are an indication of hypervolemia 10. Which of the following conditions may require fluid restriction? 1. Fever 2. Chronic Obstructive Pulmonary Disease 3. Renal Failure 4. Dehydration Correct Answer: C. In real failure, the kidney loses their ability to effectively eliminate wastes and fluids. Because of this, limiting the patients intake of oral and I.V. fluids may be necessary. Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should be encouraged.
Sample Nursing Board Exam Review Questions 4 1. All of the following are common signs and symptoms of phlebitis except: 1. Pain or discomfort at the IV insertion site 2. Edema and warmth at the IV insertion site 3. A red streak exiting the IV insertion site 4. Frank bleeding at the insertion site Correct Answer: D. Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation), or a localized allergic reaction to the needle or catheter. Signs and symptoms of phlebitis include pain or discomfort, edema and heat at the I.V. insertion site, and a red streak going up the arm or leg from the I.V. insertion site. 2. The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to: 1. Ask the patient if he/she has used ear drops before 2. Have the patient repeat the nurses instructions using her own words 3. Demonstrate the procedure to the patient and encourage to ask questions 4. Ask the patient to demonstrate the procedure Correct Answer: D. Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching. 3. Which of the following types of medications can be administered via gastrostomy tube? 1. Any oral medications 2. Capsules whole contents are dissolve in water 3. Enteric-coated tablets that are thoroughly dissolved in water 4. Most tablets designed for oral use, except for extended-duration compounds Correct Answer: D. Capsules, enteric-coated tablets, and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. The nurse should seek an alternate physicians order when an ordered medication is inappropriate for delivery by tube. 4. A patient who develops hives after receiving an antibiotic is exhibiting drug: 1. Tolerance 2. Idiosyncrasy 3. Synergism 4. Allergy Correct Answer: D. A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. The reaction can range from a rash or hives to anaphylactic shock. Tolerance to a drug
means that the patient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage. Idiosyncrasy is an individuals unique hypersensitivity to a drug, food, or other substance; it appears to be genetically determined. Synergism, is a drug interaction in which the sum of the drugs combined effects is greater than that of their separate effects. 5. A patient has returned to his room after femoral arteriography. All of the following are appropriate nursing interventions except: 1. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours 2. Check the pressure dressing for sanguineous drainage 3. Assess a vital signs every 15 minutes for 2 hours 4. Order a hemoglobin and hematocrit count 1 hour after the arteriography Correct Answer: D. A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography. 6. The nurse explains to a patient that a cough: 1. Is a protective response to clear the respiratory tract of irritants 2. Is primarily a voluntary action 3. Is induced by the administration of an antitussive drug 4. Can be inhibited by splinting the abdomen Correct Answer: A. Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntary; however it can be voluntary, as when a patient is taught to perform coughing exercises. An antitussive drug inhibits coughing. Splinting the abdomen supports the abdominal muscles when a patient coughs. 7. An infected patient has chills and begins shivering. The best nursing intervention is to: 1. Apply iced alcohol sponges 2. Provide increased cool liquids 3. Provide additional bedclothes 4. Provide increased ventilation Correct Answer: C. In an infected patient, shivering results from the bodys attempt to increase heat production and the production of neutrophils and phagocytotic action through increased skeletal muscle tension and contractions. Initial vasoconstriction may cause skin to feel cold to the touch. Applying additional bed clothes helps to equalize the body temperature and stop the chills. Attempts to cool the body result in further shivering, increased metabloism, and thus increased heat production. 8. A clinical nurse specialist is a nurse who has: 1. Been certified by the National League for Nursing 2. Received credentials from the Philippine Nurses Association 3. Graduated from an associate degree program and is a registered professional nurse
4. Completed a masters degree in the prescribed clinical area and is a registered professional nurse. Correct Answer: D. A clinical nurse specialist must have completed a masters degree in a clinical specialty and be a registered professional nurse. The National League of Nursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does not certify nurses. The American Nurses Association identifies requirements for certification and offers examinations for certification in many areas of nursing., such as medical surgical nursing. These certification (credentialing) demonstrates that the nurse has the knowledge and the ability to provide high quality nursing care in the area of her certification. A graduate of an associate degree program is not a clinical nurse specialist: however, she is prepared to provide bed side nursing with a high degree of knowledge and skill. She must successfully complete the licensing examination to become a registered professional nurse. 9. The purpose of increasing urine acidity through dietary means is to: 1. Decrease burning sensations 2. Change the urines color 3. Change the urines concentration 4. Inhibit the growth of microorganisms Correct Answer: D. Microorganisms usually do not grow in an acidic environment. 10. Clay colored stools indicate: 1. Upper GI bleeding 2. Impending constipation 3. An effect of medication 4. Bile obstruction Correct Answer: D. Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will affect the stool pigment, yielding light, clay-colored stool. Upper GI bleeding results in black or tarry stool. Constipation is characterized by small, hard masses. Many medications and foods will discolor stool for example, drugs containing iron turn stool black.; beets turn stool red. Sample Review Questions on Medical and Surgical Nursing Part2
1. Which intervention would the nurse anticipate as the initial action to be included in the care plan for a client experiencing a tension pneumothorax? A. Application of B. Increasing the C. Obtaining D. Removal of an occlusive dressing on a occlusive ventilators petroleum tidal chest dressing volume X-ray
Correct Answer: D Rationale: A tension pneumothorax occurs when the pressure increases in the pleural space. Thus, removing an occlusive dressing will release the increased pressure in the pleural space and help resolve the tension. Typically, the health care provider will insert a large bore needle initially and then a chest tube to aid in reinflating the lung. Applying an occlusive dressing will increase the pressure in the chest and worsen the tension pneumothorax. An occlusive dressing would be appropriate for an open pneumothorax. Increasing the tidal volume on the ventilator will increase the volume delivered to the chest, worsening the tension pneumothorax. The diagnosis of a tension pneumothorax is based on the clients clinical presentation. It is a medical emergency that can quickly be fatal. Obtaining a chest X-ray wastes precious minutes that may permit the client to decompensate; it may be performed once the chest tube has been inserted and the initial build of pressure has been relieved. 2. When teaching a group of women about breast health awareness and breast self-examination (BSE) at a local community center, the nurse follows the American Cancer Society (ACS) recommendations. Which recommendation would the nurse include in the teaching program? A. Bimonthly BSE and yearly mammograms beginning after the woman has had her first child B. Optional monthly BSE, yearly clinical examination, and yearly mammograms after age 40 C. Quarterly BSE until the age of 70 after which breast health awareness is no longer necessary D. Yearly BSE and follow up clinical examinations after onset of menses Correct Answer: Rationale: The ACS recommends a yearly clinical examination and yearly mammograms clients older than age 40. Monthly self-breast examination is an option for women starting their 20s. The risk of breast cancer increases with age. At age 80, there is a 1 in 8 risk developing breast cancer. B in in of
3. When providing postoperative care after a bowel resection to a client with a pre-existing history of chronic obstructive pulmonary disease (COPD) with frequent exacerbations, for which complication should the nurse be alert? A. B. C. D. Pneumothorax Acute Airway respiratory failure obstruction Atelectasis
Correct Answer: A Rationale: The client is at high risk for developing acute respiratory failure because of his history of chronic lung disease requiring frequent intubations, the anesthesia used during surgery, and the experience of surgery. Airway obstruction and atelectasis are postoperative complications, but there is no evidence that this client would be at greater risk for these complication than anyone else. The operative procedure and the clients medical history would not place this client at a greater risk for postoperative pneumothorax as compared to any other postoperative client.
4. The nurse is doing preoperative teaching for a client about to have a mechanical valve replacement. Which client statement indicates effective teaching? A. I need to make sure I have someone to care for me after this same-day surgery procedure. B. I will always need to take anticoagulants to prevent the formation of blood clots. C. I will need to take several days of steroids each time I have major dental work done. D. Because my valve is from a pig, I need to take precautions to prevent rejection of the valve. Correct Answer: B Rationale: Following mechanical valve replacement surgery, clients need to be educated about the need for lifelong oral anticoagulant therapy. (Povine or bovine valve replacements do not require anticoagulants.) Valve replacement surgery is not performed as a day surgery procedure; it requires that the client be admitted to a critical care unit for constant monitoring due to the potential for complications. Prophylactic antibiotics, not steroids, are needed after valve replacement surgery. Rejection of the artificial valve is not a major problem associated with valve replacement surgery. 5. Which collaborative intervention would be included in the care plan for a client with a venous stasis ulcer to assist with healing? A. Antiembolism B. Plaster C. Transcutaneous electrical D. Unna boot cast nerve stimulator stockings sock (TENS)
Correct Answer: D Rationale: An Unna boot is medicated gauze applied to the affected limb from the toes to the knees after the ulcer is cleaned. The boot is then wrapped in plastic wrap and hardens like a cast promoting venous return and preventing stasis. Antiembolism stockings are fit tightly and can traumatize an ulcer when applied. A plaster cast sock is usually applied to a residual limb following amputation to reduce edema. TENS is used as a pain relief measure; it would have no effect on healing. 6. A client with pulmonary edema is receiving mechanical ventilation with positive endexpiratory pressure (PEEP). When explaining to a student about the rationale for using PEEP, the nurse would indicate which rationale as its major purpose? A. Allows the client to B. Increases pulmonary C. Improves area available D. Increases the clients carbon dioxide obtain needed capillary for gas rest pressure exchange
Correct Answer: C Rationale: PEEP helps keep the alveoli expanded, increasing the area available for gas exchange, thus improving the clients oxygenation. PEEP has no effect on the clients ability to
rest, decreases pulmonary capillary pressure, and decreases the clients carbon dioxide level by increasing the area for gas exchange. 7. The nurse teaches a client about residual limb care following an amputation and assesses that he understood the teaching when he demonstrates which behavior? A. Applies lotions to keep the B. Elevates the residual limb on a C. Lies prone for several D. Wraps the residual limb in adhesive bandages skin pillow hours from following each cracking surgery day
Correct Answer: C Rationale: Lying prone for several hours each day helps prevent hip contractures and demonstrates compliance with the treatment regimen. Using lotions keeps the skin soft; however, following an amputation, the skin needs to become tough. New guidelines recommend elevating the foot of the bed because a pillow can cause flexion contractures of the hip. Adhesive bandages irritate the skin, leading to sores, breakdown, and infection. 8. A client with a history of bigeminy who is on a lidocaine drip complains of light-headedness. Which intervention would the nurse implement A. Calling the health care provider and getting a stat electrocardiogram (ECG) B. Checking the rhythm strip and assessing blood pressure C. Decreasing the lidocaine and instituting seizure precautions D. Having the client lie down and administering atropine Correct Answer: B Rationale: Before doing anything else, the nurse needs to check the rhythm strip and assess the clients blood pressure to determine the possible cause of the clients complaints and gather additional data so that a full report can be made to the health care provider. An ECG is not needed for diagnosis of arrhythmia when a rhythm strip will suffice. The client is not exhibiting signs of lidocaine toxicity and, in fact, the lidocaine may need to be increased. Atropine is the drug of choice for sinus bradycardia, not premature ventricular contractions. 9. The nurse knows a client with chronic obstructive pulmonary disease (COPD) understands the discharge teaching when he makes which statement? A. I need to drink at least 2 liters of B. I need to take a sleeping pill every night so C. I should do everything in the morning so I D. I should smoke only when I am not having difficulty breathing. fluid every day. I wake up rested. can rest later on.
Correct Answer: A Rationale: Secretions are often very thick and difficult to expectorate for clients with COPD; drinking at least 2 liters of fluid per day will help to thin the secretions and aid in expectoration. Hypnotics and sedatives such as sleeping pills depress respirations and should be avoided. The
client needs to pace himself and his activities to minimize energy expenditures and prevent exertion. The client should eliminate exposure to irritants such a smoking. 10. Which assessment finding indicates that furosemide (Lasix), a loop-diuretic, ordered for an elderly client is achieving its intended results? A. +4 pitting B. Nontender calf C. Relief of D. Systolic blood pressure of 150 mm Hg edema muscles nocturnal in on leg both legs palpation cramping
Correct Answer: D Rationale: Furosemide is commonly used as an initial step in treating hypertension. For the elderly client, a systolic blood pressure of 150 mm Hg would be considered normal and thus indicative that the drug therapy is effective. Pitting edema of +4 indicates that the drug is not achieving its intended result because fluid is still present; the clients medication regime needs to be adjusted or changed. Furosemide has no effect on calf muscle; relief of tenderness in the calf is seen in deep vein thrombosis. Loop diuretics do not typically relieve cramping. 1. When caring for a client with arterial occlusive disease of the extremities, what would the nurse include in the clients teaching plan? A. Changing positions frequently and elevating the legs above the heart to promote venous return in the legs B. Elevating the arm on a pillow with the elbow higher than the shoulder and the hand higher than the elbow C. Elevating the foot of the bed about 6 (15.2 cm) while the client is sleeping to promote venous return D. Keeping the legs in a dependent position in relationship to the heart to improve peripheral blood flow Correct Answer: D Rationale: The client with arterial occlusive disease needs to enhance the blood supply to the body parts affected; keeping legs in a dependent position in relationship to the heart to improve peripheral blood flow enhances the blood flow to the extremities. Changing positions frequently and elevating the legs above the heart to promote venous return in the legs should be included in teaching for the client with varicose veins. Elevating the arm on a pillow with the elbow higher than the shoulder and hand higher than the elbow helps to promote lymphatic drainage. Elevating the foot of the bed about 6 while the client is sleeping to promote venous return is appropriate for the client with deep vein thrombosis. 2. While caring for a client with a new amputation, the dressing inadvertently comes off the stump. Which intervention should the nurse implement first? A. B. Bedside application Elevation of the of a large tourniquet to prevent massive hemorrhage limb above heart level to promote venous return
C. Maintenance of the client in a supine position to improve peripheral blood flow D. Immediate application of an elastic compression bandage wrapped around the limb Correct Answer: D Rationale: Because excessive edema will develop in a short time, resulting in delays in rehabilitation, the nurse should wrap the limb with an elastic compression bandage immediately. Before a tourniquet would be applied, the nurse would need to assess the client for signs and symptoms of bleeding because applying a tourniquet could compromise the circulatory and neurologic status of the limb. Elevating the limb above heart level could cause contractures; in this case, venous return is not a major concern. The supine position is contraindicated. The nurse needs to keep the stump elevated by raising the foot of the bed. 3. Which assessment finding would the nurse expect to assess in a client with emphysema? A. B. C. D. Distant breath sounds Copious Cor sputum pulmonale Anemia
Correct Answer: D Rationale: With emphysema, air trapping and chronic hyperexpansion of the lungs lead to distant breath sounds. Copious amounts of sputum are produced with chronic bronchitis; with emphysema, sputum production is usually scant. Cor pulmonale (right-sided heart failure) is more commonly associated with chronic bronchitis than emphysema. Polycythemia, an increase in red blood cells, may occur, but emphysema does not lead to anemia. 4. Following a thoracentesis, which assessment finding would warrant immediate intervention by the nurse? A. Auscultation B. Complaints of C. Prolonged D. Symmetrical respirations pain periods of at of the crackles bilaterally needle insertion site uncontrolled coughing
Correct Answer: C Rationale: Uncontrolled coughing in the client following a thoracentesis may indicate the development of pulmonary edema that requires immediate attention. Bilateral crackles may indicate underlying inflammation or congestion, but immediate attention is not necessary. Complaints of pain at the needle insertion site and symmetrical respirations are normal findings. 5. A client arrives in the emergency department following a motor vehicle accident with multiple injuries to the head, chest, and extremities with minimal bleeding. Which would the nurse assess first? A. B. Airway Blood status pressure
C. Level D. Quality of peripheral pulses Correct Answer: A
Rationale: When dealing with an emergency, the ABCs airway, breathing, and circulation are the priorities and must be maintained first. Blood pressure, neurological, and neurovascular assessments are important, but in this case, airway is the priority. 6. A client receiving nasogastric tube feedings for the past 48 hours develops a hacking cough, a fever of 100.6 F (38.1 C), and is moderately dyspneic. Which complication would the nurse suspect? A. B. Chronic C. D. Pneumoconioses Aspiration obstructive pulmonary Pleural disease pneumonia (COPD) effusion
Correct Answer: A Rationale: Nasogastric tube feedings may result in aspiration leading to pneumonia, suggested by the hacking cough, low-grade fever, and moderate dyspnea. Clients with COPD have a chronic cough and usually are afebrile. Clients with pleural effusion usually have no cough and are afebrile. Clients with pneumoconioses present with chronic cough and progressive dyspnea. 7. A client is admitted to the health care facility with a diagnosis of acute arterial occlusion. While performing a physical assessment, what would the nurse expect to observe? A. B. C. D. Pulselessness Cramping Elephatism pain
Correct Answer: D Rationale: Pulselessness is one of the common manifestations of acute arterial occlusion secondary to cessation of blood flow distal to the occlusion. Cramping is a common complaint associated with varicose veins. Elephantism is an indication of secondary lymphedema. Phantom pain is pain noted following a limb amputation. 8. A client with leukemia is undergoing radiation therapy to the brain and spinal cord. In planning care for this client, the nurse would include which nursing intervention? A. A scalp ointment to prevent dryness B. Avoiding washing off the targets marksC. Not allowing the client to use a hat or scarf D. A dandruff shampoo twice daily
Correct Answer: B Rationale: The marks made by the radiation oncologist guide the technician in configuring the external beam to irradiate the area in question without causing damage to other tissues. These marks must remain in place and should not be washed off. Ointments, which are petroleumbased, could cause a radiation burn to the area. The client should be encouraged to use a hat or scarf when in the sun to prevent damage to the scalp skin and at night to prevent loss of body heat through the scalp; hats and scarves also help to foster a positive body image. Dandruff shampoo includes harsh chemicals that could damage already fragile skin; the area being irradiated should be washed with water and the skin patted dry. 9. Which intervention would the nurse include in the teaching plan for a client diagnosed with gastroesophageal reflux disease (GERD)? A. Avoiding eating within 2 B. Eating a high-fat, C. Completing D. Sleeping with the head of the bed flat hours of low-fiber all bedtime diet antibiotics
Correct Answer: A Rationale: Clients with GERD should avoid eating prior to retiring or lying down to decrease the incidence of reflux. The client with GERD will be prescribed a low-fat, high-fiber diet. Antibiotics are not used to treat GERD, although antibiotics are used for clients with Helicobacter pylori infection and peptic ulcer disease. The client with GERD should elevate the head on pillows or use blocks under the head of the bed to minimize reflux. 10. Which would the nurse include in the discharge teaching plan for an elderly client diagnosed with pneumonia? A .Demonstration of B. Demonstration of C. Discussion of proper D. Instructions about increasing fluid intake postural pursed use drainage lip of oxygen techniques breathing therapy
Correct Answer: D Rationale: Pneumonia typically causes thick secretions that may be difficult for the elderly client to expectorate; increasing fluid intake will help thin secretions, ultimately aiding in their removal. Postural drainage usually is recommended for clients diagnosed with bronchitis and emphysema. Pursed lip breathing and oxygen therapy usually are recommended for clients with chronic obstructive pulmonary disease. A client with pneumonia typically does not require oxygen at home. 1. A client who is complaining of right lower quadrant pain, nausea, and vomiting has a lowgrade fever, rebound tenderness, and an elevated white blood cell (WBC) count. Which intervention should the nurse perform first?
A. Administering antacids for gastroenteritis B. Advising the client to assume a high Fowlers position for a peptic ulcer C. Calling the surgeon in anticipation of an appendectomy D. Suggesting a course of antibiotics to treat peritonitis Correct Answer: C Rationale: The client is exhibiting classic findings associated with appendicitis, which requires surgery as soon as possible; notifying the surgeon should be the nurses first action. Rebound tenderness is not associated with gastroenteritis, which is characterized by generalized abdominal cramping, diarrhea, fever, and malaise. A high Fowlers position would not alleviate pain produced by a peptic ulcer, which includes burning, aching, and gnawing pain. Nausea and vomiting are not generally associated with peritonitis, which is indicated by diffuse abdominal pain, rebound tenderness, fever, and an elevated WBC count. 2. Which assessment finding would be an appropriate indicator for evaluating a client with heart failure and a nursing diagnosis of decreased cardiac output? A. Decreased B. Increased ability to walk C. Increased heart rate D. Weight gain of 3 pounds in one day to by intermittent the bathroom 10 beats claudication without fatigue per minute
Correct Answer: B Rationale: Fatigue may be associated with decreased cardiac output; an increase in the clients ability to ambulate to the bathroom without fatigue indicates improvement in cardiac output. A decrease in intermittent claudication indicates improved peripheral perfusion, but it does not demonstrate increased cardiac output. The body normally responds to a decrease in cardiac output by increasing the heart rate. Weight gain indicates fluid retention and a worsening of the clients heart failure. 3. A client who has frostbite is complaining of pain. In addition to giving medication, which nursing intervention should the nurse implement? A. Administration of B. Elevation of C. Gentle massage of D. Administration of warmed, humidified oxygen sodium the the body affected bicarbonate part area
Correct Answer: B Rationale: Elevation of the body part helps to reduce the edema associated with frostbite. Sodium bicarbonate is indicated for the treatment of hypothermia. Massaging the affected area may result in further tissue damage. Warm, humidified oxygen is used as treatment for hypothermia.
4. A client scheduled for a biopsy of a mass asks the nurse to explain why this surgery is necessary. Which statement would be the nurses best response? A. The physician removes the precancerous mass to prevent cancer from occurring. B. This is diagnostic surgery done to confirm or rule out malignancy. C. This will provide a more realistic look to the body part. D. This will relieve your distress and help you to be more comfortable. Correct Answer: B Rationale: A biopsy is performed to aid in diagnosing whether a mass is benign or malignant. Preventative surgery is done to remove tissue prior to its becoming cancerous; whether or not the mass is precancerous has yet to be determined. Reconstructive surgery provides a more realistic look to a body part. Palliative surgery is used to relieve the clients distress and help make him more comfortable. 5. A client with deep venous thrombosis develops a sudden onset of severe leg pain. The limb becomes pale, cold, numb, and pulseless. What medical condition would the nurse suspect? A. Acute B. C. D. Raynauds phenomenon arterial Dissecting Postphlebitic occlusion aneurysm syndrome
Correct Answer: A Rationale: The change in color, temperature, sensation, and pulse accompanied by the sudden onset of pain (the classic Ps of assessment) all suggest an acute arterial occlusion. A dissecting aneurysm usually occurs in the chest, not the legs; a tearing or ripping sensation of pain in the anterior chest, back, epigastric region, or abdomen is common. Postphlebitic syndrome is characterized by a brownish discoloration of the skin, the hallmark sign. Raynauds phenomenon involves the episodic constriction of the small arteries or arterioles of the extremities, resulting in intermittent pallor and cyanosis of the skin, fingers, toes and, possibly, the ears or nose, followed by hyperemia, which may produce rubor. 6. When obtaining the history of a client admitted with endocarditis, which information from the client interview would the nurse consider as most significant? A. Dental surgery in B. History of coronary C. History of D. Prolonged use of steroid therapy the artery recent disease marijuana past (CAD) use
Correct Answer: A Rationale: Dental surgery is one of the predisposing factors for the development of endocarditis because it may create a portal of entry for microorganisms. A history of valvular heart disease (not CAD), I.V. drug use (not marijuana use), and prolonged I.V. antibiotic therapy (not steroid therapy) are predisposing factors for endocarditis.
7. When assessing a client diagnosed with an abdominal aortic aneurysm, the nurse monitors the client for which signs and symptoms? A. Intermittent episodes B. Paresthesias and C. Positive Homans D. Pulsatile mass and systolic bruit of loss sign high of and fever with position calf chills sense pain
Correct Answer: D Rationale: A pulsatile mass and systolic bruit are classic signs of an abdominal aortic aneurysm. Intermittent episodes of high fever with chills are associated with secondary lymphedema or other infections. Paresthesias and loss of position sense are associated with peripheral arterial occlusive disease as well as neurovascular and neurologic conditions. A positive Homans sign and calf pain are symptoms of deep vein thrombosis. 8. Which scientific rationale must the nurse keep in mind when administering oxygen to a client with chronic obstructive pulmonary disease (COPD)? A. A facemask is necessary for delivery of adequate B. Oxygen is reserved for use when the client is short of breath. C. The client is encouraged to remove the oxygen as often as possible. D. The oxygen must be administered at a low rate. Correct Answer: D Rationale: The primary stimulus to breathe for the client with COPD is hypoxia. If oxygen were administered at too high a rate, the clients respiratory drive would be depressed. The increased effectiveness of using a facemask as opposed to a nasal cannula has not been proven. Due to loss of supporting structures and narrowing of airways, the condition is irreversible; intermittent oxygen is not effective. 9. Which client would require the nurse to be on highest alert for the development of a pulmonary embolism (PE)? A. A woman who has taken hormonal contraceptives for the past B. A client who has had laparoscopic gallbladder C. A client with arterial vascular disease and difficulty D. A client who has experienced multiple trauma and fractures 2 years surgery walking
Correct Answer: D Rationale: A client with massive trauma and multiple orthopedic injuries is at increased risk for developing a PE. The injury may predispose the client to fat emboli and bony fragments that can become emboli, and the prolonged period of immobility that results from the injuries and their treatment further compounds the clients risk. Women on hormonal contraceptives have a slightly higher risk for PE, but this risk is not as great as that for the client experiencing multiple trauma and fractures. The risk for cardiovascular complications increases after age 35 in women who smoke and after age 40 in women who do not smoke. Laparoscopic cholecystectomy
is now considered a relatively minor procedure requiring a short hospitalization, usually in an outclient department. A client with arterial vascular disease may be at increased risk for pulmonary emboli but PE usually develops in the venous system. 10. Which assessment finding would be the most appropriate indicator for evaluating the adequacy of gas exchange for the postoperative client with a thoracotomy? A. Effective B. Oxygen C. Report D. Report of pain relief coughing saturation of breathing and level without of deep-breathing 98% difficulty
Correct Answer: B Rationale: Following a thoracotomy, the goal is to promote adequate gas exchange, evidenced by objective parameters including oxygen saturation, normal blood gases, and breath sounds. Effective coughing and deep breathing help to maintain a patent airway and promote lung expansion, but they do not ensure adequate gas exchange. Although client reports of breathing without difficulty are an important assessment, adequacy of gas exchange is best evaluated by objective findings. Assessment and pain relief is important, but pain relief is not a reliable indicator of adequate gas exchange.
1. When auscultating the breath sounds of a client with bacterial pneumonia, the nurse would expect to find which assessment data? A. Adventitious breath sounds with crackles and wheezes B. Bronchial breath sounds over consolidated lung fields C. Decreased breath sounds with crackles and a pleural friction rub D. Wheezing with expiration more prolonged than inspiration Correct Answer: B Rationale: In normal, clear lungs, bronchial breath sounds would be heard over the large airways and vesicular breath sounds would be heard over the clear lungs. With pneumonia, exudate fills the air spaces producing consolidation and bronchial breath sounds over these areas. Adventitious breath sounds, including crackles and wheezes, would be indicative of acute respiratory failure. Decreased breath sounds with crackles and a pleural friction rub would suggest a pulmonary embolism. Wheezing with expiration that is more prolonged than inspiration is indicative of chronic obstructive pulmonary disease. 2. When documenting the assessment finding of a client with emphysema who has an increase in the anteroposterior diameter of the chest, which term would the nurse use? A. B. Barrel Flail chest chest
C. D. Pigeon chest
Correct Answer: A Rationale: Barrel chest is a term that refers to an increase in the anteroposterior diameter of the chest, resulting from overinflation of the lungs. A flail chest results from fractured ribs when a portion of the chest pulls inward upon inspiration. A funnel chest refers to a depression of the lower part of the sternum. A pigeon chest refers to an anterior displacement of the sternum protruding beyond the abdominal plane. 3. When caring for a client with a chest tube inserted in the right chest wall, which assessment data would lead the nurse to suspect that the client is experiencing a tension pneumothorax? A. A cough with purulent B. Frothy pink-tinged C. Markedly decreased ventilation in the D. Subcutaneous emphysema in the chest wall sputum sputum lung
Correct Answer: C Rationale: Decreased ventilation in the opposite lung is indicative of a mediastinal shift, which leads to a tension pneumothorax. A cough with purulent sputum is usually seen in clients diagnosed with pneumonia. Hemoptysis is indicative of lung disease, such as pulmonary embolism and lung cancer. Subcutaneous emphysema, air accumulation in the tissues giving a crackling sensation when palpitated, is usually associated with chest trauma. 4. When evaluating risk for developing cancer, which client would the nurse identify as having the highest risk? A. An asphalt road construction worker B. A new breast-feeding mother C. An oncology nurse who takes D. A vegetarian who works at a convenience store who eats meats and potatoes who works in a bank vitamins C and E daily
Correct Answer: A Rationale: Exposure to certain chemicals such as tar, soot, asphalt, oils, and sunlight put this occupation at the highest risk. Also, meats and potatoes are low in fiber, contributing to the risk of cancer. Plus, some processed meats contain chemicals that have been implicated in the development of cancer. Breast-feeding does not increase the clients risk of developing cancer. Office work also is not considered a risk factor. Working with cancer clients does not increase a persons risk for developing cancer. Vitamins C and E have been shown to demonstrate preventative attributes. A vegetarian diet is considered to be a healthier diet for deduction of cancer risk because it provides increased fiber. Cruciferous vegetables have been shown to be preventative. Working in a convenience store does not increase risk.
5. A client with a history of coronary artery disease begins to experience chest pain. After putting the client on bedrest and administering a nitroglycerin tablet sublingually, which intervention should the nurse implement first? A. Calling the B. Checking the hearts C. Getting a D. Preparing the client for angioplasty health care provider creatine kinase MB (CK-MB) level 12-lead electrocardiogram (ECG)
Correct Answer: C Rationale: For the client experiencing chest pain, obtaining a 12-lead ECG is a priority to reveal possible changes occurring during an acute anginal attack that will be helpful in treatment. Before calling the health care provider, the nurse should obtain the results of the 12lead ECG so that these results can be communicated to him. A CK-MB level may be ordered later and the client may need angioplasty in the near future, but getting the 12-lead ECG during the chest pain is the most important priority. 6. Which signs and symptoms would alert the nurse to the possibility of a major complication in a client with pericarditis? A. Crushing B. Dyspnea and C. Hypotension D. Tachycardia and oliguria chest copious and pain and blood-tinged, frothy muffled heart diaphoresis sputum sounds
Correct Answer: C Rationale: A major complication associated with pericarditis is pericardial effusion or cardiac tamponade manifested by hypotension and muffled heart sounds. Crushing chest pain and diaphoresis are signs of myocardial infarction. Dyspnea and copious blood-tinged, frothy sputum are signs of acute pulmonary edema, a complication of left-sided heart failure. Tachycardia and oliguria are signs of hemorrhagic shock. 7. Which assessment finding would the nurse identify as indicative of a clients altered peripheral vascular function? A. Ankle arm B. Capillary refill C. Diastolic blood D. Pulses graded as being +4 index time of pressure pressure less than of 84 of 3 mm 0.4 seconds Hg
Correct Answer: A Rationale: The ankle arm index is an objective indicator of arterial disease. Normal value is 1.0. Values less than 0.5 indicate ischemic rest pain. A capillary refill time of less than 3 seconds is considered normal. A diastolic blood pressure of 84 mm Hg is considered within the normal range. Pulses graded as +4 are considered normal.
8. Which valvular disorder would the nurse suspect in a client presenting with fatigue, hemoptysis, and dyspnea on exertion? A. B. C. D. Mitral stenosis Aortic Aortic Mitral insufficiency stenosis insufficiency
Correct Answer: D Rationale: Mitral stenosis is an obstruction of blood flowing from the left atrium into the left ventricle, commonly manifested by progressive fatigue due to low cardiac output, hemoptysis, and dyspnea on exertion secondary to pulmonary venous hypertension. Aortic insufficiency refers to the backflow of blood from the aorta into the left ventricle during diastole; most clients are asymptomatic, except for a complaint of a forceful heartbeat. Aortic stenosis refers to a narrowing of the orifice between the left ventricle and the aorta; many clients experience no symptoms early on, but eventually develop exertional dyspnea, dizziness, and fainting. Mitral insufficiency refers to the backflow of blood from the left ventricle and aorta; many clients experience no symptoms early on, but eventually develop exertional dyspnea, dizziness, and fainting. 9. When developing a teaching plan for clients with chronic obstructive pulmonary disease (COPD) about the prevention of acute exacerbations, which topic should be included? A. Administration B. Administration of C. Performance of deep-breathing D. Elimination of exposure to pulmonary irritants of oxygen and as coughing antibiotics needed exercises
Correct Answer: D Rationale: One aspect of exacerbation prevention focuses on eliminating the causes and contributory factors associated with COPD, such as pulmonary irritants (e.g., smoke, air pollution, occupational irritants, and allergies). Prevention would focus on eliminating these irritants. Antibiotics are used to treat bronchial infection during exacerbations, but they are not used prophylactically. Although oxygen is used in managing acute exacerbations, it is not a preventative measure. Coughing and deep breathing may help clients clear their airways and prevent further atelectasis, but they will not prevent exacerbation. 10. Which medication would the nurse expect the health care provider to order immediately for a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD)? A. B. C. D. An antitussive agent A A An bronchodilator corticosteroid anticoagulant
Correct Answer: A Rationale: Initially, for the client newly diagnosed with COPD, the health care provider would order a bronchodilator to open the airways and ease dyspnea. Corticosteroids may be ordered for the client with COPD, but they are usually used for acute exacerbations, not as an initial drug. Anticoagulants interfere with the clotting cascade and would be ordered for a client with an embolic disorder such as pulmonary embolism. An antitussive agent would be used for the client with coughing, such as that occurring with pneumonia. Sample Nursing Board Exam Review Questions 1 1. Cherry carl is scheduled to have a hysterosalpingogram. Which of the following instruction would you give her regarding this procedure? 1. 2. 3. 4. She may feel some mild cramping when the dye is inserted The sonogram of the uterus will reveal any tumors present She will not able to conceive 3 months after the procedure Many women experience mild bleeding as an after effect
Correct Answer: 1. She may feel some mild cramping when the dye is inserted 2. Bob Carl asks you what artificial insemination by donor entails. Which would be best answer? 1. 2. 3. 4. Artificial sperm are injected vaginallyt to testtubal patency Donor sperm are introduced vaginally into the uterus or cervix The husbands sperm is administered intravenously weekly Donor sperm are injected intraabdominally into each ovary
Correct Answer: 2. Donor sperm are introduced vaginally into the uterus or cervix 3. Cheryl Carl is having a GIFT procedure. What makes her a good candidate for this procedure? 1. 2. 3. 4. She has patent fallopian tubes, so fertilizes ova can be implanted into them She is Rh negative, a necessary stipulation to rule out Rh incompatibility She is a normal uterus, so spem can be injected through the cervix into it Her husband is taking sildenafil (Viagra), so all his sperm will be motile
Correct Answer: 1.She has patent fallopian tubes, so fertilizes ova can be implanted into them 4. Amy Alvarez is pregnant with her first child. Her phenotype refers to. 1. 2. 3. 4. Her concept of he