Exam 1 Flashcards
A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions?
A client who has measles
A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? Select all that apply.
- Teach the client to use the call light.
- Keep the client bed in the lowest position.
- Place a fall risk and identification badge on the client’s wrist.
A nurse is discussing laboratory values associated with the renal system with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the value?
Creatinine levels are increased in clients who have acute kidney injury.
A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk of renal calculi?
Dehydration
A patient is scheduled to undergo dialysis. What is the highest-priority action that the nurse should perform before starting dialysis?
Obtain the patient’s weight
The nurse must check the patient’s weight before and after dialysis to determine how much fluid has been removed.
The nurse is attending to a patient who is receiving hemodialysis for chronic kidney disease. The nurse understands that hemodialysis is associated with complications. Which complications should the nurse be observant for in the patient? Select all that apply.
Hypotension
Hepatitis type B
Muscle cramp
The patient on hemodialysis may have decreased blood pressure due to rapid removal of blood. Hepatitis type B is a blood-borne infection, and hemodialysis poses a high risk for transmission of hepatitis B. Muscle cramps are a common complication of hemodialysis. Factors associated with the development of muscle cramps in hemodialysis include hypotension, hypovolemia, a high ultrafiltration rate (large interdialytic weight gain), and low-sodium dialysis solution.
A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client?
Confusion
Confusion is a clinical finding of UTis specifically associated with older adult clients.
The laboratory values of a client with renal calculi reveal a serum calcium within expected limits and an elevated serum chloride. The nurse concludes that the stone probably is composed of:
It contains uric acid.
Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client?
Removing the catheter within 24 hours.
Rationale: Infections can be prevented by removing the catheter within 24 hours, if the client does not need it.
The nurse is performing cardiopulmonary suction CPR on adult client. When performing chest compression, the nurse should depress the sternum by how many inches?
2 inches.
The nurse is performing rescue breathing on a 7-year-old child. The nurse delivers one breath per how many seconds to the child?
6-8 seconds
Rationale-In a child between the ages of 1 and 8 years, one breath every 6-8 seconds is delivered
The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room?
Have a client wear a surgical mask
Rationale:
Clients with airborne infections such as TB, measles, or chickenpox (varicella) are confined to a negative-pressure room except when traveling to various departments for essential diagnostic procedures or surgery. While being transported through the health care facility, the client on airborne transmission-based precautions wears a surgical mask to protect health care workers (HCWs) and other clients from respiratory secretions.
A nurse is teaching Hands On Basic Life Support for adults in the community. What should the rescuer do first after determining that the person is not responding and the emergency medical system has been activated?
perform chest compression at rate of 100/min
What is the preferred site for a pulse check in an infant about to receIve CPR?
Brachial (slightly above the elbow)
If the patient is found not breathing and bleeding heavily in a dangerous area
Priority is to remove the victim from the immediate vicinity
The nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When performing chest compressions the nurse compresses at least how many times?
100 times per minute
the nurse is performing CPR on an adult. the nurse should deliver how many breaths per minute to the client?
Ventilate the adult at a rate of 10 to 12 breaths/min (one breath every 5 to 6 seconds).
A nurse is assessing the urine of a client with a urinary tract infection. For which characteristic should the nurse assess each specimen of urine?
Clarity.
What precautions should the nurse take when caring for a client with antibiotic-resistant bacteria after notifying the HCP?
Move the client to a private room
Rationale:
Contact precautions are recommended in acute care settings for MRSA when there is a risk for transmission or wounds that cannot be contained by dressings. The client should be in a single room. All equipment, such as stethoscopes and blood pressure devices, should be for the client’s sole use and kept in the room. Health care workers must perform hand hygiene (wash hands with soap and water) after direct contact with the client and their environment and before leaving the isolation room. Contact precautions require health care workers to wear PPE such as gloves and a gown, which should be readily available
A client with a history of heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sims position, receiving oxygen at 2 L/min via nasal cannula. Which action should the nurse take first?
Raise the client to high-Fowler position
Raising the client to high-Fowler position will decrease orthopnea by using gravity to keep fluid in lower extremities, putting less stress on the heart.
A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next?
Obtained vital sign.
Rationale:
Immediately before administration of an analgesic, an assessment of vital signs is necessary to determine whether any contraindications to the medication exist (e.g., hypotension, respirations ≤12 breaths/min). Pain prevents both psychological and physiologic rest. Before the administration of an analgesic, the nurse must check the healthcare provider’s prescription, the time of the last administration, and the client’s vital signs. A complete assessment including vital signs should be done before documenting.
During the postoperative period after surgery for a kidney transplant, the client’s creatinine level is 3.1 mg/dL (260 mcmol/L). What should the nurse do first in response to this laboratory result?
Assess for decrease urine output.
Rationale:
The expected serum creatinine range is 0.7 to 1.4 mg /dL (62 to 124 mcmol/L). The nurse should obtain additional information that may indicate acute rejection; therefore, the nurse must first assess for decreased urine output and changes in vital signs.
A nurse is caring for a client whose laboratory values indicate the presence of hyponatremia. For which risk factors should the nurse assess the client that most likely may have caused the hyponatremia? (Select all that apply.)
Profuse diaphoresis.
Rapid intravenous IV infusion of 5% dextrose in water
A client’s serum potassium level is below the normal range. Which clinical indicators should
the nurse determine are consistent with hypokalemia?
Muscle weakness
Abdominal cramping
Irregular HR
Decreased bowel sounds
A client’s parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery?
Muscle spasms
Rationale:
Removal of the parathyroids causes hypocalcemia and associated neuromuscular irritability.
Patient with chronic kidney disease knows it is time for dialysis when
Hypervolemia (fluid overfload from lack of kidney filtration)
A patient is taking hydrochlorothiazide (HCTZ), a potassium-wasting diuretic, for treatment of HF. The nurse will teach the patient to report symptoms of adverse effects such as:
Generalized weakness
The nurse is assessing the respiratory status of the client at 2-hour intervals as a nursing safety priority. Which condition is affecting the client?
Hypokalemia
Rationale
In case of hypokalemia, the nurse should assess the respiratory status of the client every 2 hours.
A client with the diagnosis of Cushing syndrome has the following laboratory results: Na (sodium) 149 mEq/L (149 mmol/L); K + (potassium) 3.2 mEq/L (3.2 mmol/L); Hb (hemoglobin) 17 g/dL (170 mmol/L); and glucose 90 mg/dL (5 mmol/L). What should the nurse teach the client? Select all that apply
Avoid foods high in salt
Eat foods high in potassium
Rationale:
A sodium level of more than 145 mEq (145 mmol/L) is considered hypernatremia; the client should be taught to avoid foods high in sodium (e.g., processed foods, specific condiments). A potassium level less than 3.5 mEq/L (3.5 mmol/L) is considered hypokalemia. Therefore, the client should be encouraged to eat foods high in potassium
Which client should a nurse consider the greatest risk for developing hypernatremia?
63 year old who has had watery diarrhea since traveling abroad
The healthcare team is organizing a primary survey of a client. What are the priorities to assess during the breathing component? Select all that apply.
Observe for chest trauma
Assess breath sounds and respiratory effort
A client with a head injury underwent a physical examination. The nurse observes that the client’s temperature assessments do not correspond with the client’s condition. An injury to which part of the brain may be the reason for this condition?
Hypothalamus
The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment?
Determining drug allergies
The nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach pain. When determining the order of the assessment, the nurse recognizes that it is important to assess the symptomatic quadrant:
Last
A disturbed client is brought to the emergency department by the police. What should be included in the nurse’s initial mental assessment?
Current behavior, cognitive function, orientation
A client is brought to the emergency department after an automobile collision. The client’s blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. For which early clinical indicator of decreased arterial pressure should the nurse assess the client?
Reduced peripheral pulses
Rationale:
Hypovolemia results in decreased cardiac output and decreased arterial pressure, which are reflected by a weak peripheral pulse. The skin will be cool and pale because of vasoconstriction. The pulse pressure narrows with decreased cardiac output associated with hypovolemic shock. Lethargy with confusion is a late sign of shock.
Which component of delegation is retained while the delegator is delegating the client’s care task to the nursing aide?
Accountability
Accountability is retained by the delegator while delegating a client’s care task to the nursing aide. Every individual on the healthcare team has authority for the delegated task. The nursing aide is just responsible for the delegated task, so the delegator retains the accountability.
A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the student nurse indicates to the primary nurse
that the student nurse understands the purpose of this therapy?
“It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion.”
A client receiving peritoneal dialysis develops symptoms of severe respiratory difficulty during the infusion of the dialysate solution. Which action would the nurse take?
Drain the fluid from the peritoneal cavity
Rationale:
Pressure from the fluid may cause upward displacement of the diaphragm; draining the solution reduces intra-abdominal pressure, which allows the thoracic cavity to expand on inspiration. Additional fluid will aggravate the problem. Auscultation is important, but it does not alleviate the problem. The client should be placed in the semi-Fowler position for peritoneal dialysis; this allows inflow of fluid while not impinging on the thoracic cavity
A client is to have hemodialysis. What must the nurse do before this treatment?
Weigh the client to establish a baseline for later comparison
Rationale:
A baseline weight must be obtained to be able to determine the net fluid loss from dialysis.
When assessing a client during peritoneal dialysis, a nurse observes that drainage of the dialysate from the peritoneal cavity has ceased before the required volume has returned. What should the nurse instruct the client to do?
Turn from side to side
Rationale:
.Turning from side to side will change the position of the catheter, thereby freeing the drainage holes of the tubing, which may be obstructed. Drinking a glass of water and deep breathing and coughing do not influence the drainage of dialysate from the peritoneal cavity. The position of the catheter should be changed only by the primary healthcare provider.
A nurse is performing peritoneal dialysis for a client. Which action should the nurse take?
Warm the dialysate solution slightly before installation
What criteria should the nurse consider when determining if an infection should be
categorized as a health care associated infection?
Occurred in conjunction with treatment for an illness
Which action performed by the nursing student during the chest examination of a client needs correction?
Placing the stethoscope over bony prominences
Rationale:
The stethoscope should be placed over the lung tissue and not over bony prominences during chest auscultation. The nursing student should palpate the two ribs inferiorly in the midaxillary line and around the posterior chest. When documenting the location of lung sounds, the nursing student should divide the anterior and posterior lungs into thirds to describe the sounds. At each placement of the stethoscope, the nursing student should listen to at least one cycle of inspiration and expiration.
