Exam 1 Flashcards
A client receiving palliative care who has advanced dementia is nonverbal and restless and moans when the family attempts to touch or comfort the client. Which nursing intervention is appropriate for this client?
A. Administer acetaminophen rectally for pain.
B. Instruct the family to avoid touching the client to prevent pain.
C. Provide passive range of motion to increase mobility once a shift.
D. Obtain a prescription for transdermal fentanyl for pain.
D. Obtain a prescription for transdermal fentanyl for pain
The family of a client who is near death is concerned about a loud rattling that occurs with the client’s breathing. What nursing intervention is appropriate? Select all that apply.
A. Administer hyoscyamine as prescribed to dry up secretions.
B. Turn the client onto one side to help decrease the gurgling with respirations.
C. Suction the client regularly to remove secretions in the bronchi and oropharynx.
D. Assess the client for signs of dyspnea or respiratory distress.
E. Administer diuretics as prescribed to help decrease the wet respirations.
F. Teach the family about the buildup of secretions that occurs when a client is near death.
A. Administer hyoscyamine as prescribed to dry up secretions.
B. Turn the client onto one side to help decrease the gurgling with respirations.
D. Assess the client for signs of dyspnea or respiratory distress.
F. Teach the family about the buildup of secretions that occurs when a client is near death.
The family of a client experiencing terminal dehydration requests that intravenous fluids be started. What is the nurse’s best response?
A. “We can start fluids to help ease the dehydration.”
B. “Intravenous fluids can increase discomfort for the client.”
C. “Intravenous fluids will likely prolong life.”
D. “Terminal dehydration can be managed better with pain medication.”
B. “Intravenous fluids can increase discomfort for the client.”
A client receiving palliative care for a terminal cancer diagnosis asks the nurse, “Why is this happening to me?” What is the best nursing response?
A. “I don’t know. God knows when your time is up on this earth.”
B. “I’m sorry. I know that this is a very difficult time for you.”
C. “It’s going to be OK; at least you aren’t leaving any family behind.”
D. “We’ll make sure that all of your needs are met, so don’t worry.”
B. “I’m sorry. I know that this is a very difficult time for you.”
The nurse is caring for four clients. Which client will benefit from palliative care?
A. 69-year-old with ovarian cancer and three months to live
B. 74-year-old with chronic obstructive pulmonary disease
C. 77-year-old who underwent hip replacement surgery after falling
D. 81-year-old with end-stage dementia after living with the condition 12 years
ANS: B
Palliative care is both a philosophy of care and an organized, structured system for delivering care for people with serious illness who may not meet hospice eligibility criteria. The desired outcome for palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. Clients with under 6 months to live benefit from hospice care. Clients who have restorative surgery (e.g., hip replacement) and no other comorbid conditions benefit from rehabilitation.
The hospice nurse is caring for a Roman Catholic client with lung cancer who is expected to live less than two weeks. When the client requests to be baptized, what is the appropriate nursing response?
A. Perform the act of baptism
B. Contact a priest to visit with the client
C. Ask the client if he or she has been baptized before
D. Request that the family contact the client’s spiritual leader
ANS: B
The nurse’s role is to act as an advocate for the client. When the client requests some type of spiritual care (e.g., baptism), the nurse will contact the appropriate spiritual authority (e.g., the priest) to honor the client’s request. In the Roman Catholic faith, only in emergency circumstances can a layperson baptize an individual; otherwise, baptism is performed by a priest. Asking the client if he or she has been baptized before is not the concern of the nurse. Requesting that the family contact the client’s spiritual leader is incorrect, as the family may be grieving during this time of loss also. The nurse can address the client’s request by directly arranging for a priest to visit.
A competent patient who has just been diagnosed with a brain tumor and two years to live asks about physician-assisted death (PAD). What is the appropriate nursing response?
A. “It sounds like this is a very scary time for you.”
B. “This process is illegal, and I cannot discuss it.”
C. “I will not be able to care for you from this point forward.”
D. “Your health care provider will have to talk with you about this.”
ANS: A
The nurse’s role is to assess what the client is saying. Because the client has just been diagnosed, it is likely the client is frightened. The nurse can provide an open-ended statement and then further assess the client’s concerns and needs based on the client’s response. Although PAD is illegal in some places, it has been legalized in certain states, and legislation is open in other states who are seeking to approve this process. The nurse cannot participate in PAD, but can still (at this time) provide care for the client. Turning the client over to the health care provider without further assessing the client’s needs is inappropriate. The client may simply be fearful and need to verbally express concern, or may benefit from therapeutic dialogue which the nurse can provide.
A client had a 20-gauge short peripheral catheter (SPC) inserted for antibiotic administration 48 hours ago. Which nursing intervention is appropriate?
A. Discontinue the SPC.
B. Relocate the SPC for infection control.
C. Assess the SPC for redness, swelling, or pain.
D. Change the occlusive dressing covering the SPC.
C. Assess the SPC for redness, swelling, or pain.
The primary health care provider has prescribed 1 L of D5NS to infuse at a rate of 125 mL/hr. The nurse begins the infusion at 0700 (7 a.m.). When will the nurse anticipate completion of the infusion?
A. 1300 hours (1 p.m.)
B. 1500 hours (3 p.m.)
C. 1900 hours (7 p.m.)
D. 2100 hours (9 p.m.)
B. 1500 hours (3 p.m.)
A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What is the priority nursing action?
A. Contact the primary health care provider
B. Document findings in the electronic health record
C. Change the IV site to a new location
D. Stop the infusion of the drug
D. Stop the infusion of the drug
An older adult client receiving an infusion of 5% dextrose in 0.9% normal saline at 150 mL/hour has developed shortness of breath with a decrease in oxygen saturation to 86%. What is the priority nursing intervention?
A. Notify the health care provider
B. Place the client on oxygen
C. Sit the client upright in bed
D. Assess the client’s lung sounds
C. Sit the client upright in bed
Because the client is short of breath, the priority action that can be done immediately is to sit the client upright in bed. Assessing the lung sounds can occur after sitting the client upright. Use of oxygen and contacting the healthcare provider will follow the priority action. The rate of infusion is likely too fast for an older adult client which has created fluid build-up. The nurse will anticipate fine crackles in the lung bases and decrease in the IV flow rate and notify the health care provider.
A new nurse is preparing to insert a vascular access device in a client. Which action by the new nurse requires intervention by the experienced nurse?
A. Performing hand hygiene prior to insertion.
B. Preparing for insertion immediately following cleaning with iodophors.
C. Using friction to clean the skin around the insertion site.
D. Clipping the hairs in the preferred insertion area.
B. Preparing for insertion immediately following cleaning with iodophors.
Current recommendations call for using friction when cleaning the skin to penetrate the layers of the epidermis. Iodophors such as povidone-iodine require contact with the skin for a minimum of 2 minutes to be effective. Skin should never be shaved before venipuncture, but excessive amounts of hair should be clipped.
A client with severe burns over 85% of the body is being transported to the ED. The paramedic tells the nurse over the phone that IV access could not be established in the field. What type of IV device does the nurse anticipate will be ordered upon the client’s arrival?
A. PICC line
B. Central line
C. Intraosseous catheter
D. Subcutaneous infusion
C. Intraosseous (IO) therapy allows access to the rich vascular network located in the long bones. Victims of trauma, burns, cardiac arrest, and other life-threatening conditions benefit from this therapy because often clinicians are unable to access these clients’ vascular systems for traditional IV therapy. If IV access cannot be obtained within the first few minutes of resuscitation procedures, IO may be attempted. After establishing IO access, efforts should continue to obtain IV access as well.
During IV catheter insertion, a client with dehydration reports feeling “pins and needles” in the arm. What is the appropriate nursing response?
A. “Nerve puncture may have occurred.”
B. “That is a normal sensation that will go away.”
C. “It is likely that the vein I was accessing has collapsed.”
D. “That means that the catheter is placed in the appropriate location.”
A. “Nerve puncture may have occurred.”
Reports of tingling, feeling “pins and needles” in the extremity, or numbness during the venipuncture procedure can indicate nerve puncture. The procedure should be stopped immediately, the catheter removed, and a new site chosen. Transsection of the nerve can result in permanent loss of function, and local nerve damage can become a chronic systemic pain syndrome.
A client who 3 days ago underwent extensive abdominal surgery for cancer reports having a difficult time “catching her breath” and feeling very scared. After assessing the client, what is the nurse’s best action or response to prevent harm?
A. Ask the client about possible drug allergies
B. Apply oxygen and initiate the Rapid Response Team
C. Determine when she last received an opioid dose
D. Check the oxygen saturation and encourage her to cough
B. Apply oxygen and initiate the Rapid Response Team
Which condition, sign, or symptom does the nurse consider most relevant in assessing a client suspected to have ARDS? Select all that apply.
A. Dyspnea
B. Electrocardiogram shows ST elevation
C. Intercostal retractions
D. PaO 2 84% on oxygen at 6 L/min
E. Substernal pain or rubbing
F. Wheezing on exhalation
A. Dyspnea
C. Intercostal retractions
D. PaO 2 84% on oxygen at 6 L/min
The nurse is caring for a group of clients on a Telemetry unit. When providing client education, which client will the nurse determine most needs information regarding preventing pulmonary embolism
(РЕ)?
A. A woman who frequently flies to Europe (prolonged travel)
B. A man who works on a farm
C. A man admitted for a myocardial infarction
D. A woman with a bleeding disorder
A. A woman who frequently flies to Europe (prolonged travel)
The nurse is caring for a group of clients on a medical surgical unit. For which of these individuals does the nurse provide immediate interventions to reduce the risk for pulmonary embolism (PE)?
A. A client with diabetes and cellulitis of the leg
B. A client receiving IV fluids through a peripheral line
C. A client returning from an open reduction and internal fixation of the tibia (orthopedic, Gl surgery, gynecology surgery have high risk of DVT and PE due to immobility) d.
D. A client with fluid volume deficit and hypokalemia receiving potassium
C. A client returning from an open reduction and internal fixation of the tibia (orthopedic, Gl surgery,
The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms consistent with PE will the nurse assess?
A. Dizziness and syncope
B. Shortness of breath (SOB) worsening over the last 2 weeks
C. Inspiratory Chest Pain
D. productive cough
E. Pink, frothy sputum
F. Tachycardia
A. Dizziness and syncope
c. inspiratory chest pain
f. tachycardia
(dizziness, syncope, hypotension, and fainting, sharp, pleuritic, inspir
A patient is being evaluated for acute respiratory distress syndrome (ARDS). On assessment of the patient, the nurse notes tachypnea, dyspnea, and confusion. For which test would the nurse expect to prepare the patient to confirm the diagnosis of ARDS?
A. Chest xray
B. Measurement of ABG
C. CBC w/ platelets
D. MRI of chest w/ contrast
A. Chest x-ray
A patient with aspiration pneumonia presents with a heart rate of 128 beats/min, respiratory rate of 32 breaths/min, blood pressure of 148/92 mm Hg, and functional saturation of oxygen on 88% on room air. The patient reports shortness of breath (SOB) and fatigue. Which blood test would the nurse anticipate first?
A. Blood glucose
B. Chemistry panel
C. Measurement of ABGs
D. Prothrombin time/partial thromboplastin time/international normalized ratio (PT/PTT/INR)
C. Measurement of ABGs
A patient with pneumonia reports increased sweating, persistent coughing, shortness of breath and palpitations. The nurse notes tachycardia and cyanosis. The patient is receiving oxygen via a nasal cannula at 2 L/min. Which action would the nurse take next? SATA
A. Administer an antipyretic.
B. Notify the health care provider.
C. Inform the respiratory therapist.
D. Give a bolus of normal saline solution.
E. Increase oxygen concentration to 6 L/min.
B, C
The nurse should not give a bolus of normal saline solution. Many patients with acute respiratory distress syndrome require fluid restriction to minimize lung damage. The high dose of fluid may worsen the patient’s condition.The nurse cannot increase the oxygen concentration without an order from the health care provider.
A nurse is caring for a patient who is suspected of developing acute respiratory distress syndrome (ARDS). The patient is receiving oxygen at 15 L /min through a nonrebreather mask while awaiting further evaluation. What should the nurse implement for this procedure to be most effective?
A. Ensure the mask fits snuggly on the patient’s face.
B. Encourage the patient to remove the mask when it becomes uncomfortable.
C. Obtain baseline vital signs before initiating oxygen supplementation therapy.
D. Encourage the patient to remove the mask periodically for deep breathing exercises.
A.
Collecting baseline vital signs will be helpful to the nurse in determining whether oxygen therapy has been effective, but this does not make the treatment more effective.
A patient with acute respiratory distress syndrome (ARDS) secondary to a chest injury has crackles in the bilateral posterior lung fields. The nurse also notes tachycardia, delayed capillary refill, decreased urine output, and the following arterial blood gas (ABG) results: pH 7.56, PaO2 51, PaCo2 28, HCO3 24, SaO2 76%. Which provider order would the nurse implement first?
Measure urine output.
Administer furosemide.
Place the patient in a prone position.
Prepare the patient for mechanical ventilation.
Prepare the patient for mechanical ventilation
The nurse is caring for a patient diagnosed with acute respiratory distress syndrome (ARDS). On assessment, the nurse notes crackles in the lungs and peripheral edema. Which nursing assessments are appropriate for the nurse to obtain? SATA
Skin integrity
Intake/output
Oxygen saturation
Blood glucose level
Serum albumin level
Skin integrity, I&O, O2 sat
The client, a woman who is 5 feet 11 inches tall and 176 lb (80 kg), has been mechanically ventilated at a tidal volume of 400 mL and a respiratory rate of 12 breaths/min for the past 24 hours. The most recent arterial blood gas (ABG) results for this client are pH = 7.32; PaO 2 = 84 mm Hg; PaCO 2 = 56 mm Hg. What is the nurse’s interpretation of these results?
A. Ventilation adequate to maintain oxygenation.
B. Ventilation excessive; respiratory alkalosis present.
C. Ventilation inadequate; respiratory acidosis present.
D. Ventilation status cannot be determined from information presented.
C. Ventilation inadequate; respiratory acidosis present.
An attempt by a primary health care provider to intubate a client for mechanical ventilation is unsuccessful after 45 seconds. What is the nurse’s priority action?
A. Placing a nasotracheal tube
B. Assessing for bilateral breath sounds
C. Assessing oxygen saturation by pulse oximetry
D. Applying oxygen with a bag-valve-mask device
D. Applying oxygen with a bag-valve-mask device
Which actions does the nurse ensure are performed for a client being mechanically ventilated to prevent ventilator-associated pneumonia (VAP)? Select all that apply.
A. Assessing temperature every 4 hours
B. Checking ventilator settings every 4 hours
C. Getting the patient out of bed as soon as prescribed
D. Keeping the head of the bed elevated to 30 degrees or above
E. Maintaining the client in the prone position
F. Providing adequate humidification
G. Providing meticulous mouth care every 12 hours
H. Suggesting that the pneumonia vaccine be prescribed
C, D, G
A client being mechanically ventilated has all of the following changes. Which changes are most relevant in helping the nurse determine whether suctioning is needed at this time? Select all that apply.
A. Decreased SpO 2
B. Elevated temperature
C. Crackles auscultated over the trachea
D. Crackles auscultated in the lung periphery
E. High-pressure ventilator alarm sounds
F. Presence of fluid within the endotracheal tube
G. Presence of fluid within the ventilator tubing
A, C, E, F
