EXAM B Flashcards
1. A nurse is assessing a client for manifestations of left-sided heart failure. Which of the following findings should the nurse expect? A: Weight gain B: Enlarged liver C: Distended abdomen D: Cool extremities
D: Cool extremities
MY ANSWER
Rational: The nurse should expect to find cool extremities in the client who has left-sided heart failure due to a decreased cardiac output leading to impaired tissue perfusion.
2. A Nurse is assessing a 6-month-old infant who has bacterial pneumonia. Which of the following Manifestations Should the nurse expect? A: Protruding tongue B: Facial flushing C: Nasal flaring D: Tympany with chest percussion
C: Nasal flaring
Rational: Infants who have bacterial pneumonia can exhibit manifestations such as nasal flaring and retractions of the intercostal and substernal spaces due to attempts to breathe in more oxygen to compensate for hypoxia.
- A nurse is caring for a school-age child who was admitted to the emergency department for acute asthma exacerbation. Which of the following actions should the nurse take first?
A: Encourage the child to take frequent sips of cool fluids.
B: Apply humidified oxygen with a simple mask.
C: Start a peripheral access IV.
D: Administer an albuterol nebulizer treatment
B: Apply humidified oxygen with a simple mask.
Rational: The first action the nurse should take when using the airway, breathing, and circulation approach to client care for a school-age child who is experiencing acute asthma exacerbation is to apply humidified oxygen with a simple mask. Humidified oxygen should be administered at a level to maintain oxygen saturation above 90%.
- A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following client statements indicates an understanding of the teaching?
A: “I’ll wash my feet every day with soap and lukewarm water.”
B: “I’ll apply lotion to my feet daily, especially in between my toes.”
C: “It’s okay for me to go barefoot in the house, but not outside.”
D: “I’ll soak my feet every evening before bedtime.”
A: “I’ll wash my feet every day with soap and lukewarm water.”
Rational: The client should keep her feet clean to prevent abrasions and infection. A client who has diabetic neuropathy has reduced sensation in the feet. Therefore, the client should use an elbow or a thermometer to test the temperature of the water and ensure that it is lukewarm. Hot water can irritate the skin and lead to breakdown.
- A nurse is reviewing the medical record of a client who has decreased urinary output. Which of the following findings should the nurse identify as a risk factor for the development of pyelonephritis?
A: Diabetes mellitus
B: Radical prostatectomy 2 years ago
C: Cholelithiasis
D: Taking permethrin to treat pediculosis capitis
A: Diabetes mellitus
Rational: The nurse should identify that clients who have diabetes mellitus are at increased risk for the development of pyelonephritis due to a loss of bladder tone as a result of neuropathy, or from an ascending lower urinary tract infection caused by glycosuria.
6. A nurse is assessing a client who has acute cholecystitis. Which of the following findings should the nurse expect? (Select all that apply.) A: Fever B: Dyspepsia C: Pain radiating to the left shoulder D: Blood-tinged stools E: Eructation -
A: Fever is correct.
Rational: The nurse should expect to find a fever in the client who has acute cholecystitis due to the inflammatory process.
B: Dyspepsia is correct.
Rational: The nurse should expect to find dyspepsia or indigestion in the client who has acute cholecystitis due to the biliary stasis from conditions affecting the filling or emptying of the gallbladder.
E: Eructation is correct.
Rational: The nurse should expect the client who has acute cholecystitis to exhibit eructation, or belching, due to the biliary stasis from conditions affecting the filling or emptying of the gallbladder.
- A nurse is an emergency department is caring for a client who has appendicitis. Which of the following actions should the nurse take?
A: Restrict oral intake to clear fluids.
B: Place a heating pad on the client’s abdomen.
C: Place the client in semi-Fowler’s position.
D: Administer an enema.
C: Place the client in semi-Fowler’s position.
Rational: The nurse should place the client in semi-Fowler’s position to contain abdominal drainage in the lower abdomen and prevent it from seeping into the peritoneum.
- A nurse is planning care for a client following collection of admission data. Which of the following findings should the nurse identify as the priority client need?
A: The client requests to see a priest for spiritual guidance.
B: The client reports coughing and a change of voice whenever he eats.
C: The client reports pain immediately following physical therapy.
D: The client is worried about financially supporting his family because of his illness.
B: The client reports coughing and a change of voice whenever he eats.
Rational: When using Maslow’s hierarchy of needs, the nurse should determine that the priority finding is the client’s physiological needs, such as coughing and a change of voice whenever he eats. This finding indicates a risk for aspiration, which can impair the client’s breathing and oxygenation status. Difficulty eating also creates an impairment of nutrition. Breathing, oxygenation, and nutrition are all physiological needs. Therefore, the nurse should identify this finding as the priority client need.
- A nurse is caring for a client who has respiratory acidosis due to opioid oversedation. Which of the following actions should the nurse take first?
A: Place the client on mechanical ventilation.
B: Apply oxygen using a rebreather oxygen mask.
C: Ensure a patent airway using a chin-lift maneuver.
D: Administer a reversal agent to the client.
C: Ensure a patent airway using a chin-lift maneuver.
Rational: The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to open the client’s airway by performing a chin-lift maneuver.
- A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for developing respiratory acidosis?
A: A client who has a fever
B: A client who has abdominal ascites
C: A client who is anxious
D: A client who is receiving nasogastric suctioning
B: A client who has abdominal ascites
Rational: The nurse should identify that a client who has abdominal ascites can experience a restriction of chest expansion, which impairs gas exchange and places the client at an increased risk for developing respiratory acidosis.
- A nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following statements should the nurse make?
A: “Arranging small stuffed animals in the crib is recommended to provide a feeling of security for your baby.”
B: “Moving the crib near a window in the nursery will provide your baby with necessary fresh air and natural light.”
C: “Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet.”
D: “Placing your baby on her tummy in the crib will hasten drowsiness and provide a more restful night’s sleep.”
C: “Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet.”
Rational: The nurse should instruct the parents to dress the newborn in a one-piece sleeper or a “sleep-sack” at bedtime, which keeps the newborn’s body covered. Blankets and quilts significantly increase the newborn’s risk of suffocation and should be avoided.
12. A nurse is reviewing the laboratory results of an adult male client who has hyperlipidemia and is making lifestyle changes to improve his cholesterol levels. Which of the following findings indicates to the nurse that the client has achieved a therapeutic response? A: LDL 168 mg/dL B: HDL 50 mg/dL C: Total cholesterol 268 mg/dL D: Triglycerides 250 mg/dL
B: HDL 50 mg/dL
Rational: This finding indicates that the client has achieved a therapeutic response from a lifestyle change because the HDL is within the expected reference range of greater than 45 mg/dL for an adult male client.
- A nurse is providing teaching to the parent of a school-age child who has a severe bee allergy and a new prescription for an epinephrine auto-injector. Which of the following instructions should the nurse include?
A: “Administer the medication into your child’s abdomen.”
B: “Expect your child to sleep for several hours after receiving the medication.”
C: “Place your child’s unused extra syringes in the refrigerator for storage.”
D: “Give a second injection if the first fails to reverse your child’s symptoms.”
D: “Give a second injection if the first fails to reverse your child’s symptoms.”
Rational: The nurse should instruct the parent to administer a second dose, using a second auto-injector, if the first dose doesn’t completely reverse the child’s allergic reaction. The effects of the medication will begin to fade in 20 min. However, the child should be transported to the nearest hospital immediately because hospitalization for a few hours following administration of the injection is recommended. The nurse should instruct the parent to bring the auto-injector with the child to the hospital.
- A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
A: Distract the client by having him complete a puzzle.
B: Encourage the client to take a deep breath every 2 seconds.
C: Administer methylphenidate to the client.
D: Stay with the client until manifestations subside.
D: Stay with the client until manifestations subside.
Rational: The nurse should stay with the client during a panic attack until manifestations subside and the client is reoriented to reality. This ensures the client’s safety and conveys concern to the client.
- A nurse is preparing to mix NPH insulin and insulin aspart in a single syringe for a client who has type 2 diabetes mellitus. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all Steps.)
A: Withdraw the prescribed volume of insulin aspart into the syringe.
B: Inject air into the vial equal to the amount of NPH insulin prescribed.
C: Withdraw the prescribed volume of NPH insulin into the syringe.
D: Inject air into the vial equal to the amount of insulin aspart prescribed
B: Inject air into the vial equal to the amount of NPH insulin prescribed.
D: Inject air into the vial equal to the amount of insulin aspart prescribed
A: Withdraw the prescribed volume of insulin aspart into the syringe.
C: Withdraw the prescribed volume of NPH insulin into the syringe.
The nurse should always withdraw short-acting insulin before long-acting insulin to avoid contaminating the short-acting vial. The nurse should first prepare the NPH insulin vial by filling the syringe with air equal to the amount prescribed and injecting it into the NPH vial. Then, the nurse should prepare the insulin aspart vial by filling the syringe with air equal to the amount prescribed and inject it into the insulin aspart vial. With the syringe still in the insulin aspart vial, the nurse should withdraw the correct dose of medication into the syringe. Finally, the nurse should withdraw the correct dose of NPH insulin into the syringe.
16. A nurse is assessing an 18-month-old toddler who has gastroenteritis with dehydration. The toddler is able to consume 3 mL of oral rehydration solution every 5 minutes but still has emesis and diarrhea. Which if the following medications should the nurse anticipate administering to the toddler? A: Polyethylene glycol B: Bumetanide C: Loperamide D: Ondansetron -
D: Ondansetron
Rational: The nurse should anticipate administering ondansetron to the toddler. Ondansetron is administered to toddlers who have gastroenteritis and dehydration to decrease the episodes of emesis and to help eliminate the need for intravenous fluids.
- A nurse is assessing for adverse medication reactions with a client who reports taking more than the recommended dose of acetaminophen for the management of chronic pain. Which of the following findings should the nurse identify as an adverse effect of acetaminophen?
A: Elevated aspartate aminotransferase levels
B: Decreased skin turgor
C: Elevated WBC count
D: Decreased audio acuity
A: Elevated aspartate aminotransferase levels
Rational: The nurse should identify that an elevated aspartate aminotransferase (AST) is an indication of liver injury, which is an adverse effect of excessive doses of acetaminophen. In addition to elevated liver enzymes, other indications of liver injury include diaphoresis, nausea and vomiting, abdominal pain, and diarrhea.
18. A nurse is reviewing the laboratory results of a client who is scheduled for surgery and notes a potassium level of 6 mEq/L. Which of the following ECG findings should the nurse expect? A: Heart rate 64/min B: Tall T waves C: Shortened PR interval D: QRS 0.08 seconds
B: Tall T waves
Raional: The nurse should identify that a potassium level of 6 mEq/L is above the expected reference range of 3.5 to 5 mEq/L, indicating that the client has hyperkalemia. Tall T waves are a manifestation of hyperkalemia when the potassium level is greater than 6 mEq/L, which can affect the myocardium and impact the client’s surgical risk. The nurse should report this elevated potassium level to the provider.
- A nurse is assessing a 6-month-old infant who has gastroenteritis with mild dehydration. Which of the following findings should the nurse expect?
A: Absence of tears when crying
B: Loss of 6% of body weight
C: Sunken anterior fontanel
D: Capillary refill greater than 2 seconds
D: Capillary refill greater than 2 seconds
Rational: The nurse should expect an infant who has mild dehydration to have a capillary refill time of greater than 2 seconds. Other manifestations of mild dehydration include slight thirst, decreased urine output, and moist mucus membranes.
- A nurse is assessing a client who has acute pyelonephritis. Which of the following findings should the nurse expect?
A: Pain with palpation to the substernal notch
B: Urinary burning
C: Ecchymosis over the flank
D: Radiating pain to the right shoulder
B: Urinary burning
Rational: A client who has acute pyelonephritis can experience burning, frequency, and urgency with urination.
- A home health nurse is assessing a client who has COPD. The client has a respiratory rate of 22/min and reports shortness of breath. Which of the following actions should the nurse take first?
A: Place the client in high-Fowler’s position.
B: Encourage the client to perform diaphragmatic breathing.
C: Instruct the client to perform a huff-coughing technique.
D: Administer a nebulized bronchodilator.
A: Place the client in high-Fowler’s position.
Rational: According to evidence-based practice, the first action the nurse should take is to place the client in an upright, or high-Fowler’s, position to facilitate ease of breathing.
22. A nurse is monitoring a client who has metabolic acidosis due to salicylate overdose. For which of the following finding should the nurse monitor? A: Flushed, dry skin B: Seizures C: Hyperreflexia D: Positive Trousseau's sign
A: Flushed, dry skin
Rational: The nurse should monitor a client who has metabolic acidosis for manifestations of warm, flushed, and dry skin due to vasodilation from an increased respiratory rate and the loss of CO2.
23. A nurse is assessing a client who has hypermagnesemia. Which of the following manifestations should the nurse expect? A: Hyperactive deep tendon reflexes B: Abdominal distention C: Bradycardia D: Positive Trousseau's sign
C: Bradycardia
Rational: The nurse should expect to find bradycardia in a client who has hypermagnesemia, as well as other cardiac manifestations, including peripheral vasodilation and hypotension due to a reduced membrane excitability. Clients who have severe hypermagnesemia are at an increased risk for cardiac arrest.
- A nurse is assessing a client who has an external fixator to the right lower arm following musculoskeletal trauma. Which of the following findings should indicate to the nurse that the client has developed compartment syndrome?
A: Serous drainage is present on the pin site dressings
B: Flushing of the skin on the right arm
C: Bounding pulse palpated in the radial artery
D: Numbness to the fingers on the right arm
D: Numbness to the fingers on the right arm
Rational: The nurse should identify a decrease in sensation, such as numbness and tingling of the fingers, as one of the first indications that the client might be developing compartment syndrome of the right lower arm. Compartment syndrome is the result of edema and ischemia, a complication following musculoskeletal injury. Other manifestations include increased pain, paralysis, pallor, and decreased or absent pulses.