Exit 17 Flashcards
A client is scheduled for insertion of an inferior vena cava (IVC) filter. Nurse Patricia consults the physician about withholding which regularly scheduled medication on the day before the surgery?
A. Potassium Chloride
B. Warfarin Sodium
C. Furosemide
D. Docusate
B. Warfarin Sodium
In the preoperative period, the nurse should consult with the physician about withholding Warfarin Sodium to avoid the occurrence of hemorrhage.
A nurse is planning to assess the corneal reflex on an unconscious client. Which of the following is the safest stimulus to touch the client’s cornea?
A. Cotton buds
B. Sterile glove
C. Sterile tongue depressor
D. Wisp of cotton
D. Wisp of cotton
A client who is unconscious is at greater risk for corneal abrasion. For this reason, the safest way to test the corneal reflex is by touching the cornea lightly with a wisp of cotton.
A female client develops an infection at the catheter insertion site. The nurse in charge uses the term “iatrogenic” when describing the infection because it resulted from:
A. Client’s developmental level
B. Therapeutic procedure
C. Poor hygiene
D. Inadequate dietary patterns
B. Therapeutic procedure
Iatrogenic infection is caused by the health care provider or is induced inadvertently by medical treatment or procedures.
Nurse Carol is assessing a client with Parkinson’s disease. The nurse recognizes bradykinesia when the client exhibits:
A. Intentional tremor
B. Paralysis of limbs
C. Muscle spasm
D. Lack of spontaneous movement
D. Lack of spontaneous movement
Bradykinesia is the slowing down from the initiation and execution of movement.
A client who suffered from an automobile accident complains of seeing frequent flashes of light. The nurse should expect:
A. Myopia
B. Detached retina
C. Glaucoma
D. Scleroderma
B. Detached retina
This symptom is caused by the stimulation of retinal cells by ocular movement.
Kate with severe head injury is being monitored by the nurse for increasing intracranial pressure (ICP). Which finding should be the most indicative sign of increasing intracranial pressure?
A. Intermittent tachycardia
B. Polydipsia
C. Tachypnea
D. Increased restlessness
D. Increased restlessness
Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system.
A hospitalized client had a tonic-clonic seizure while walking down the hall. During the seizure, the nurse’s priority should be:
A. Hold the client’s arms and leg firmly
B. Place the client immediately on a soft surface
C. Protect the client’s head from injury
D. Attempt to insert a tongue depressor between the client’s teeth
C. Protect the client’s head from injury
Rhythmic contraction and relaxation associated with tonic-clonic seizure can cause repeated banging of the head.
A client has undergone a right pneumonectomy. When turning the client, the nurse should plan to position the client either:
A. Right side-lying position or supine
B. High Fowler’s position
C. Right or left side-lying position
D. Low Fowler’s position
A. Right side-lying position or supine
The right side-lying position or supine position permits ventilation of the remaining lung and prevents fluid from draining into the sutured bronchial stump.
Nurse Jenny should caution a female client who is sexually active about taking Isoniazid (INH) because the drug has which of the following side effects?
A. Prevents ovulation
B. Has a mutagenic effect on ova
C. Decreases the effectiveness of oral contraceptives
D. Increases the risk of vaginal infection
C. Decreases the effectiveness of oral contraceptives
Isoniazid (INH) interferes with the effectiveness of oral contraceptives, and clients of childbearing age should be counseled to use an alternative form of birth control while taking this drug.
A client has undergone a gastrectomy. Nurse Jovy is aware that the best position for the client is:
A. Left side-lying
B. Low Fowler’s
C. Prone
D. Supine
B. Low Fowler’s
A client who has had abdominal surgery is best placed in a low Fowler’s position. This relaxes abdominal muscles and provides maximum respiratory and cardiovascular function.
During the initial postoperative period of the client’s stoma, the nurse evaluates which of the following observations should be reported immediately to the physician?
A. Stoma is dark red to purple
B. Stoma oozes a small amount of blood
C. Stoma is slightly edematous
D. Stoma does not expel stool
A. Stoma is dark red to purple
A dark red to purple stoma indicates inadequate blood supply.
Kate, who has been diagnosed with ulcerative colitis, is following the physician’s order for bed rest with bathroom privileges. What is the rationale for this activity restriction?
A. Prevent injury
B. Promote rest and comfort
C. Reduce intestinal peristalsis
D. Conserve energy
C. Reduce intestinal peristalsis
The rationale for activity restriction is to help reduce the hypermotility of the colon.
Nurse KC should regularly assess the client’s ability to metabolize the total parenteral nutrition (TPN) solution adequately by monitoring the client for which of the following signs:
A. Hyperglycemia
B. Hypoglycemia
C. Hypertension
D. Elevated blood urea nitrogen concentration
A. Hyperglycemia
During Total Parenteral Nutrition (TPN) administration, the client should be monitored regularly for hyperglycemia.
A female client has acute pancreatitis. Which of the following signs and symptoms would the nurse expect to see?
A. Constipation
B. Hypertension
C. Ascites
D. Jaundice
D. Jaundice
Jaundice may be present in acute pancreatitis owing to obstruction of the biliary duct.
A client is suspected to develop tetany after a subtotal thyroidectomy. Which of the following symptoms might indicate tetany?
A. Tingling in the fingers
B. Pain in hands and feet
C. Tension on the suture lines
D. Bleeding on the back of the dressing
A. Tingling in the fingers
Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or removed.
A 58-year-old woman has been newly diagnosed with hypothyroidism. The nurse is aware that the signs and symptoms of hypothyroidism include:
A. Diarrhea
B. Vomiting
C. Tachycardia
D. Weight gain
D. Weight gain
Typical signs of hypothyroidism include weight gain, fatigue, decreased energy, apathy, brittle nails, dry skin, cold intolerance, constipation, and numbness.
A client has undergone an ileal conduit, the nurse in charge should closely monitor the client for the occurrence of which of the following complications related to pelvic surgery?
A. Ascites
B. Thrombophlebitis
C. Inguinal hernia
D. Peritonitis
B. Thrombophlebitis
After pelvic surgery, there is an increased chance of thrombophlebitis owing to the pelvic manipulation that can interfere with circulation and promote venous stasis.
Dr. Marquez is about to defibrillate a client in ventricular fibrillation and says in a loud voice “clear”. What should be the action of the nurse?
A. Place conductive gel pads for defibrillation on the client’s chest
B. Turn off the mechanical ventilator
C. Shut off the client’s IV infusion
D. Step away from the bed and make sure all others have done the same
D. Step away from the bed and make sure all others have done the same
For the safety of all personnel, if the defibrillator paddles are being discharged, all personnel must stand back and be clear of all contact with the client or the client’s bed.
A client has been diagnosed with glomerulonephritis and complains of thirst. The nurse should offer:
A. Juice
B. Ginger ale
C. Milkshake
D. Hard candy
D. Hard candy
Hard candy will relieve thirst and increase carbohydrates but does not supply extra fluid.
A client with acute renal failure is aware that the most serious complication of this condition is:
A. Constipation
B. Anemia
C. Infection
D. Platelet dysfunction
C. Infection
Infection is responsible for one-third of the traumatic or surgically induced death of clients with renal failure as well as medically induced acute renal failure (ARF).
