Exit 20 Flashcards
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the
A. Surgical repair of a diseased coronary artery
B. Placement of an automatic internal cardiac defibrillator
C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
D. Non-invasive radiographic examination of the heart
C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization. Aorta coronary bypass Graft is the surgical procedure to repair a diseased coronary artery.
A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize
A. They can expect the child will be mentally retarded
B. Administration of thyroid hormone will prevent problems
C. This rare problem is always hereditary
D. Physical growth/development will be delayed
B. Administration of thyroid hormone will prevent problems
Early identification and continued treatment with hormone replacement correct this condition.
A priority goal of involuntary hospitalization of the severely mentally ill client is
A. Re-orientation to reality
B. Elimination of symptoms
C. Protection from harm to self or others
D. Return to independent functioning
C. Protection from self-harm and harm to others
Involuntary hospitalization may be required for persons considered dangerous to self or others or for individuals who are considered gravely disabled.
A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of “suppression”?
A. “I don’t remember anything about what happened to me.”
B. “I’d rather not talk about it right now.”
C. “It’s the other entire guy’s fault! He was going too fast.”
D. “My mother is heartbroken about this.”
A. “I don’t remember anything about what happened to me.”
Suppression is willfully putting an unacceptable thought or feeling out of one’s mind. A deliberate exclusion “voluntary forgetting” is generally used to protect one’s own self-esteem.
The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?
A. Altered tissue perfusion
B. Risk for fluid volume deficit
C. High risk for hemorrhage
D. Risk for infection
D. Risk for infection
Membranes ruptured over 24 hours prior to birth greatly increases the risk of infection to both mother and the newborn.
A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should:
A. Expose the cast to air and turn the child frequently
B. Use a heat lamp to reduce the drying time
C. Handle the cast with the abductor bar
D. Turn the child as little as possible
A. Expose the cast to air and turn the child frequently
The child should be turned every 2 hours, with surface exposed to the air.
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
A. Instruct the client to maintain a regular diet the day prior to the examination
B. Restrict the client’s fluid intake 4 hours prior to the examination
C. Administer a laxative to the client the evening before the examination
D. Inform the client that only 1 x-ray of his abdomen is necessary
C. Administer a laxative to the client the evening before the examination
Bowel prep is important because it will allow greater visualization of the bladder and ureters.
Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent’s remark: “We just don’t know how he caught the disease!” The nurse’s response is based on an understanding that
A. AGN is a streptococcal infection that involves the kidney tubules
B. The disease is easily transmissible in schools and camps
C. The illness is usually associated with chronic respiratory infections
D. It is not “caught” but is a response to a previous B-hemolytic strep infection
D. It is not “caught” but is a response to a previous B-hemolytic strep infection
AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior and is considered as a noninfectious renal disease.
The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the healthcare provider immediately?
A. 3 episodes of vomiting in 1 hour
B. Periodic crying and irritability
C. Vigorous sucking on a pacifier
D. No measurable voiding in 4 hours
D. No measurable voiding in 4 hours
The concern is possible hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys.
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action?
A. Check vital signs
B. Massage the fundus
C. Offer a bedpan
D. Check for perineal lacerations
B. Massage the fundus
The nurse’s first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery.
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
A. Unequal leg length
B. Limited adduction
C. Diminished femoral pulses
D. Symmetrical gluteal folds
A. Unequal leg length
Shortening of a leg is a sign of developmental dysplasia of the hip.
To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would
A. Assist the client to use the bedside commode
B. Administer stool softeners every day as ordered
C. Administer antidysrhythmics prn as ordered
D. Maintain the client on strict bed rest
B. Administer stool softeners every day as ordered
Administering stool softeners every day will prevent straining on defecation which causes the Valsalva maneuver. If constipation occurs then laxatives would be necessary to prevent straining. If straining on defecation produced the Valsalva maneuver and rhythm disturbances resulted then antidysrhythmics would be appropriate.
On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to:
A. Give the client orientation materials and review the unit rules and regulations
B. Introduce him/her and accompany the client to the client’s room
C. Take the client to the day room and introduce her to the other clients
D. Ask the nursing assistant to get the client’s vital signs and complete the admission search
B. Introduce him/herself and accompany the client to the client’s room
Anxiety is triggered by change that threatens the individual’s sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting.
During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?
A. “I have constant blurred vision.”
B. “I can’t see on my left side.”
C. “I have to turn my head to see my room.”
D. “I have specks floating in my eyes.”
C. “I have to turn my head to see my room.”
Intraocular pressure becomes elevated which slowly produces a progressive loss of the peripheral visual field in the affected eye along with rainbow halos around lights. Intraocular pressure becomes elevated from the microscopic obstruction of the trabecular meshwork. If left untreated or undetected blindness results in the affected eye.
A client with asthma has low pitched wheezes present in the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
A. Has increased airway obstruction
B. Has improved airway obstruction
C. Needs to be suctioned
D. Exhibits hyperventilation
A. Has increased airway obstruction
The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions no support exists to indicate the need for suctioning.
