Exit 4 Flashcards
The primary reason for rapid continuous rewarming of the area affected by frostbite is to:
A. Lessen the amount of cellular damage.
B. Prevent the formation of blisters.
C. Promote movement.
D. Prevent pain and discomfort.
A. Lessen the amount of cellular damage.
Rapid continuous rewarming of a frostbite primarily lessens cellular damage. It does not prevent the formation of blisters, promote movement, or prevent pain and discomfort, although pain might increase temporarily as feeling returns.
A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse’s response is based on the knowledge that hemodialysis works by:
A. Passing water through a dialyzing membrane
B. Eliminating plasma proteins from the blood
C. Lowering the pH by removing nonvolatile acids
D. Filtering waste through a dialyzing membrane
D. Filtering waste through a dialyzing membrane
Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood. It does not pass water through a dialyzing membrane, eliminate plasma proteins, or lower the pH.
During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate?
A. Administer an antibiotic
B. Contact the physician for an order for immune globulin
C. Administer an antiviral
D. Tell the client that he should remain in isolation for 2 weeks
B. Contact the physician for an order for immune globulin
The client who is immunosuppressed and exposed to measles should be treated with medications to boost his immunity to the virus. Antibiotics or antivirals are not effective, and isolation is not a preventive measure at this stage.
A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?
A. The client should be placed in a room with negative pressure.
B. Infection requires close contact; therefore, the door may remain open.
C. Transmission is highly likely, so the client should wear a mask at all times.
D. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.
D. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.
MRSA spreads through direct contact, not airborne, so negative pressure is unnecessary, and the door can remain open. A mask is not required for the client at all times, but hand washing, gloves, and gowns are essential.
A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates an understanding of phantom limb pain?
A. “The pain will go away in a few days.”
B. “The pain is due to peripheral nervous system interruptions. I will get you some pain medication.”
C. “The pain is psychological because your foot is no longer there.”
D. “The pain and itching are due to the infection you had before the surgery.”
B. “The pain is due to peripheral nervous system interruptions. I will get you some pain medication.”
Phantom limb pain is caused by peripheral nervous system interruptions. It is not psychological, typically does not resolve quickly, and is not related to infection.
A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the:
A. Head of the pancreas
B. Proximal third section of the small intestines
C. Stomach and duodenum
D. Esophagus and jejunum
A. Head of the pancreas
The Whipple procedure involves removing the head of the pancreas, part of the stomach, the jejunum, and other structures, not the entire stomach, duodenum, esophagus, or proximal third of the small intestines.
The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to AVOID eating:
A. Packed fruits
B. Salt
C. Fresh raw pepper
D. Ketchup
C. Fresh raw pepper
Fresh raw or whole pepper can harbor bacteria unless thoroughly cooked. Packed fruits are allowed since they are processed and pasteurized, and salt and ketchup do not pose a bacterial risk.
A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:
A. Have a Protime done monthly
B. Eat more fruits and vegetables
C. Drink more liquids
D. Avoid crowds
A. Have a Protime done monthly
Coumadin requires monitoring of bleeding times via Protime tests. Increased intake of dark-green vegetables can affect vitamin K levels and clotting, while drinking more liquids and avoiding crowds are unrelated to Coumadin therapy.
The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to:
A. Perform the Valsalva maneuver as the catheter is advanced
B. Turn his head to the left side and hyperextend the neck
C. Take slow, deep breaths as the catheter is removed
D. Turn his head to the right while maintaining a sniffing position
A. Perform the Valsalva maneuver as the catheter is advanced
The Valsalva maneuver helps prevent air embolism during catheter removal. Slow, deep breaths, head turning, or hyperextension of the neck are not recommended during this procedure.
A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:
A. Allergies to pineapples and bananas
B. A history of streptococcal infections
C. Prior therapy with phenytoin
D. A history of alcohol abuse
B. A history of streptococcal infections
Antibodies from past streptococcal infections can render streptokinase ineffective. Allergies to pineapples, bananas, phenytoin use, or alcohol abuse are irrelevant to streptokinase efficacy.
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
A. Using oil- or cream-based soaps
B. Flossing between the teeth
C. The intake of salt
D. Using an electric razor
B. Flossing between the teeth
Clients with leukemia and bone marrow suppression should avoid flossing due to bleeding risks from decreased platelets. Using oil or cream-based soaps, consuming salt, and using an electric razor are allowed.
The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:
A. Apply the new tie before removing the old one.
B. Have a helper present.
C. Hold the tracheotomy with the nondominant hand while removing the old tie.
D. Ask the doctor to suture the tracheostomy in place.
A. Apply the new tie before removing the old one.
This method prevents accidental decannulation. Having a helper, holding the tracheotomy with the nondominant hand, or asking for sutures are not as effective in preventing displacement.
The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:
A. Turning the client to the left side
B. Milking the tube to ensure patency
C. Slowing the intravenous infusion
D. Notifying the physician
D. Notifying the physician
An output of 300 mL indicates possible hemorrhage and requires immediate medical attention. Turning the client, milking the tube, or slowing the IV infusion are inappropriate actions in this situation.
The infant is admitted to the unit with tetralogy of Fallot. The nurse would anticipate an order for which medication?
A. Digoxin
B. Epinephrine
C. Aminophylline
D. Atropine
A. Digoxin
The infant withTetralogy of Fallot involves four heart defects:A large ventricular septal defect (VSD),Pulmonary stenosis,Right ventricular hypertrophy and an Overriding aorta.
Digoxin helps slow and strengthen the heart in tetralogy of Fallot. Epinephrine, aminophylline, and atropine are not indicated as they can increase heart rate, which is not desirable in this condition.
The nurse is educating the lady’s club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram below, sleect where the Tail of Spence is.
A. Up into the axilla region
The Tail of Spence is located in the upper outer quadrant of the breast.
The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
A. Tire easily
B. Grow normally
C. Need more calories
D. Be more susceptible to viral infections
A. Tire easily
The toddler with a ventricular septal defect will tire easily due to the extra workload on the heart. The child will not grow normally without surgical intervention and will not need more calories specifically. They will be more susceptible to bacterial rather than viral infections.
The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:
A. Determine lung maturity
B. Measure the fetal activity
C. Show the effect of contractions on fetal heart rate
D. Measure the wellbeing of the fetus
B. Measure the fetal activity
A nonstress test determines fetal activity and well-being by monitoring fetal heart rate responses to movements. It does not determine lung maturity, show contractions, or measure neurological well-being directly.
A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:
A. Be injected into the deltoid muscle
B. Be injected into the abdomen
C. Aspirate after the injection
D. Clear the air from the syringe before injections
B. Be injected into the abdomen
Lovenox should be injected into the abdomen for proper absorption. It should not be injected into the deltoid muscle, aspiration is not necessary, and air should not be cleared from the syringe before injection.
The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:
A. Administer the medications together in one syringe
B. Administer the medication separately
C. Administer the Valium, wait 5 minutes, and then inject the Phenergan
D. Question the order because they cannot be given at the same time
B. Administer the medication separately
Valium and Phenergan should be administered separately as they are not compatible in the same syringe. Administering one after the other immediately is acceptable, and questioning the order is unnecessary as they can be given concurrently but separately.
