Exit 6 Flashcards
The client is having an arteriogram. During the procedure, the client tells the nurse, “I’m feeling really hot.” Which response would be best?
A. “You are having an allergic reaction. I will get an order for Benadryl”
B. “That feeling of warmth is normal when the dye is injected”
C. “That feeling of warmth indicates that the clots in the coronary vessels are dissolving”
D. “I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing”
B. “That feeling of warmth is normal when the dye is injected”
It is normal for the client to have a warm sensation when dye is injected. Options A, C, and D indicate that the nurse believes that the hot feeling is abnormal, so they are incorrect.
The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?
A. The nursing assistant wears gloves while giving the client a bath
B. The nurse wears goggles while drawing blood from the client
C. The doctor washes his hands before examining the client
D. The nurse wears gloves to take the client’s vital signs
D. The nurse wears gloves to take the client’s vital signs
It is not necessary to wear gloves to take the vital signs of the client. If the client has an active infection with methicillin-resistant Staphylococcus aureus, gloves should be worn. Options A, B, and C indicate proper knowledge of infection control.
The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective?
A. The client loses consciousness
B. The client vomits
C. The client’s ECG indicates tachycardia
D. The client has a grand mal seizure
D. The client has a grand mal seizure
During ECT, the client will have a grand mal seizure, indicating the completion of the electroconvulsive therapy. Options A, B, and C do not indicate that the ECT has been effective.
The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:
A. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep
B. Scrape the skin with a piece of cardboard and bring it to the clinic
C. Obtain a stool specimen in the afternoon
D. Bring a hair sample to the clinic for evaluation
A. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep
The mother should use a flashlight to examine the rectal area about 2-3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape, which should then be brought in to be evaluated.
The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?
A. Treatment is not recommended for children less than 10 years of age
B. The entire family should be treated
C. Medication therapy will continue for 1 year
D. Intravenous antibiotic therapy will be ordered
B. The entire family should be treated
Enterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain.
The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
A. The client receiving linear accelerator radiation therapy for lung cancer
B. The client with a radium implant for cervical cancer
C. The client who has just been administered soluble brachytherapy for thyroid cancer
D. The client who returned from placement of iridium seeds for prostate cancer
A. The client receiving linear accelerator radiation therapy for lung cancer
The client receiving linear accelerator therapy travels to the radium department for therapy and does not pose a radiation risk to the pregnant nurse. Options B, C, and D involve clients with radioactivity present, posing a risk.
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
A. The client with Cushing’s disease
B. The client with diabetes
C. The client with acromegaly
D. The client with myxedema
A. The client with Cushing’s disease
The client with Cushing’s disease has adrenocortical hypersecretion, causing immunosuppression. Options B, C, and D do not pose risks to others or themselves.
The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:
A. Negligence
B. Tort
C. Assault
D. Malpractice
D. Malpractice
The nurse can be charged with malpractice for administering an incorrect dosage that causes harm. Negligence is failing to perform care, a tort is a wrongful act, and assault is a violent attack.
Which assignment should not be performed by the licensed practical nurse?
A. Inserting a Foley catheter
B. Discontinuing a nasogastric tube
C. Obtaining a sputum specimen
D. Starting a blood transfusion
D. Starting a blood transfusion
The licensed practical nurse should not be assigned to begin a blood transfusion. They can insert a Foley catheter, discontinue a nasogastric tube, and collect a sputum specimen.
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?
A. Continuing to monitor the vital signs.
B. Contacting the physician
C. Asking the client how he feels
D. Asking the LPN to continue the post-op care
B. Contacting the physician
The vital signs are abnormal and should be reported immediately. Continuing to monitor can lead to deterioration, asking how the client feels provides subjective data, and assigning to an LPN is inappropriate.
Which nurse should be assigned to care for the postpartum client with preeclampsia?
A. The RN with 2 weeks of experience in postpartum
B. The RN with 3 years of experience in labor and delivery
C. The RN with 10 years of experience in surgery
D. The RN with 1 year of experience in the neonatal intensive care unit
B. The RN with 3 years of experience in labor and delivery
The nurse with experience in labor and delivery knows the most about possible complications involving preeclampsia. The other nurses lack sufficient experience with postpartum clients.
Which information should be reported to the state Board of Nursing?
A. The facility fails to provide literature in both Spanish and English
B. The narcotic count has been incorrect on the unit for the past 3 days
C. The client fails to receive an itemized account of his bills and services received during his hospital stay
D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath
B. The narcotic count has been incorrect on the unit for the past 3 days
Incorrect narcotic counts should be reported to the Board of Nursing. The Joint Commission on Accreditation of Hospitals may be interested in issues A and C, while the failure to care for a client may result in termination but not Board reporting.
The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
A. Call the Board of Nursing.
B. File a formal reprimand.
C. Terminate the nurse.
D. Charge the nurse with a tort
B. File a formal reprimand
Documenting the incident by filing a formal reprimand is the next action after discussing the problem. Termination and Board reporting are subsequent steps if behavior continues or harm results.
The home health nurse is planning for the day’s visits. Which client should be seen first?
A. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube.
B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension.
C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line.
D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter.
D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter.
The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The others are more stable.
The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
A. A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis
B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury
D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. The other groupings involve clients who need more specialized or isolated care.
The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eye drops, the nurse should recognize that it is essential to consider which of the following?
A. The eye should be cleansed with warm water, removing any exudate, before instilling the eye drops
B. The child should be allowed to instill his own eye drops
C. The mother should be allowed to instill the eye drops
D. If the eye is clear from any redness or edema, the eye drops should be held
A. The eye should be cleansed with warm water, removing any exudate, before instilling the eye drops
Before instilling eye drops, the nurse should cleanse the area with water. A 6-year-old is not developmentally ready to instill his own eye drops, and although the mother can instill the eye drops, the area must be cleansed first.
The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction?
A. “It is okay to give my child white grape juice for breakfast”
B. “My child can have a grilled cheese sandwich for lunch”
C. “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch”
D. “For a snack, my child can have ice cream”
C. “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch”
Hot dogs pose a risk of aspiration for a child due to their size and shape. The other food choices do not pose such a risk.
A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?
A. Ask the parent/guardian to leave the room when assessments are being performed.
B. Ask the parent/guardian to take the child’s favorite blanket home because anything from the outside should not be brought into the hospital.
C. Ask the parent/guardian to room-in with the child.
D. If the child is screaming, tell him this is inappropriate behavior.
C. Ask the parent/guardian to room-in with the child.
Rooming-in promotes parent-child attachment and provides comfort to the child. Items familiar to the child should be allowed in the hospital to provide comfort.
Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?
A. Remove the mold and clean every week.
B. Store the hearing aid in a warm place.
C. Clean the lint from the hearing aid with a toothpick.
D. Change the batteries weekly.
B. Store the hearing aid in a warm place.
The hearing aid should be stored in a warm, dry place. It should be cleaned daily, and a toothpick should not be used as it might break off in the hearing aid. Battery replacement frequency depends on usage and type.
A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
A. Body image disturbance.
B. Impaired verbal communication.
C. Risk for aspiration.
D. Pain.
C. Risk for aspiration.
Risk for aspiration is the highest priority due to the potential for airway obstruction from bleeding or swelling after a tonsillectomy.
