Fundamentals Flashcards
The nurse notes blanching, coolness, and edema at the peripheral insertion (IV) site. On the basis of these findings, the nurse would implement which action first?
1. Remove the IV
2. Apply a warm compress
3. Check for a blood return
4. Measure the area of infiltration
Answer: 1
As infiltration can be damaging to the surrounding tissue, the appropriate first action is to remove the IV to oprevent further damage. Once the IV is removed, further action would be taken, depending on the medication infusing @ the time of infiltration and based on agency protocol. This may include aspiration of fluid from the site, injection of an antidote, application of warm or cool compresses for specified time intervals, or elevation of the extremity.
The nurse has received the client assignment for the day. Which client would the nurse assess first?
1. The client who has a nasogastric tube attached to intermittent suction
2. The client who needs to receive subQ insulin before breakfast
3. The client who is 2 days postoperative and is complaining of incisional pain
4. The client who has a blood glucose level of 50 mg/dL (2.8 mmol/L) and complains of blurred vision
Answer: 4
This pt has a low blood glucose level and symptoms reflective of hypoglycemia. This pt should be assessed first so that treatment can be implemented. Once this pt is sbalized the assessments of the other pts can be done.
The nurse prepares to care for a pt on contact precautions who has a hospital-acquired infection caused by MRSA. The pt has an abdominal wound the requires irrigation and has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning. The nurse would assemble which necessary protective items before entering the pt’s room?
1. Gloves and gown
2. Gloves and face shield
3. Gloves, gown, and face shield
4. Gloves, gown, and shoe protectors
Answer: 3
Because of the potential for splashes of infective material occurring during the ewound irrigation or suctioning of the tracheosomy
A pt w/ end-stand chronic COPD has selected guided imagery to help cope w/ psychological stress. Which pt statement indicates the best understanding of this stress-reducation measure?
1. “This will help only if I play music @ the same time.”
2. “This will work for me if I am alone in a quiet area.”
3. “I need to do this when I lie down in case i fall asleep.”
4. “The best thing about this is that I can use it anywhere, anytime.”
Answer: 4
Guided imagery involves the pt creating an image in the mind, concentrating on the image, and gradually becoming less aware of the offending stimulus. It can be done anytime and anywhere; some pts may use other relaxation techniques or play music w/ it.
A pt w/ Parkinson’s disease develops akinesia while ambulating, increasing the risk for falls. Which suggestion would the nurse provide to the pt to alleviate this problem?
1. Use a wheelchair to move around
2. Stand erect and use a cane to ambulate
3. Keep the feet close together while ambulating and use a walker
4. Consciously think about walking over imaginary lines on the floor
Answer: 4
Pts w/ Parkinson’s disease can develop bradkinesia (slow movement) or akinesia (freezing or no movement). Having these pts imagine lines on teh floor to walk over can keep them moving forward while remaining safe.
The nurse monitors a pt receiving a digoxin for which early manifestation of digoxin toxicity?
1. Anorexia
2. Facial pain
3. Photophobia
4. Yellow color preception
Answer: 1
Digoxin is a cardiac glycoside that is used to manage and treat heart feailure in some pts and to control ventricular rates in some pts w/ A-fib. Teh most common early manifestations of toxicity include GI disturbances (anorexia, N/V); neurological abnormalities (fatigue, headache, weakness, depression, drowsiness, confusion, and nightmares. Other signs include facial pain, personality changes, and ocular disturbances (photophobia, diplopia, light flashes, halos around bright objects, yellow or green color perception), are later signs of toxicity.
A MRI study is prescribed for a pt w/ a suspected brain tumor. The nurse would implement which action to prepare the pt for this test?
1. Shave the groin for insertion of a femoral catheter
2. Remove all metal-containing objects from the pt
3. Keep the pt NPO for 6 hrs before the test
4. Instruct the pt in inhalation techniques for administration of a radioisotope.
Answer: 2
In a MRI study, radiofrquency pulses in a magnetic field are converted into pictures. All metal objects (rings, bracelets, hairpins, and watches) should be removed. In addition, a hx should be taken to ascertain whether the pt has any internal metallic devices (orthopedic hardware, pacemakers, or shrapnel). An IV cathter may be inserted if a contrast agent is prescribed. A femoral catheter is not used for this diagnostic test. Shaving is not a common practice d/t risk for microabrasions and infection. If needed, hair may be clipped away from an insertion site. NPO status is not necessary for an MRI study of the head. Inhalation of a radioisotope may be prescribed w/ other types of scans, but it i is not part of the procedures for a MRI.
A pt w/ renial insufficiency has a magnesium level of 3.5 mEq/L (1.44 mol/L). On the basis of this lab result, the nurse interprets which sign as significant?
1. Hyperpnea
2. Drowsiness
3. Hypertension
4. Physical hyperactivity
Answer: 2
The normal magnesium level is 1.8 to 2.6 mEq/L (0.74 to 1.07 mmol/L). A magnesium level of 3.5 mEq/L (1.44 mol/L) indicates hypermagnesemia. Neurological manifestations begin to occur when magnesium levels are elevated and are noted as symptoms neurological depression (drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia) , as well as bradycardia and hypotension.
A client is scheduled for angioplasty. The pt says to the nurse “I’m so afraid that it will hurt and will make me worse off than I am.” Which response by the nurse is therapeutic?
1. “Can you tell me what you understand about the procedure?’
2. “Your fears are a sign that you really should have this procedure.”
3. “Those are very normal fears, but please be assured that everything will be okay.”
4. “Try not to worry. This is a well-known and easy procedure for the cardiologist.”
Answer: 1
Correct option utilizes a therapeutic communication technique that explores the pt’s feelings, determine the level of pt understanding about the procedure, and displays caring. Option 2 demeans the pt and does not encourage further sharing by the pt. Option 3 does not address the pt’s fears, provides false reassurance, and puts the pt’s feelings on hold. Option 4 diminishes the pt’s feelings by directing attention away from the pt and toward the cardiologist’s importance.
The nurse is caring for a hospitalized pt w/ a diagnosis of heart failure who suddenly complains of SOB and dyspnea during activity. After assisting the pt to bed and placing the pt in high-Fowler’s position, the nurse would take which immediate action?
1. Administer high-flow O2 to the pt
2. Call the consulting cardiologist to report the findings
3. Prepare to administer an additional dose of furosemide
4. Obtain a set of vital signs and perform focused respiratory and cardiovascular assessments
Answer: 4
The pt’s SOB and dyspnea may be d/t the development of pulmonary edema (complication of heart failure) or it could be heart failure exacerbation which may be expected partidcularly on exertion or during activity. Use the nursing process and note that the vital signs and assessment data would be needed before administering O2, administering medications, or contacting the cardiologist. Although the cardiologist may need to be notified, this is not the immediate action. B/c there is no data in the question that indicate the presence of pulmonary edema, Option 4 is correct.
The nurse is caring for a pt w/ terminal cancer. The nurse would consider which factor when planning pain relief?
1. Not all pain is real
2. Opioid analgesics are highly addictive
3. Opioid analgesics can cause tachycardia
4. Around-the-clock dosing gives better pain relief than as-needed dosing
Answer: 4
Around-the-clock dosing provides ↑ pain relief and ↓ stressors associated w/ pain (anxiety, fear). Pain is what the pt describes it as, and any indication of pain should be perceived as real for the pt. Opioid analgesics may be addictive, but this is not a concern for the pt w/ terminal cancer. Not all opioid analgesics cause tachycardia.
The nurse is caring for a pt who just returned from the recovery room after undergoing abdominal surgery. The nurse would monitor for which early sign of hypovolemic shock?
1. Sleepiness
2. Increased pulse rate
3. Increased depth of respiration
4. Increased orientation to surroundings
Answer: 2
Think about the pathophysiology that occurs in hypovolemic shock to direct you to the correct option. Restlessness is one of the earilest signs, followed by cardiovascular changes (↑ HR and ↓ BP). Sleepiness is expected in a pt who has just returned from surgery. Alhtough increased depth of respirations occurs in hypovolemic shock, it is not an early sign. Rather, it occurs as the shock progresses– it is important to discern beteween early and late signs of impending shock. Increased orientation to surroundings is expected and will occur as the effects of anesthesia resolve.
The nurse is teaching a pt in skeletal leg traction about measures to increase bed mobility. Which item would be the most helpful for this pt?
1. Television
2. Fracture bed pan
3. Overhead trapeze
4. Reading materials
Answer: 3
The use of an overhead trapeze is extremely helpful in assisting a pt to move about in bed and to get on and off the bedpan
The nurse provides medication instructions to a pt about digoxin. Which statement by the pt indicates understanding of its adverse effects?
1. “Blurred vision is expected.”
2. “If my pulse rate drops below 60 beats per minute, I should let my cardiologist know.”
3. “If I am nauseated or vomiting, I should stay on liquids and take some liquid antacids.”
4. “This medication may cause headache and weakness, but that is nothing to worry about.”
Answer: 2
Digoxin is a cardiac glycoside and works by ↑ contractility of the heart. THis medication has a narrow therapeutic range, and toxicity is a major concern. Currentl, it is considered 2nd-line treatment for heart failure b/c of its narrow therapeutic range and potential for adverse effects. Adverse effects that indicate toxicity include GI disturbances, neurological abnormalities, bradycardia, or other cardiac irregularities, and ocular disturbances. If any of these occurs, the cardiologist is notified. Additionally, the pt needs to notify the cardiologist if the pulse rate drops below 60 bpm, b/c serious dysrhythmias are another potential adverse effect of digoxin therapy.
The nurse has provided discharge instructions to a pt who has undergone a right mastectomy w/ axillary lymph node dissection. Which statement by the pt indicates a need for further teaching regarding home care measures?
1. “I should use a straight razor to shave under my arms.”
2. “I should inform all of my other doctors that I have had this surgical procedure.”
3. “I need to be sure that I do not have blood pressures or blood drawn from my right arm.”
4. “I need to be sure to wear thick mitt hand covers or use thick pot holders when I am cooking and touching hot pans.”
Answer: 1
Recall that edema and infection are concerns w/ this pt d/t the removal of lymph nodes in the surgical area. Lymphadenopathy w/ associated lymphedema can result, and the pt needs to be instructed in the measures that will avoid trauma to the affected arm. Recalling that trauma to the affect arm could potentially result in edema and/or infection will direct you to the correct option.
