QB 11

Question 1

a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints.

Answer 1

Contracture

Question 2

a band of scar tissue that forms between organs after a surgical procedure

Answer 2

adhesions

If the abdominal cavity is accessed for a surgical procedure, healing of the tissues can be complicated. At times, the body may overheal, which can result in an alteration in organ and tissue function. Organs and tissues may heal together or be drawn together with the formation of scar tissue, called adhesions. Adhesions shorten and tighten, pulling the structures that are connected by this scar tissue.

Abdominal adhesions are bands of fibrous tissue that can form between abdominal tissues and organs, thus eliminating the normal slippery surface between tissues and organs, which promotes smooth movement of functioning organs. While some clients experience chronic abdominal pain, in most cases, clients with abdominal adhesions are asymptomatic.

Surgery-related causes of abdominal adhesions include blood or blood clots that were not rinsed away during surgery, contact of internal tissues with foreign materials (e.g., gauze, surgical gloves, stitches), cuts involving internal organs, drying out of internal organs, and handling of internal organs. Complications of abdominal adhesions include intestinal obstruction and female infertility.

Question 3

Urinary catheterization and preventing UTIs

Answer 3

Nurse should do routine assessment of urine color, amount, and consistency. Urine should be clear, and amber or yellow in color. The minimum amount of urine produced should be 30 mL/hr or 720 mL/day. If the urine becomes cloudy, dark, bloody, or foul-smelling, the nurse needs to alert the health care provider of a possible UTI.

Urine output provides information about kidney function. The kidneys’ ability to make and concentrate urine is a reflection of fluid overload/fluid deficit in the body. Urine can be obtained by voiding or catheterization. When obtaining urine through catheterization, the client is at an increased risk for a urinary tract infection (UTI). Because of this, the nurse needs to implement interventions to prevent UTIs

Question 4

What to remember about Gout

Answer 4

To prevent gout attacks, educate the client about changes in diet to decrease foods high in purine (organ meats, meat soups, gravy, anchovies, sardines, fish, seafood, asparagus, spinach, peas, dried legumes, and wild game) and the need to increase fluid intake.

A high carbohydrate diet increases uric acid excretion.

Gout is characterized by the overproduction or underexcretion of uric acid. High purine foods increase the incidence of gout.

Question 5

A prolonged state of unconsciousness during which a client is unresponsive to the environment and cannot be awakened by any stimulation, including pain.

Answer 5

COMA

Clients in a coma cannot be aroused, and the eyes do not open in response to any stimulation. Client exhibits absent pupillary response to light, no responses of limbs (except for reflex movements), no response to painful stimuli (except for reflex movements), and irregular breathing

Appropriate actions when providing care to this client include: assessing the client using the Glasgow Coma Scale; maintaining a patent airway; providing frequent position changes to maintain skin integrity; performing passive range of motion exercises; maintaining integrity of a urinary catheter; assessing for hydration and maintaining fluid balance; managing nutritional needs; and providing sensory stimulation (e.g., talking to the client between procedures), as well as educating the family about the needs of client and the care provided

Nurses are required to introduce themselves to every client, even those who may be comatose, during the initial contact at the beginning of a shift. Many health care institutions now require staff members to write their names and titles on a board in the client’s room. In addition to introductions, the nurse should also review the daily plan of care with the client or family, as applicable.

Question 6

Even though the client is comatose, the nurse should orient the client to place and time at least every 8 hours.

TRUE OR FALSE

Answer 6

TRUE

Question 7

The nurse needs to be aware the _______________-undergo major function changes with aging, which occur because of fluctuating hormone levels that control electrolyte and fluid balance. The most notable change is with the sodium level that can be corrected by monitoring fluid intake.

Answer 7

kidneys

An increase in antidiuretic hormone and atrial natriuretic peptide, and a decrease in renin and aldosterone, lead to decreased sodium reabsorption and increased water retention by the kidneys, which can cause low sodium or hyponatremia.

Question 8

The nurse prepares to perform a breast examination on a 20-year-old female client. Which question is most important for the nurse to ask before beginning the examination?

1. “When was your last menstrual period?”
2. “Do you have a family history of breast cancer?”
3. “How much caffeine do you consume a day?”
4. “Have you ever had a mammography?”

Answer 8

the nurse should recognize the importance of determining when the client last had a menstrual cycle. If the breasts are assessed immediately before or during menses, the client may exhibit swelling and tenderness and experience unnecessary discomfort during the examination.

Breast examination is ideally done about 1 week after the onset of menses, when hormonal influences on the breasts are at a low level.

Question 9

Tumors in the colon - things to remember

Answer 9

Tumors in the colon are typically slow growing, and a client may not experience symptoms until the tumor is advanced. Tumors in the ascending or right colon grow along the bowel wall, whereas tumors in the descending or left colon grow around the circumference of the colon, which can lead to obstruction. Clinical manifestations vary depending on the location of the tumor. Tumors in the ascending or right colon are characterized by abdominal pain, night sweats, anemia, and fever, whereas

tumors in the descending or left colon cause changes in bowel pattern (constipation and/or diarrhea), blood in stool, abdominal pain and/or distention, and vomiting.

A tumor in the descending colon will cause changes in the shape and size of stools caused by the efforts of solid waste material to get past the obstructing tumor. The client may also experience bouts of constipation and diarrhea. This is the body’s attempt to rid itself of solid waste material in the colon. Rectal bleeding is often the first symptom of a tumor in the colon and can indicate that the tumor has permeated several layers of the colon wall.

Question 10

Low urinary output is expected in the first 24 hours after surgery, but it is expected to increase by the second or third day.

TRUE OR FALSE

Answer 10

TRUE

Question 11

Nursing principles for the client with dementia

Answer 11

Assume a face-to-face position when speaking to the client.

By speaking face-to-face, the nurse maximizes verbal and nonverbal cues. The nurse should use short, simple words and phrases, and speak slowly to give the client time to process information.

With dementia, the client may demonstrate memory and cognitive impairment with or without associated behavioral problems. The nurse should determine the client’s ability to perform activities of daily living and assess the client’s social and physical support, work history, cognitive ability, memory, communication, and behavior changes.

The nurse should provide frequent verbal, written, and visual orientation.

The nurse should also use simple language when communicating with the client, make eye contact, and reduce environmental stimulation.

Question 12

TB risk factors

Answer 12

Tuberculosis (TB) risk factors include: clients who live with someone with active TB, immunocompromised clients (especially those who are HIV positive), clients who have traveled to places with high rates of TB, and those residing or working in hospitals, prisons, skilled nursing facilities, and homeless shelters. Age at time of exposure, the very young and the elderly, increases risk of infection.

Question 13

The nurse knows that anyone in close contact with an individual infected with tuberculosis (or suspected to be infected) requires testing and follow up to ensure that the disease does not spread. If tuberculosis has spread to other individuals, monitoring and prompt treatment can be initiated. Children who have latent tuberculosis are treated for ________________ months to prevent the disease from developing.

true or false

Answer 13

true

9

Question 14

What to remember about burns and skin grafting

Answer 14

Adherence of the graft takes between 7 to 10 days and unnecessary movement can adversely effect this process. Rejection does not occur immediately, but will become a priority after the dressing is removed in 3 to 5 days.

Graft adherence to the site is essential for vascularization and “taking” or survival of the graft. Immobilization of the graft and the limb is a priority. A thin fibrin network develops quickly after graft placement, but it takes 7 to 10 days for the graft to really adhere and longer than that to mature.

Question 15

A client returns to the unit after placement of a split-thickness autograft to a burn on the right arm. Which intervention does the nurse give the highest immediate priority?

1. Managing pain at the recipient site.
2. Immobilizing the graft.
3. Minimizing light exposure.
4. Observing for signs of rejection.

Answer 15

1) INCORRECT— Managing pain is an issue, but not the highest initial priority. The donor site is usually more painful than recipient site because of exposed nerve endings. An autograft means a layer of the client’s own unburned skin is removed and grafted to the burn wound.
2) CORRECT — Graft adherence to the site is essential for vascularization and “taking” or survival of the graft. Immobilization of the graft and the limb is a priority. A thin fibrin network develops quickly after graft placement, but it takes 7 to 10 days for the graft to really adhere and longer than that to mature.
3) INCORRECT— There is no need for minimizing light exposure at this time. A client needs to be taught that, once donor and recipient sites have healed, direct sunlight must be completely avoided for 1 year because of the skin’s increased sensitivity to ultraviolet rays.
4) INCORRECT— Rejection is not an immediate concern. Once the pressure dressings are removed in 3 to 5 days, continual assessing of the graft for healing should be done related to vascularization, such as continued adherence to the site, absence of necrotic graft tissue, dusky color, or a sharp line of color demarcation.

Question 16

This law stipulates that client private health information is only to be shared by those who have a need to know in order to provide quality care.

Answer 16

HIPPA

Health Insurance Portability and Accountability Act

Confidentiality refers to protecting and safeguarding a client’s personal, identifiable health information, and data. Never assume the right to look at any type of client health information unless it is needed it in order to do the job. Have an awareness that conversations about private client information may be overheard in public areas of the health care facility. Unless officially authorized to do so by the client, nurses do not discuss or share the client’s personal information, including health care data, with family, friends, co-workers, other members of the health care team, insurance providers, or financial aid organizations. The nurse should hold self and colleagues accountable when it comes to respecting client confidentiality and privacy.

Question 17

A normal WBC for an adult is 5000–10,000/mm 3 (5-10×10 9/L). The normal WBC for a child is 5,000–13,000/mm 3 (5-13×10 9/L).

TRUE OR FALSE

Answer 17

TRUE

Question 18

The normal hemoglobin for an adult male is 13–18 g/dL (130–180 g/L). The normal hemoglobin for an adult female is 12–16 g/dL (120–160 g/L). The normal hemoglobin for a child (3–12 years) is 11–12.5 g/dL (110–12.5 g/L).

TRUE OR FALSE

Answer 18

TRUE

Question 19

BUBBLE-EE

postpartum assessment

Answer 19

breasts, uterus, bowel, bladder, lochia, episiotomy/perineum, extremities, and emotions

Question 20

What is Magaldrate ?

Answer 20

Magaldrate is a common antacid drug that is used for the treatment of duodenal and gastric ulcers, esophagitis from gastroesophageal reflux

Magaldrate, an antacid, can cause hypermagnesemia

Question 21

The nurse provides care for a client diagnosed with hyperthyroidism. Which intervention does the nurse include in the plan of care for this client?

1. Extra blankets.
2. Small, frequent meals.
3. Quiet environment.
4. High-fiber diet.

Answer 21

1) INCORRECT - These clients have heat intolerance and need a cool environment, not extra blankets.
2) INCORRECT - Six full meals each day that are high in calories are needed because of the hypermetabolic state.

3) CORRECT — This client is in a hypermetabolic state, so a physically and mentally restful environment is helpful.

4) INCORRECT - These foods should be avoided because they cause increased peristalsis.

Hyperthyroidism causes a hypermetabolic state. The nurse understands the body functions are increased and commonly include such manifestations as an elevated body temperature, rapid heart rate, restlessness, and weight loss. Until treatment becomes effective, actions to counterbalance the internal stimulation are initiated. In this scenario, the nurse will provide a calm quiet environment.

In a client with hyperthyroidism, there is an excess secretion of the thyroid hormones (thyroxine [T4] and triiodothyronine [T3]), resulting in an accelerated metabolism. Signs and symptoms of hyperthyroidism include restlessness, tremors, loss of weight despite an increase in appetite, intolerance to heat, tachycardia, hypertension, flushed skin, fever and insomnia. Swelling in the neck (goiter) and exophthalmos (bulging of eyes) may also be present. Provide client education regarding proper use of antithyroid medications. Monitor vital signs and administer beta-blocker, if needed. Promote periods of rest and provide psychological support. Weigh client daily and consult a dietitian to ensure appropriate caloric intake.

Question 22

Postoperative respiratory care includes the use of an incentive spirometer. This device ensures adequate lung inflation which can be painful after surgery.

TRUE OR FALSE

Answer 22

TRUE

Question 23

CAD risk factors

Answer 23

Coronary artery disease (CAD) risk factors include increased low-density lipoprotein (LDL) cholesterol, decreased high-density lipoprotein (HDL) cholesterol, elevated triglycerides, hypertension, smoking, diabetes mellitus, sedentary lifestyle, obesity, metabolic syndrome, increased serum homocysteine level, family history of CAD. Diets high in sodium, fat, and trans-fat increase the risk for CAD. Postmenopausal women and men older than 45 years of age are at increased risk for CAD.

If the coronary arteries are involved, the client may present with chest pain, shortness of breath, and arrhythmias.

If the carotid arteries are involved, the client may present with symptoms of a stroke (i.e. sudden weakness, dizziness or loss of coordination, difficulty talking, facial droop, sudden vision problems, and sudden severe headaches).

Question 24

The nurse provides care for a client 2 hours after placement of a cuffed tracheostomy tube. When the nurse enters the client’s room, the tracheostomy tube is displaced out of the stoma. Which action does the nurse take first?

1. Place oxygen at 6 L per minute over the stoma opening.
2. Auscultate bilateral breath sounds.
3. Check the client’s pulse oxygenation reading.
4. Use a hemostat to dilate the opening of the stoma.

View Explanation

Answer 24

1) INCORRECT - Unless the airway is opened, the client will not be able to access the oxygen. With a newly placed tracheostomy, the stoma will not stay open. The nurse should first dilate the opening of the stoma, and then place oxygen.
2) INCORRECT - This assessment is not relevant at this time, as the client cannot breathe with a closed stoma.
3) INCORRECT - This assessment is not relevant at this time, as the issue is that the client does not have a patent airway. The nurse should first establish an airway.
4) CORRECT— The client’s issue is the loss of an airway. The first action is to open the airway. A newly placed tracheostomy will not stay open without the tube. Some stoma swelling is expected due to the recent surgical procedure as well. The nurse should utilize hemostats to open the airway.

The nurse needs to ensure that the client has an adequate airway. This is especially true for clients who have artificial airways, necessitating the need for certain items to be at the bedside at all times. For the client with a dislodged tracheostomy tube, a hemostat is inserted into the stoma and gently opened to create an opening for adequate ventilation. Because the tracheostomy is so new, there is an increased risk that the opening will close or collapse. It is for this very reason that a hemostat should be at the bedside of every client with a tracheostomy.

Content Refresher

When ventilatory effort is diminished (loss of airway), adequate oxygen is not taken into the lungs and limits the amount that is available for gas exchange at the alveolar level. If the airway is reduced, an inadequate amount of oxygen is taken in and available for alveolar gas exchange. These factors create the condition for hypoxemia and resulting hypoxia.

When caring for a client who is unable to maintain a patent airway, the nurse must take measures to establish a patent airway and to maintain or improve ventilation and oxygenation.

Question 25

Initially, increased blood pressure may be the only overt sign of hypertension. With severe hypertension, secondary symptoms occur in response to increased cardiac workload, damage to blood vessels, or injury to specific organs. Such secondary symptoms may include dyspnea, dizziness, fatigue, and angina.

TRUE OR FALSE

Answer 25

TRUE

Question 26

A bulging fontanel may indicate an increase in intracranial pressure, whereas a depressed fontanelle may indicate that the infant is ______________. Fontanels may bulge normally when the child is crying loudly, but should be _________ when the child is resting.

Answer 26

dehydrated; flat

The anterior and posterior fontanels on a newborn should feel soft and appear flat. Bulging of these areas when the child is at rest could indicate additional fluid in the cerebral tissue and increased intracranial pressure (ICP)

Question 27

The nurse understands that secondary malignancy is a potential risk, depending on the type of chemotherapy and radiation the client received

Answer 27

Alkylating chemotherapy and high-dose radiation are likely to cause secondary malignancies as late effects of treatment.

Late effects of chemotherapy and radiation occur months to years after therapy is completed and can potentially affect every body system. Late radiation therapy effects may affect the client’s liver, kidneys, lungs, heart, muscles, bones, and connective tissues.

Long-term effects of chemotherapy include cardiac toxicity, cataracts, arthralgias, endocrine alterations, renal insufficiency, hepatitis, osteoporosis, and neurocognitive dysfunction.

The client may also be at risk for secondary malignancies, including leukemia, angiosarcoma, and skin cancer. However, the potential risk of developing a secondary malignancy is not a contraindication for treating active cancer.

Question 28

Auscultation of fetal heart tones can occur at 8 to 12 weeks of pregnancy with the use of a Doppler ultrasound stethoscope.

TRUE OR FALSE

Answer 28

TRUE

One way to validate pregnancy is through a urine pregnancy test; however, a more definitive way is to palpate the abdomen, identify uterine structures, and assess for fetal heart sounds. The presence of the fetal heart beat is a positive confirmation once the fetus reaches 2 to 3 months of gestation.

Fetal development is characterized by physiological growth and development that takes place over approximately 40 weeks. The first 8 weeks of development is called the embryonic stage. By the end of this stage, all essential external and internal structures have been formed. Prenatal development is most dramatic during the remaining 32 weeks, the fetal stage. Organ systems continue to develop and grow. The heart is beating and the lungs have developed sufficiently that breathing is possible. During this stage, the fetus becomes more active, and the mother begins to feel fetal movements. Towards the end of this stage, organ systems have matured and the fetus is ready to live outside the womb.

Question 29

TRUE OR FALSE

We should seek to elevate a client’s heels off the bed in order to prevent pressure ulcers

Answer 29

TRUE

The National Pressure Ulcer Advisory Panel recommends that the nurse ensure that the client ’s heels are free from the bed. Additionally, the staff should use heel offloading devices or polyurethane foam dressings on individuals at high-risk for heel ulcers. The nurse should inspect all of the skin upon admission as soon as possible (but within 8 hours). Heel pressure injury can develop over a short period. When a client suffers from neuropathy (e.g., reduce leg sensation), the client may not feel pain on the injured heels.

Question 30

What to remember about developmental dysplasia of the hip

Answer 30

characterized by a hip socket that does not fully cover the ball portion of the upper thighbone, thus permitting the hip joint to become completely or partially dislocated

Especially when assessing an infant client, asymmetrical findings are a cause for concern. Vertebrae should be in straight alignment, the arms should demonstrate equal length and range of motion, and the legs should be equal in length. Gluteal and thigh folds should be symmetrical, as well. Asymmetry of gluteal and thigh folds is a sign of hip dysplasia, which may be unilateral or bilateral. For the client diagnosed with unilateral hip dysplasia, assessment findings may include a hip click in addition to unequal limb length and unequal knee height.

Question 31

Use of IV fluid boluses, also referred to as fluid challenge or fluid resuscitation, is a lifesaving intervention intended to restore circulating volume, improve cardiac output, and perfuse vital organs. The nurse assesses the client’s _________________________. This information will help the nurse evaluate effectiveness and adverse effects related to IV fluid boluses. Boluses are best delivered using a__________________- needle and infusing the solution using an IV pump

Answer 31

large-bore; vital signs, urine output, heart and lung sounds, and mental status

Question 32

The nurse prepares to administer medication via IV push into an established IV line. Which action does the nurse take?

1. Select the port farthest from the insertion site.
2. Ensure that the tubing above the injection port is patent.
3. Time the medication administration with a watch.
4. Explain the procedure to the client after completion.

View Explanation

Answer 32

1) INCORRECT – The port selected should be the one closest to the IV insertion site for three reasons. Less dilution of the medication will occur, the medication will move into the vascular system more readily, and it is easier to assess if catheter placement is correct by blood return.
2) INCORRECT – Tubing above the port should be occluded by pinching the tubing gently, stopping the IV solution flow while the medication is pushed.
3) CORRECT – Using a watch to time the administration ensures safe drug infusion. Ideally, the watch should have a second hand or digital readout. Many medications that are ordered as IV push or bolus need to be given slowly over several minutes.
4) INCORRECT – Client teaching should be done prior to administration regarding purpose of the medication and side effects to report.

Question 33

Safety principles of IV push medication administration

Answer 33

Injection of medication into the port that is farthest from the IV insertion site may delay delivery of the medication to the client. The port selected should be the one closest to the IV insertion site for three reasons. Less dilution of the medication will occur, the medication will move into the vascular system more readily, and it is easier to assess if catheter placement is correct by blood return.

When injecting a medication bolus into an IV tubing injection port, the IV tubing proximal to (above) the injection port should be occluded to prevent backward flow of the medication into the IV tubing and primary IV solution. Medication administration should be carefully timed to ensure client safety.

Potential adverse effects vary depending on the medication and may include hearing loss, speed shock, (A sudden and severe physiological reaction to medications administered into the bloodstream too quickly. Symptoms include chest tightness, irregular pulse, loss of consciousness, and cardiac arrest) hypotension, itching, and skin flushing.

Question 34

The nurse prepares to administer the Haemophilus influenzae type b (Hib) vaccine to a 4-month-old infant. The nurse teaches the infant’s parent about the vaccine. Which information does the nurse include in the teaching?

1. “Monitor your child for signs of allergic reaction for a few hours after the vaccine.”
2. “Your child will receive 1 or 2 doses of the vaccine, depending on the vaccine used.”
3. “Immediately notify the health care provider of a low-grade fever.”
4. “This vaccine cannot be given at the same time as other vaccines.”

Answer 34

1) CORRECT -Signs of allergic reaction to the Hib vaccine include hives, facial and airway edema, difficulty breathing, tachycardia, dizziness, and weakness. These typically begin a few minutes to a few hours after the child receives the vaccine.
2) INCORRECT - Several brands of Hib vaccines are available. Depending on the brand used, the child will require 3 or 4 doses of vaccine.
3) INCORRECT - Mild adverse effects, such as low-grade fever and redness and warmth or swelling at the injection site, may occur. They are usually mild and go away on their own. Therefore, it is not necessary to notify the health care provider.
4) INCORRECT - Hib may be given at the same time as other vaccines. In fact it may be given as part of a combination vaccine.

Haemophilus influenzaetype b (Hib) disease is a common cause of meningitis in children. The Hib vaccine series provides passive immunity to protect children under 5 years of age from contracting Hib disease. As with any vaccine, side effects such as redness and tenderness at the injection site and/or a slight may occur. Rarely, serious adverse reactions such as hives, facial and laryngeal edema, high fever, tachycardia, and tachypnea may occur. The parent/caregiver should be informed of what to do in case of severe reaction to a vaccine.

Question 35

The nurse provides care for a client in labor. The nurse assesses a fetal heart rate of 59 beats per minute. Which action does the nurse take?

1. Turn the client in a right lateral position, start an IV, and call the health care provider.
2. Turn the client in a left lateral position, administer oxygen, and increase the intravenous flow rate.
3. Call the health care provider and move the client to the operating room for a cesarean section.
4. Place the client in Trendelenburg position, administer oxygen, and administer IV fluids.

View Explanation

Answer 35

1) INCORRECT - Placing the client on the right side will not completely relieve pressure on the vena cava.
2) CORRECT — Placing the client on the left side reduces compression of the vena cava and aorta, improving blood return and perfusion. Increasing IV fluid increases available volume for perfusion. Administering additional oxygen to the client provides better oxygenation to the fetus.
3) INCORRECT - Persistent fetal bradycardia may indicate cord compression or separation of the placenta, but it always indicates fetal distress. The client may require surgery, but preparation for this is done after positioning the client to provide immediate relief to the fetus.
4) INCORRECT - Trendelenburg position is used only if the umbilical cord is prolapsed.

The fetus should have a heart rate that ranges from 110 to 160 beats per minute throughout the labor process. Temporary, non-recurring decelerations of 80 to 100 beats per minute might be acceptable. When the fetal heart rate drops to less than 80 beats per minute, immediate intervention is always necessary, regardless of how long it lasts or whether it fluctuates back upward. Turning the laboring mother on the left side produces immediate cardiac output benefits to the fetus. Any intervention that increases the mother’s cardiac output is beneficial to the fetus.

Content Refresher

Fetal monitoring can be external or internal . This procedure is performed to evaluate fetal heart rate (FHR) and variability between beats, especially in relation to the uterine contractions of labor. With laboring clients, the FHR and the duration and interval of uterine contractions are recorded to continuously evaluate the baseline heart rate and changes in rate and pattern, which is reflective of fetal oxygenation. Steps can be taken to help oxygenate the fetus, such as having the mother change position or applying an oxygen mask to the mother. If these procedures are ineffective, or if further monitoring suggests that the fetus is at risk, an emergency cesarean section may be recommended.

Question 36

Best position to facilitate breathing

Answer 36

Fowlers Position

The nurse is aware that the position that best facilitates breathing is one in which the diaphragm moves freely and restriction of lung expansion is minimized.

When ventilatory effort is diminished (due to pain or weakness), adequate oxygen is not taken into the lungs. If the size of the airway is reduced, an inadequate amount of oxygen is taken in and available for alveolar gas exchange. These factors create the condition for hypoxemia and resulting hypoxia. Therefore, the nurse should assist in maintaining a patent airway and improving ventilation and oxygenation. To do this, the nurse needs to elevate the head of bed or place the client in an upright position to facilitate breathing and promote lung expansion. In addition, supplemental oxygen is administered at prescribed rate and method. Monitor the client’s breathing pattern and observe for signs of respiratory distress. Teach appropriate breathing techniques, such as use of the incentive spirometer and controlled coughing.

Question 37

When caring for a client at risk for fluid volume overload, assess the client’s

Answer 37

intake and output, lab values for hemoglobin, hematocrit, electrolyte levels, urine specific gravity, vital signs, lung sounds, and changes in the client’s weight.

Fluid volume overload is a potential complication of IV fluid infusion; signs include weight gain, increased abdominal girth, neck vein distention, elevated blood pressure, rapid respirations, and edema.

Symptoms include confusion, weakness, fatigue, and difficulty breathing. The nurse should alert the health care provider immediately as untreated fluid overload can result in heart failure.

Question 38

TRUE OR FALSE

Combination drug therapy is the most effective way to treat TB. With correct therapy, clients quickly become non-contagious. Failure to take medications correctly results in drug-resistant TB.

Answer 38

TRUE

The most effective way to reduce the spread of Mycobacterium that causes tuberculosis is to take all medication as prescribed, for as long as it is prescribed. Stopping the medication too soon can lead to drug-resistant tuberculosis, which is much more difficult to treat and cure.

Caring for the client with active tuberculosis (TB) focuses on reducing symptoms, controlling the spread of infection, and medication management. The initial treatment is aggressive, using four antibiotics for at least 2 months, and often much longer. The primary medications used are isoniazid, rifampin, pyrazinamide, and ethambutol. Direct observation therapy (DOT) may be implemented to ensure medication adherence and to decrease resistance to the medications.

Question 39

B6 supplementation is necessary to prevent serious side effects and potential adverse effects of antitubercular medications.

TRUE OR FALSE

Answer 39

TRUE

B6 has many functions, but notably plays a role in synthesizing neurotransmitters necessary for nerve function.

The client with tuberculosis is likely to be taking isoniazid (INH), a mainstay in prevention and treatment of tuberculosis, used in combination with other antitubercular drugs if the disease is active. Vitamin B6 is given to prevent the peripheral neuropathy, dizziness, and ataxias that can occur with this drug.

Question 40

According to the Centers for Disease Control and Prevention (CDC), use of a chlorhexidine-impregnated sponge dressing or disc is one of the strategies the nurse should implement to reduce central line-associated infections. The disc should not be removed and should not be changed more often than once a week unless the client reports discomfort when the site is palpated or there are other signs/symptoms of infection.

TRUE OR FALSE

Answer 40

TRUE

The disc is impregnated with an anti-microbial product intended to help prevent infections at the insertion site.

The nurse is aware that a central venous catheter is inserted using a sterile procedure, and all care of this site is done using the same approach. Because the access site provides a direct line into the client’s vascular system, extra effort should be taken to reduce the risk of an infection. In this scenario, the client’s spouse is asking about part of the existing dressing. The nurse will explain that the central line wound care kit includes a gauze sponge impregnated with an anti-microbial substance to help prevent infection of the site and subsequent infection in the client’s body. This sponge is placed over the site and changed according to the manufacturer’s recommendations.

Question 41

Stroke immediate care

Answer 41

The client transported to the hospital because of a cerebrovascular accident (CVA or stroke) must be seen as soon as possible.

The nurse should assess time of onset of symptoms and description of symptoms.

Assess for facial droop, arm drift, sensory deficits, paresis, headache, visual changes, incontinence, dizziness, and changes in speech or gait. Assess baseline vital signs. Assess for nausea and vomiting. Assess past medical history for diabetes, hypertension, atrial fibrillation, or other cardiac dysrhythmias. Assess level of consciousness using Glasgow coma scale (GCS). If ischemic stroke is diagnosed, the need for thrombolytic therapy is within 3 hours of symptoms.

Question 42

A client at 16 weeks’ gestation asks the nurse what her baby looks like at this point in the pregnancy. Which is an accurate response by the nurse?

1. “Your baby has a heartbeat, and its arms and legs are just starting to form.”
2. “Your baby can hear and breathe at this point.”
3. “Your baby likes to suck his or her thumb and weighs about half a pound.”
4. “Your baby’s heart has formed, and we can tell if you are having a boy or a girl.”

Answer 42

1) INCORRECT — This response by the nurse describes fetal development at 8 weeks.
2) INCORRECT — The baby is able to hear at 38 weeks, whereas the lungs acquire definitive shape at 12 weeks.
3) INCORRECT — At 20 weeks, the fetus can suck and weighs approximately 11 ounces.
4) CORRECT — At 16 weeks, intestines begin to collect meconium, lanugo is present on the body, and the skin is transparent with visible blood vessels. In addition, the heart is formed and sex determination is possible.

Question 43

pathophysiology of a premature ventricular contraction (PVC)

Answer 43

Since the contraction is premature, the ventricle may not be adequately filled with blood before contracting and less blood moves through the vascular system, adversely affecting perfusion

Premature ventricular contractions can cause hemodynamic compromise. Blood pressure and peripheral perfusion would be assessed to anticipate and to monitor the effects of the condition.

Question 44

Principles of giving a newborn a bath the first time

Answer 44

Newborns cannot effectively regulate body temperature, so if a bath is given during the time in the hospital (and it usually is), great care is taken to keep the newborn as warm as possible before, during, and after the bath.

The waxy vernix caseosa is protective to the newborn, so the aim of the first bath is simply to remove blood from the birth process. This white, cheesy substance helps maintain heat and can provide protection to the skin against bacteria. The nurse should try to leave as much on the skin as possible.

Because the newborn’s skin is covered with host-defense proteins that help protect a newborn against bacterial infections, only plain warm water should be used for routine bathing.

If a cleanser is required, it should be mild and have a neutral pH

Alkaline soaps, oils, powder, and lotions provide a medium for bacterial growth

Skin-to-skin holding and breastfeeding (to prevent hypoglycemia) generally should occur before the newborn’s first bath.

Question 45

The nurse knows that rheumatic fever, which affects the heart, is a reaction to the microorganism that causes strep throat. The nurse needs to first assess if the client experienced strep throat or pharyngitis over the last few weeks, and if so, whether the client finished the full course of prescribed antibiotics.

TRUE OR FALSE

Answer 45

TRUE

Rheumatic fever typically begins 1–6 weeks after having pharyngitis or strep throat caused by group A beta-hemolytic streptococci.

Question 46

Treatment for breast engorgement

Answer 46

instruct the client to alternate between heat and cold packs to assist with discomfort, in addition with manual expression of milk. Instruct the client to alternate the starting breast during each feeding. Instruct the client to empty the breasts completely while breastfeeding (evidenced by the infant sucking without swallowing). Instruct the client to discuss with the health care provider about taking a mild analgesic approximately 20 minutes before breastfeeding.

. Because the client is producing milk, adequate oral fluid intake is required to ensure for a constant supply of breast milk to meet the newborn’s nutritional needs.

The client needs to wear a well-fitting bra at all times.

Increasing the frequency of feedings will help reduce the volume of engorgement

express some of the milk from the breasts.

Question 47

a collection of blood between a skull bone and its periosteum.

Answer 47

cephalhematoma

The cephalhematoma does not cross a cranial suture line. It appears several hours or the day after birth.

Question 48

Interventions for the agitated client at risk for harm to self or others

Answer 48

Immediate intervention is required for the agitated client, which is considered an acute behavioral emergency. The use of physical and chemical (medication-based) restraints have been replaced with the use of non-coercive approaches. The nurse should de-escalate the situation by verbally engaging the client and establishing a collaborative relationship. While de-escalating the situation, the nurse should avoid coercive interventions that escalate the client’s agitation; avoid the use of physical or chemical restraints, if possible; ensure safety for all (client, staff, and others in the care area); and help the client manage emotions and distress and maintain or regain control of behavior.