SATA 2

Question 1

1. A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? Select all that apply.
2. Restrict all visitors.
3. Place the child on a low-bacteria diet.
4. Change dressings using sterile technique.
5. Encourage the consumption of fresh fruits and vegetables.
6. Perform meticulous hand washing before caring for the child.
7. Allow fresh-cut flowers in the room as long as they are kept in a vase with fresh water.

Answer 1

1. Answer: 2, 3, and 5.
2. Place the child on a low-bacteria diet.
3. Change dressings using sterile technique.
4. Perform meticulous hand washing before caring for the child.

For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed with sterile technique. Not all visitors need to be restricted, but anyone who is ill should not be allowed in the child’s room. Meticulous hand washing is required before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy).

Question 2

2. A 16-year-old child is brought to the emergency department by his mother with a complaint that the child just experienced a tonic-clonic seizure. On arrival in the emergency department no apparent seizures were occurring. The mother states that her son is taking medication for the seizure disorder. The nurse plans care, knowing that which of the following medications are used for long-term control of tonic-clonic seizures? Select all that apply.
3. Diazepam (Valium)
4. Alprazolam (Xanax)
5. Gabapentin (Neurontin)
6. Ethosuximide (Zarontin)
7. Carbamazepine (Tegretol)
8. Methylphenidate (Ritalin)

Answer 2

2. Answers: 3, 4, and 5.
3. Gabapentin (Neurontin)
4. Ethosuximide (Zarontin)
5. Carbamazepine (Tegretol)

Medications that are prescribed for long-term control of tonic-clonic seizures are gabapentin, ethosuximide, and carbamazepine. Diazepam is a medication that is prescribed to halt tonic-clonic episodes, and methylphenidate is a medication used to treat attention deficit hyperactivity disorder. Both of these medications are not suitable for long-term control of a seizure condition. Alprazolam is a medication used to treat anxiety.

Question 3

3. A child has been diagnosed with meningococcal meningitis. Which of the following isolation techniquesis appropriate?
4. Enteric precautions
5. Neutropenic precautions
6. No precautions are required as long as antibiotics have been started.
7. Isolation precautions for at least 24 hours after the initiation of antibiotics

Answer 3

3. Answer: 4.
4. Isolation precautions for at least 24 hours after the initiation of antibiotics

Meningococcal meningitis is transmitted primarily by droplet infection. Isolation is begun and maintained for at least 24 hours after antibiotics are given. Options 1, 2, and 3 are incorrect.

Question 4

4. A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Choose the interventions that the health care provider would likely prescribe. Select all that apply.
5. Monitor intake and output.
6. Monitor vital signs.
7. Maintain sodium-reduced diet.
8. Monitor electrolyte levels.
9. Increase water intake orally.
10. Administer sodium replacements.

Answer 4

4. Answers: 1, 2, 3, 4, and 5.
5. Monitor intake and output.
6. Monitor vital signs.
7. Maintain sodium-reduced diet.
8. Monitor electrolyte levels.
9. Increase water intake orally.

Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L. Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia.

Question 5

5. A client has died, and a nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. The nurse’s appropriate action is to:
6. Show acceptance of feelings.
7. Provide information needed for decision making.
8. Suggest a referral to a mental health professional.
9. Remain with the family member without discussing funeral arrangements.

Answer 5

5. Answer: 4.
6. Remain with the family member without discussing funeral arrangements.

The family member is exhibiting the first stage of grief (denial), and the nurse should remain with the family member. Option 1 is an appropriate intervention for the acceptance or reorganization and restitution stage. Option 2 may be an appropriate intervention for the bargaining stage. Option 3 may be an appropriate intervention for depression.

Question 6

6. A client is scheduled for a myelogram, and the nurse provides a list of instructions to the client regarding preparation for the procedure. Which instructions should the nurse place on the list? Select all that apply.
7. Jewelry will need to be removed.
8. An informed consent will need to be signed.
9. A trained x-ray technician performs the procedure.
10. The procedure will take approximately 45 minutes.
11. A liquid diet can be consumed on the day of the procedure.
12. Solid food intake needs to be restricted only on the day of the procedure.

Answer 6

6. Answer: 1, 2, and 4.
7. Jewelry will need to be removed.
8. An informed consent will need to be signed.
9. The procedure will take approximately 45 minutes.

Client preparation for a myelogram includes instructing the client to restrict food and fluids for 4 to 8 hours before the procedure. The client is told that the procedure takes about 45 minutes. An informed consent is required because the procedure is invasive and is therefore performed by the health care provider. The client will need to remove jewelry and metal objects from the chest area. The client is also told that pretest medications may be prescribed for relaxation.

Question 7

7. A client with a closed head injury is receiving phenytoin (Dilantin), an anticonvulsant medication. Which of the following would indicate that the client is experiencing side effects related to this medication? Select all that apply.
8. Ataxia
9. Sedation
10. Constipation
11. Bleeding gums
12. Hyperglycemia
13. Decreased platelet count

Answer 7

7. Answers: 3, 4, 5, and 6.
8. Constipation
9. Bleeding gums
10. Hyperglycemia
11. Decreased platelet count

Dilantin causes blood dyscrasias, such as decreased platelet counts and decreased white blood cell counts; it contributes to constipation as well. Gingival hyperplasia can occur, causing gums to bleed easily, and blood glucose levels can elevate when taking phenytoin. Sedation is a side effect of barbiturates, not phenytoin. Ataxia is a side effect of benzodiazepines.

Question 8

8. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply.
9. Radiation
10. Chemotherapy
11. Increased fluid intake
12. Serum sodium blood levels
13. Decreased oral sodium intake
14. Medication that is antagonistic to antidiuretic hormone (ADH)

Answer 8

8. Answers: 1, 2, 4, and 6.
9. Radiation
10. Chemotherapy
11. Serum sodium blood levels
12. Medication that is antagonistic to antidiuretic hormone (ADH)

Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. SIADH is managed by treating the condition and its cause, and treatment usually includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH. Sodium levels are monitored closely, because hypernatremia can suddenly develop as a result of treatment. The immediate institution of appropriate cancer therapy (usually either radiation or chemotherapy) can cause tumor regression so that ADH
synthesis and release processes return to normal.

Question 9

9. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply.
10. Radiation
11. Chemotherapy
12. Increased fluid intake
13. Serum sodium blood levels
14. Decreased oral sodium intake
15. Medication that is antagonistic to antidiuretic hormone (ADH)

Answer 9

9. Answers: 1, 2, 4 and 6.
10. Radiation
11. Chemotherapy
12. Serum sodium blood levels
13. Medication that is antagonistic to antidiuretic hormone (ADH)

Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. SIADH is managed by treating the condition and its cause, and treatment usually includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH. Sodium levels are monitored closely, because hypernatremia can suddenly develop as a result of treatment. The immediate institution of appropriate cancer therapy (usually either radiation or chemotherapy) can cause tumor regression so that ADH synthesis and release processes return to normal.

Question 10

10. The clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which of the following would the nurse include for this type of data collection? Select all that apply.
11. Auscultating lung sounds
12. Obtaining the client’s temperature
13. Checking the strength of peripheral pulses
14. Obtaining information about the client’s respirations
15. Performing a musculoskeletal and neurological examination
16. Asking the client about a family history of any illness or disease

Answer 10

10. Answers: 1, 2, and 4.
11. Auscultating lung sounds
12. Obtaining the client’s temperature
13. Obtaining information about the client’s respirations

A focused data collection process focuses on a limited or short-term problem, such as the client’s complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion the nurse would focus on the respiratory system and the presence of an infection. A complete data collection includes a complete health history and physical examination and forms a baseline database. Checking the strength of peripheral pulses relates to a vascular assessment, which is not related to this client’s complaints. A musculoskeletal and neurological examination also is not related to this client’s complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete data collection. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

Question 11

11. A community health nurse is conducting a teaching session about terrorism with members of the community and discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted via which route(s)? Select all that apply.
12. Skin
13. Kissing
14. Inhalation
15. Gastrointestinal
16. Direct contact with an infected individual
17. Sexual contact with an infected individual

Answer 11

11. Answers: 1, 3, and 4.
12. Skin
13. Inhalation
14. Gastrointestinal

Anthrax is caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. It cannot be spread from person to person.

Question 12

12. The emergency room nurse is providing discharge teaching to the parents of a 2-year-old child who sustained burns from a hot cup of coffee that had been left on the kitchen counter. The nurse evaluates that the parents have correctly understood the teaching when they state which of the following?
13. “We will be sure to not leave hot liquids unattended.”
14. “I guess my child needs to understand what the word ‘hot’ means.”
15. “We will be sure that our child stays in his room when we work in the kitchen.”
16. “We will install a safety gate as soon as we get home so that our child can’t get into the kitchen.”

Answer 12

12. Answer: 1.
13. “We will be sure to not leave hot liquids unattended.”

Toddlers, with their increased mobility and developing motor skills, can reach hot water, open fires, or hot objects placed on counters and stoves above their eye level. Parents should be encouraged to remain in the kitchen when preparing a meal and reminded to use the back burners on the stove. Pot handles should be turned inward and toward the middle of the stove. Hot liquids should never be left unattended, and the toddler should always be supervised. Options 2, 3, and 4 do not reflect an adequate understanding of the principles of safety.

Question 13

13. A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice?
14. A task approach method is used to provide care to clients.
15. Managed care concepts and tools are used when providing client care.
16. Nursing staff are led by a nurse when providing care to a group of clients.
17. A single registered nurse is responsible for providing nursing care to a group of clients.

Answer 13

13. Answer: 3.
14. Nursing staff are led by a nurse when providing care to a group of clients.

In team nursing, nursing personnel are led by a nurse when providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing.

Question 14

14. A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant?
15. A client who requires wound irrigation
16. A client who requires frequent ambulation
17. A client who is receiving continuous tube feedings
18. A client who requires frequent vital signs after a cardiac catheterization

Answer 14

14. Answer: 2.
15. A client who requires frequent ambulation

The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires frequent ambulation. The nursing assistant is skilled in this task. The client who had a cardiac catheterization will require specific monitoring in addition to that of the vital signs. Wound irrigations and tube feedings are not performed by unlicensed personnel.

Question 15

15. A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client’s malpractice claim. Select all that apply.
16. Failure to replace body fluids
17. Increased risk of hypotension
18. Failure to teach the client adequately
19. Increased need to protect the client
20. Excessive bumetanide administration
21. Lack of follow-up nursing actions

Answer 15

15. Answers: 2, 3, 4, and 6.
16. Increased risk of hypotension
17. Failure to teach the client adequately
18. Increased need to protect the client
19. Lack of follow-up nursing actions

To prove malpractice against a nurse, the plaintiff must prove that the nurse owed a duty to the client, that the nurse breached the duty, and that as a result harm was caused to person or property. The client has an increased risk of hypotension (option 2) because hypotension is a common adverse effect of bumetanide, this is the second dose within 4 hours, and the client has heart failure. The client can prove that the nurse did not protect him by failing to provide adequate teaching and perform correct and timely nursing interventions (options 3, 4, and 6) after administering the bumetanide. After the first 15-minute check, the nurse should continue increased client monitoring to ensure client compliance with safety measures. Replacing fluid volume is not the issue; furthermore, the goal of therapy is to reduce total body fluid. No data indicate that the dose of bumetanide, a loop diuretic, was excessive. However, because this medication can cause hypotension, especially after a repeat dose, the nurse should instruct the client to remain in bed and provide him with a urinal. It may be difficult for the client to prove that the second dose of bumetanide caused the injury.

Question 16

16. A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply.
17. Monitor the client’s ability to void.
18. Maintain the client in a flat position.
19. Restrict fluid intake for a period of 2 hours.
20. Monitor the client’s ability to move the extremities.
21. Inspect the puncture site for swelling, redness, and drainage.
22. Maintain the client on a nothing-by-mouth (NPO) status for 24 hours.

Answer 16

16. Answers: 1, 2, 4, and 5.
17. Monitor the client’s ability to void.
18. Maintain the client in a flat position.
19. Monitor the client’s ability to move the extremities.
20. Inspect the puncture site for swelling, redness, and drainage.

Following a lumbar puncture, the client remains flat in bed for 6 to 24 hours, depending on the health care provider’s prescriptions. A liberal fluid intake (not NPO status) is encouraged to replace cerebrospinal fluid removed during the procedure, unless contraindicated by the client’s condition. The nurse checks the puncture site for redness and drainage, and monitors the client’s ability to void and move the extremities.

Question 17

17. A nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department for treatment on the evening shift. The nurse would assign the highest priority to which of the following clients?
18. A client complaining of muscle aches, a headache, and malaise
19. A client who twisted her ankle when she fell while rollerblading
20. A client with a minor laceration on the index finger sustained while cutting an eggplant
21. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

Answer 17

17. Answers: 4.
18. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

In an emergency department, triage involves classifying clients according to their need for care, and it includes establishing priorities of care. The type of illness, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits and those who sustained a chemical splash to the eyes are classified as emergent, and these clients are the number 1 priority. Clients with conditions such as simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones have urgent needs, and these clients are classified as the number 2 priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are

Question 18

18. A nurse enters a client’s room and notes that the client’s lawyer is present and that the client is preparing a living will. The living will requires that the client’s signature be witnessed, and the client asks the nurse to witness the signature. Which of the following is the appropriate nursing action?
19. Decline to sign the will.
20. Sign the will as a witness to the signature only.
21. Call the hospital lawyer before signing the will.
22. Sign the will, clearly identifying credentials and employment agency.

Answer 18

18. Answers: 1
19. Decline to sign the will.

Living wills are required to be in writing and signed by the client. The client’s signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee from being a witness, including a nurse in a facility in which the client is receiving care.

Question 19

19. A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? Select all that apply.
20. “I enjoy exercising but I need to be careful.”
21. “I need to pace my activities throughout the day.”
22. “I need to limit playing football to only the weekends.”
23. “I should gauge my activity level by my energy level.”
24. “I should exercise in the evening to encourage a good sleep pattern.”

Answer 19

19. Answers: 3 and 5.
20. “I need to limit playing football to only the weekends.”
21. “I should exercise in the evening to encourage a good sleep pattern.”

The client should be instructed to avoid high-impact activity or contact sports such as football. Exercising late in the evening may interfere with restful sleep. The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to use energy level as a guide to activity.

Question 20

20. A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.
21. Administering oxygen
22. Inserting a Foley catheter
23. Administering furosemide (Lasix)
24. Administering morphine sulfate intravenously
25. Transporting the client to the coronary care unit
26. Placing the client in a low Fowler’s side-lying position

Answer 20

20. Answers: 1, 2, 3, and 4.
21. Administering oxygen
22. Inserting a Foley catheter
23. Administering furosemide (Lasix)
24. Administering morphine sulfate intravenously

Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler’s position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client’s response to treatment is successful.