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SATA 3 Flashcards

1
Q
  1. A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply.
  2. Scant mucus
  3. Early onset cough
  4. Marked weight loss
  5. Purulent mucus production
  6. Mild episodes of dyspnea
A
  1. Answers: 2, 4, and 5.
  2. Early onset cough
  3. Purulent mucus production
  4. Mild episodes of dyspnea

Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea.

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2
Q
  1. A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client’s efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?
  2. Identifying the client’s ability to function
  3. Identifying the client’s potential for self-harm
  4. Inquiring about the client’s feelings that may affect coping
  5. Inquiring about the client’s perception of the cause of the neighbor’s death
A
  1. Answer: 3.
  2. Inquiring about the client’s feelings that may affect coping

The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client’s feelings. Options 1, 2, and 4 do not directly address the client’s feelings.

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3
Q
  1. A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client’s hospital gown?
  2. Using a hospital gown with snaps at the sleeves
  3. Disconnecting the IV tubing from the catheter in the vein
  4. Checking the IV flow rate immediately after changing the hospital gown
  5. Putting the bag and tubing through the sleeve, followed by the client’s arm
A
  1. Answer: 2.
  2. Disconnecting the IV tubing from the catheter in the vein

The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to infection. Options 1 and 4 are appropriate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected during the change.

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4
Q
  1. A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first?
  2. A client on a ventilator
  3. A client in skeletal traction
  4. A postoperative client preparing for discharge
  5. A client admitted on the previous shift who has a diagnosis of gastroenteritis
A
  1. Answer: 1.
  2. A client on a ventilator

The airway is always a high priority, and the nurse first checks the client on a ventilator. The clients described in options 2, 3, and 4 have needs that would be identified as intermediate priorities.

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5
Q
  1. A nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection?
  2. Respiratory
  3. Psychosocial
  4. Neurological
  5. Cardiovascular
A
  1. Answer: 2.
    The psychosocial data is the least priority during the initial admission data collection. In the African-American culture, it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally, respiratory, neurological, and cardiovascular data include physiological assessments that
    would be the priority.
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6
Q
  1. A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply.
  2. Wearing gloves when emptying the client’s bedpan
  3. Keeping all linens in the room until the implant is removed
  4. Wearing a film (dosimeter) badge when in the client’s room
  5. Wearing a lead apron when providing direct care to the client
  6. Placing the client in a semiprivate room at the end of the hallway
A
  1. Answer: 1, 2, 3, and 4.
  2. Wearing gloves when emptying the client’s bedpan
  3. Keeping all linens in the room until the implant is removed
  4. Wearing a film (dosimeter) badge when in the client’s room
  5. Wearing a lead apron when providing direct care to the client

A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify interventions that are necessary for a client with a radiation device.

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7
Q
  1. The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply.
  2. On the left side
  3. With the neck flexed
  4. Supine on the left side
  5. With extreme hip flexion
  6. In a semi-Fowler’s position
  7. With the head in a midline position
A
  1. Answers: 5 and 6.
  2. In a semi-Fowler’s position
  3. With the head in a midline position

Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent the displacement of the cranial contents.

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8
Q
  1. A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to:
  2. Treat thyroid storm.
  3. Prevent cardiac irritability.
  4. Treat hypocalcemic tetany.
  5. Stimulate the release of parathyroid hormone.
A
  1. Answer: 3.

3. Treat hypocalcemic tetany.

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9
Q
  1. A nurse is caring for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure?
  2. Gloves and a gown
  3. Gloves and goggles
  4. Gloves, a gown, and goggles
  5. Gloves, a gown, and shoe protectors
A
  1. Answer: 3.
  2. Gloves, a gown, and goggles

Goggles are worn to protect the mucous membranes of the eye during interventions that may produce
splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not
necessary.

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10
Q
  1. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?
  2. Metabolic acidosis
  3. Metabolic alkalosis
  4. Respiratory acidosis
  5. Respiratory alkalosis
A
  1. Answer: 2
  2. Metabolic alkalosis

The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition. Options 3 and 4 deal with respiratory problems. Option 1 relates to acidosis.

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11
Q
  1. A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Based on this documentation, which of the following did the nurse most likely observe?
  2. Respirations that cease for several seconds
  3. Respirations that are regular but abnormally slow
  4. Respirations that are labored and increased in depth and rate
  5. Respirations that are abnormally deep, regular, and increased in rate
A
  1. Answer: 4.
  2. Respirations that are abnormally deep, regular, and increased in rate

Kussmaul’s respirations are abnormally deep, regular, and increased in rate. In apnea, respirations cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.

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12
Q
  1. Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.
  2. Monitor for hemorrhage.
  3. Administer eye medications.
  4. Maintain the eye patch or shield.
  5. Assist with activities of daily living.
  6. Encourage coughing and deep breathing.
  7. Educate regarding symptoms of retinal detachment.
A
  1. Answers: 1, 2, 3, 4, and 6.
  2. Monitor for hemorrhage.
  3. Administer eye medications.
  4. Maintain the eye patch or shield.
  5. Assist with activities of daily living.
  6. Educate regarding symptoms of retinal detachment.

An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse’s assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.

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13
Q
  1. A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?
  2. Intense thirst
  3. Slow bounding pulse
  4. Dry mucous membranes
  5. Postural blood pressure changes
A
  1. Answer: 4.
  2. Postural blood pressure changes

Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes
and intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid thready pulse is noted.

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14
Q
  1. A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications?
  2. A 60-year-old male client with rhinitis
  3. A 24-year-old male client with a lower back injury
  4. A 10-year-old female client with a urinary tract infection
  5. A 45-year-old female client with a history of migraine headaches
A
  1. Answer: 3.
  2. A 10-year-old female client with a urinary tract infection

Children should not be given herbal therapies, especially in the home and without professional
supervision. There are no general contraindications for the clients described in options 1, 2, and 4.

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15
Q
  1. A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.
  2. Call a code blue.
  3. Notify the registered nurse.
  4. Place the infant in a prone position.
  5. Prepare to administer morphine sulfate.
  6. Prepare to administer intravenous fluids.
  7. Prepare to administer 100% oxygen by face mask.
A
  1. Answers: 2, 4, 5, and 6.
  2. Notify the registered nurse.
  3. Prepare to administer morphine sulfate.
  4. Prepare to administer intravenous fluids.
  5. Prepare to administer 100% oxygen by face mask.

The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids,as prescribed.

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16
Q
  1. A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply.
  2. Oliguria
  3. Seizures
  4. Contractions
  5. Proteinuria 3+
  6. Muscle cramps
  7. Blood pressure 168/116 mm Hg
A
  1. Answers: 1, 4, and 6.
  2. Oliguria
  3. Proteinuria 3+
  4. Blood pressure 168/116 mm Hg

Severe preeclampsia is characterized by blood pressure higher than 160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia, although the client is monitored for these occurrences.

17
Q
  1. A nurse is monitoring a client with Graves’ disease for signs of thyrotoxicosis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis? Select all that apply.
  2. Bradycardia
  3. Fever
  4. Sweating
  5. Agitation
  6. Pallor
A
  1. Answers: 2, 3, and 4.
  2. Fever
  3. Sweating
  4. Agitation

Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body’s tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.

18
Q
  1. A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.
  2. Severely anxious client
  3. Pneumonia client
  4. Diabetic mellitus client
  5. Malnourished client
  6. Asthma client
  7. Renal failure client
A
  1. Answers: 3, 4, and 6.
  2. Diabetic mellitus client
  3. Malnourished client
  4. Renal failure client

Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis because of the increasing acids in the body. Options 1, 2, and 5 are respiratory problems, not metabolic, and result in either respiratory acidosis or respiratory alkalosis.

19
Q
  1. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.
  2. To avoid activities that require bending over
  3. To contact the surgeon if eye scratchiness occurs
  4. To place an eye shield on the surgical eye at bedtime
  5. That episodes of sudden severepain in the eye is expected
  6. To contact the surgeon if a decrease in visual acuity occurs
  7. To take acetaminophen (Tylenol) for minor eye discomfort
A
  1. Answers: 1, 3, 5, and 6.
  2. To avoid activities that require bending over
  3. To place an eye shield on the surgical eye at bedtime
  4. To contact the surgeon if a decrease in visual acuity occurs
  5. To take acetaminophen (Tylenol) for minor eye discomfort

After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

20
Q
  1. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.
  2. To avoid activities that require bending over
  3. To contact the surgeon if eye scratchiness occurs
  4. To place an eye shield on the surgical eye at bedtime
  5. That episodes of sudden severe pain in the eye is expected
  6. To contact the surgeon if a decrease in visual acuity occurs
  7. To take acetaminophen (Tylenol) for minor eye discomfort
A
  1. Answers: 1, 3, 5, and 6.
  2. To avoid activities that require bending over
  3. To place an eye shield on the surgical eye at bedtime
  4. To contact the surgeon if a decrease in visual acuity occurs
  5. To take acetaminophen (Tylenol) for minor eye discomfort

After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

SATA (5 decks)

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