test 11/7 Flashcards
(48 cards)
After being treated with heparin therapy for thrombophlebitis, a multiparous client who gave birth 4 days ago is to be discharged on oral warfarin. After teaching the client about the medication and possible effects, which client statement indicates successful teaching?
a. “I can take two aspirin if I get uterine cramps.”
b. “Protamine sulfate should be available if I need it.”
c. “I should use a soft toothbrush to brush my teeth.”
d. “I can drink an occasional glass of wine if I desire.”
c. “I should use a soft toothbrush to brush my teeth.”
Explanation:
Successful teaching is demonstrated when the client says, “I should use a soft toothbrush to brush my teeth.” Heparin therapy can cause the gums to bleed, so a soft toothbrush should be used to minimize this adverse effect. Use of aspirin and other nonsteroidal anti-inflammatory medications should be avoided because of the increased risk for possible hemorrhage. Protamine sulfate is the antidote for heparin therapy. Vitamin K is the antidote for warfarin excess. Alcohol can inhibit the metabolism of oral anticoagulants and should be avoided.
An 80-year-old woman is receiving treatment with oral fluconazole for a fungal infection Following yesterday’s and today’s dose, she reports an upset stomach to the charge nurse. How should the nurse at the facility best respond to the woman’s report?
A. Assess the client for signs and symptoms of an infusion reaction.
B. Arrange for the client to receive intravenous fluconazole on an outpatient basis.
C. Stop administering the fluconazole and inform the client’s physician.
D. Provide food along with the fluconazole when administering it in the future.
D
Fluconazole has the potential to cause gastric distress, a problem that may be mitigated by administering the drug with food. Infusion reactions do not occur with the administration of fluconazole and it is likely unnecessary to arrange for IV administration, to stop the drug, or to immediately inform the resident’s physician.
A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?
A. The client says that he has been urinating less frequently at night.
B.The client says he has been hungry in the evening.
C. The client says his rings have become tight and are difficult to remove.
D. The client says he is short of breath when ambulating.
C
Clients may observe that rings, shoes, or clothing have become tight. The client would most likely be urinating more frequently in the evening. Accumulation of blood in abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger. Shortness of breath with ambulation would occur most often in left-sided heart failure.
A client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as:
A. a heightened response to a medication.
B. a diminished response to a drug so that more medication is required to achieve the same effect.
C. an allergic reaction to a medication.
D. an ability to take the same drug for extended periods.
B. a diminished response to a drug so that more medication is required to achieve the same effect.
Explanation:
Tolerance occurs when the body requires higher doses of substances, such as alcohol, opioids, or benzodiazepines, to achieve desired effects. Increased response indicates a need for less of a drug to achieve the same effects. Allergic reactions are autoimmune responses to a particular drug or class of drugs.
A nurse notices repetitive late decelerations on the fetal heart monitor. The best initial actions by the nurse include:
A. prepare for birth, reposition the patient, and begin pushing.
B perform sterile vaginal examination, increase IV fluids, and apply oxygen.
C notify the provider, explain findings to the client, and begin pushing.
D. reposition the client, apply oxygen, and increase IV fluids.
D
Late decelerations on a fetal heart monitor indicate uteroplacental insufficiency. Interventions to improve perfusion include repositioning the client, oxygen, and IV fluids. A sterile vaginal exam is not indicated at this time. Late decelerations are not expected findings and do not indicate an imminent birth.
Acetaminophen overdose has the potential to cause fatal:
A. kidney damage.
B. pancreas damage.
C. lung damage.
D. liver damage.
D
Potentially fatal hepatotoxicity is the main concern with acetaminophen overdose. It is most likely to occur with doses or 20 g or more.
When assessing the skin of a client with allergic contact dermatitis, the nurse would most likley expect to find irritation at which area?
A. Lower arms
B. Ankles
C. Plantar aspects of the feet
D. Dorsal aspect of the hand
Dorsal aspect of the hand
Explanation:
With allergic contact dermatitis, irritation is most common on the dorsal aspects of the hand. Irritant, phototoxic, and photoallergic types of contact dermatitis are commonly seen on the hands and lower arms.
Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? A. Calcium B. Magnesium C. Potassium D. Sodium
D
Sodium is the primary determinant of ECF osmolality. Sodium plays a major role in controlling water distribution throughout the body because it does not easily cross the intracellular wall membrane and because of its abundance and high concentration in the body. Potassium, calcium, and magnesium are not primary determinants of ECF osmolality.
The nurse assists and educates clients about blood pressure regulation. Based on this information, the nurse asks the client what the number 80 in the blood pressure 120/80 represents. Which response by the client demonstrates correct understanding of the basic concepts of blood pressure?
A. Systolic pressure
B. Cardiac output
C. Pulse pressure
D. Diastolic pressure
D
Cardiac output is the amount of blood the ventricles pump out in 1 minute; normally, 4 to 6 L/minute. Blood pressure is the force exerted by the blood against the walls of the blood vessels. Systolic blood pressure, in this example 120, is the force during ventricular contraction. Diastolic blood pressure, in this example is 80, is the force during ventricular relaxation. The difference between systolic and diastolic pressure is called pulse pressure.
A nursing diagnosis of “Ineffective coping” has been chosen for a client after receiving a diagnosis of prostate cancer. What assessments would the nurse consider as evidence for this diagnosis? (Select all that apply.)
A. The client asks for information relating to the cancer diagnosis.
B. The client reports an inability to get adequate restful sleep.
C. The client has difficulty concentrating on the details of treatment options.
D. The client states, “I can’t handle all of this.”
E. The client requests the minister of his church to visit.
B C D
Inability to sleep, difficulty concentrating, and the client’s verbalization of being overwhelmed are evidence of inability to cope. Seeking information related to the diagnosis and seeking out a spiritual adviser are positive ways of coping.
A nursing instructor is giving a lecture on the immune system. Which of the following cells will the instructor include in her discussion on phagocytosis? A. Plasma cells and memory cells B. Regulator T cells and Helper T cells C. Neutrophils and monocytes D. Lymphokines and Suppressor T cells
C
Neutrophils and monocytes are phagocytes, cells that perform phagocytosis.
After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin?
A. Stratum corneum
B. Dermis
C. Epidermis
D. Papillary layer
B
The dermis is often referred to as the true skin. The epidermis is the outermost layer of the skin, with the stratum corneum as the outermost layer of the epidermis. The papillary layer is the outermost layer of the dermis that lieds directly beneath the epidermis.
An 80-year-old woman is receiving treatment with oral fluconazole for a fungal infection Following yesterday’s and today’s dose, she reports an upset stomach to the charge nurse. How should the nurse at the facility best respond to the woman’s report?
A. Provide food along with the fluconazole when administering it in the future.
B. Stop administering the fluconazole and inform the client’s physician.
C. Arrange for the client to receive intravenous fluconazole on an outpatient basis.
D. Assess the client for signs and symptoms of an infusion reaction.
Provide food along with the fluconazole when administering it in the future.
Explanation:
Fluconazole has the potential to cause gastric distress, a problem that may be mitigated by administering the drug with food. Infusion reactions do not occur with the administration of fluconazole and it is likely unnecessary to arrange for IV administration, to stop the drug, or to immediately inform the resident’s physician.
While reading a physician’s progress notes, a student notes that an assigned patient is having hypoxia. What abnormal assessments would the student expect to find?
A. diarrhea, flatulence, decreased skin turgor
B. dyspnea, tachycardia, cyanosis
C. abdominal pain, hyperthermia, dry skin
D. hypotension, reddened skin, edema
B
If a problem exists in ventilation, respiration, or perfusion, hypoxia (a condition in which an inadequate amount of oxygen is available to cells) may occur. The most common symptoms are dyspnea, elevated blood pressure, increased respirations and pulse, pallor, and cyanosis. Other common symptoms are anxiety and restlessness.
A 65-year-old client has come to the emergency department reporting light-headedness, chest pain, and shortness of breath. As you finish your assessment, the physician enters and orders tests to ascertain what is causing the client's problems. In your client education, you explain the tests. Which test is used to identify cardiac rhythms? A. Echocardiogram B. Electroencephalogram C. Electrocardiogram D. Electrocautery
C
An electrocardiogram is used to identify normal and abnormal cardiac rhythms. An electrocardiogram is the device used to identify normal and abnormal cardiac rhythms.
The nurse is conducting the physical assessment of a client at the health care facility. The nurse uses the pulse oximetry technique to monitor the oxygen saturation in the client's blood. Which of the following pulse oximeter ranges indicates that the client is adequately oxygenated? A. 80% to 90% B. 85% to 95% C. 95% to 100% D. 90% to 95%
C
If the client is adequately oxygenated, the pulse oximeter reading should be between 95% and 100%. Pulse oximetry is a noninvasive, transcutaneous technique for periodically or continuously monitoring the oxygen saturation in the blood. The normal range of oxygen saturation in the blood is between 95% and 100%. A sustained level of less than 90% is a cause for concern. If the oxygen saturation remains low, the client requires oxygen therapy.
Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity?
A.Intermittent claudication
B. Acute limb ischemia
C. Dizziness
D. Vertigo
A
The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease.
A 40-year-old client with a diagnosis of fibromyalgia has been prescribed cyclobenzaprine (Flexeril) as an adjunct to her existing drug regimen. What nursing diagnosis should the nurse prioritize for the nursing care plan for this client?
a. Risk for Injury related to CNS depressant effects
b. Diarrhea related to anticholinergic effects
c. Altered Nutrition, Less than Body Requirements, related to appetite suppression
d. Impaired Swallowing related to increased muscle tone
a
Risk for Injury related to CNS depressant effects
Explanation:
The CNS depression that is associated with the use of cyclobenzaprine constitutes a risk for injury. The anticholinergic effects of the drug constitute a risk for constipation, not diarrhea. Nutrition and swallowing are not typically affected by the use of cyclobenzaprine.
A nurse is assessing a client’s fluid balance status. The nurse understands that which organ plays the major role in regulating fluid balance?
A. Intestines
B. Kidneys
C. Lungs
D. Skin
B
Although the skin, gastrointestinal tract, and lungs play a role in fluid balance, the kidneys are the major organs regulating fluid balance, conserving or excreting water and electrolytes as necessary to maintain homeostasis.
A client's immune response include phagocytosis of the bacteria that have infected the client. What cells are capable of performing this role in the immune response? A. Basophils B. Eosinophils C. Monocytes D. Immunoglobulins
C
Macrophages, or monocytes, are mature leukocytes capable of phagocytizing an antigen. Basophils are myelocytic leukocytes incapable of phagocytosis; some of them are fixed and do not circulate. Eosinophils are circulating myelocytic leukocytes whose function is unknown. Immunoglobulins are the released form of antibodies.
The nurse is preparing to measure the depth of a client’s tunneled wound. Which implement should the nurse use to measure the depth accurately?
A. a small plastic ruler
B. an otic curette
C. a sterile tongue blade lubricated with water soluble gel
D. a sterile, flexible applicator moistened with saline
a sterile, flexible applicator moistened with saline
Explanation:
A sterile, flexible applicator is the safest implement to use. A small plastic ruler is not sterile. A sterile tongue blade lubricated with water soluble gel is too large to use in a wound bed. An otic curette is a surgical instrument designed for scraping or debriding biological tissue or debris in a biopsy, excision, or cleaning procedure and not flexible.
Which education points would the nurse use to explain the development of pressure injuries to clients and how to prevent them? Select all that apply.
A.”The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation.”
B. “The skin can tolerate considerable pressure without cell death, but for short periods only.”
C. “Most pressure injuries occur over the trochanter and calcaneus.”
D. “The major predisposing factor for a pressure injury is internal pressure over an area, resulting in occluded blood capillaries and poor circulation to the tissues.”
E. “Generally, a pressure injury will not appear within the first 2 days in a person who has not moved for an extended period of time.”
F. “Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue.”
A B F
Explanation:
Pressure injuries usually occur over bony prominences. The skin can tolerate considerable pressure without cell death, but for short periods only. The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation. Pressure injuries can develop in a variety of locations where bony prominences are located. The most common are the coccyx and sacrum. A pressure injury can appear in less than 2 hours of time, depending on the factors present. Most pressure injuries develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, or when soft tissue undergoes pressure in combination with shear and/or friction.
What is the function of the thymus gland?
A. Produces stem cells
B. Programs T lymphocytes to become regulator or effector T cells
C. Programs B lymphocytes to become regulator or effector B cells
D. Develops the lymphatic system
B
The thymus gland is located in the neck below the thyroid gland. It extends into the thorax behind the top of the sternum. The thymus gland produces lymphocytes during fetal development. It may be the embryonic origin of other lymphoid structures such as the spleen and lymph nodes. After birth, the thymus gland programs T lymphocytes to become regulator or effector T cells. The thymus gland becomes smaller during adolescence but retains some activity throughout the life cycle. Options A, B, and C are incorrect.
Mr. Sanchez is a 56-year-old Mexican American who has a diagnosis of heart failure. The nurse's morning lung assessment of the client reveals crackles in the mid to lower lungs and respiratory rate of 32. The nurse notices that the client is restless, and his skin has an ashen appearance. Which nursing action is the priority intervention? A. Limit the client's activity. B. Assess capillary refill. C. Assess fluid intake. D Obtain a pulse oximetry reading.
D
The focused assessment of the client?s respiratory status indicates signs of respiratory compromise and possible hypoxia, as evidenced by the client’s restlessness and the ashen appearance of the skin. To fully assess the respiratory status of the client, it is important to take the pulse oximetry measurement. Capillary refill and fluid intake assessment do not address the primary problem of respiratory compromise. Limiting activity is not an assessment.
