The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nu
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The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nurse to take?
1. Leave the cuff inflated and suction through the tracheostomy.
2. Deflate the cuff and suction through the tracheostomy tube.
3. Inflate the cuff pressure to 40 mm Hg before suctioning.
4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning. - ANSWER 1) CORRECT - Implementation: outcome desired; cuff inflation decreases the risk of aspiration; cuff position and pressure should be assessed frequently; swallowing and breathing will cause tracheostomy tube movement
2) Implementation: outcome not desired; accumulated oral secretions above the cuff will drain into the bronchi; increased risk of infection
3) Implementation: outcome not desired; cuff pressure should be less than 20 mm Hg (25 cm H2O); risk of trauma to trachea with higher pressures
4) Implementation: outcome not desired; increases the risk of trauma to lower airways
A young adult brings a friend to the emergency department and states that the friend has been using heroin. Which action by the nurse is the MOST appropriate?
1. Assess pupil size and reactivity.
2. Assess oxygen saturation levels.
3. Palpate dorsalis pedis pulses.
4. Ask the client if he knows today's date. - ANSWER 1) Assessment: outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin overdose
2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas exchange and possible respiratory arrest
3) Assessment: outcome not priority; most important to assess airway and breathing
4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may be seen; not priority
The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which question is MOST important for the nurse to ask?
1. "Have you tried other methods to stop smoking?"
2. "How long have you been smoking?"
3. "Have you ever had chest pain?"
4. "Do you have a partial dental bridge?" - ANSWER 1) Assessment: outcome not priority but may be appropriate; can be asked as part of assessment
2) Assessment: outcome not priority but may be appropriate; should be assessed for further teaching
3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction; increases heart rate and myocardial oxygen consumption; increased risk of angina and myocardial infarction
4) Assessment: outcome may be appropriate but not priority; gum is place between cheek and gums; may stain dental work
The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client has pressed the button 11 times and received 6 doses of morphine during the last hour. Which is the MOST appropriate action for the nurse to take?
1. Assess the patency of the PCA IV tubing.
2. Determine the client's understanding of the PCA pump function.
3. Obtain an order to begin a PCA infusion of fentanyl.
4. Ask the client to describe the pain. - ANSWER 1) Assessment: outcome not priority but may be appropriate; if tubing is obstructed, alarm is activated
2) Assessment: outcome may be appropriate but not priority; more important to determine pain level, description of the pain, region and radiation of the pain, and relieving factors
3) Implementation: outcome not desired; more important to assess severity of pain and pain relief first
4) CORRECT - Assessment: outcome priority; must validate that client is in pain before implementation
A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is MOST appropriate?
1. Place the client flat on her back.
2. Elevate the head of the bed 30 degrees.
3. Place the client on her left side with her legs flexed.
4. Place the client supine with the foot of the bed elevated. - ANSWER 1) Implementation: outcome not desired; no increase in venous return
2) Implementation: outcome not desired; will decrease venous return
3) CORRECT - Implementation: outcome desired; will increase venous return and cardiac output; fetal pressure on inferior vena cava reduced
4) Implementation: outcome not desired; elevation of legs will increase venous return, but fetal pressure on vena cava will prevent blood return to heart
A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid status?
1. Urinary output of 1,500 mL in 24 hours.
2. Serum hematocrit 52%.
3. Oral fluid intake of 900 mL in 24 hours.
4. Blood pressure of 100/82. - ANSWER 1) CORRECT - Assessment: outcome priority; increased amounts of antidiuretic hormone secreted; urine output decreased and concentrated
2) Assessment: outcome not priority; indicates that blood is hemoconcentrated
3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours
4) Assessment: outcome not priority; normal BP is 120/80
The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the morning. Which medication should the nurse question giving to the client?
1. 20 mg oral escitalopram (Celexa) in the morning.
2. 40 mg oral furosemide (Lasix) in the morning.
3. 300 mg of oral gabapentin (Neurontin) twice daily.
4. 10 mg zolpidem (Ambien) at bedtime. - ANSWER 1) Implementation: outcome not a problem; no interaction with ACE inhibitors; is an SSRI antidepressant
2) CORRECT - Implementation: outcome potential problem; may promote significant diuresis; first dose of ACE inhibitors increases risk of "first dose" phenomenon due to vasodilation; combination of vasodilation and diuresis increases risk of orthostatic hypotension
3) Implementation: outcome not a problem; no interaction; gabapentin classified as antiseizure medication; off-label use for neuropathic pain
4) Implementation: outcome not a problem; is a hypnotic; no interaction with ACE inhibitors
The home care nurse visits a client with a halo fixator traction device. Which client statement MOST concerns the nurse?
1. "My wife looks at the pin sites every day."
2. "I like to bathe in the tub."
3. "I drove to the library yesterday."
4. "I drink with a straw." - ANSWER 1) Assessment: outcome desired; risk of infection at pin sites; client should be taught signs of inflammation and infection
2) Implementation: outcome desired; showers increase risk of infection at pin sites
3) CORRECT - Implementation: outcome not desired and may be a problem; client is not able to turn with halo device; increases the risk of injury to self and others
4) Implementation: outcome desired; difficulty manipulating cup or glass due to immobilized neck
The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement?
1. "I have been sleeping 6 hours at night."
2. "I have lost 2 lbs in the past week."
3. "Lately, I have trouble watching television."
4. "I have much less muscle tension now." - ANSWER 1) CORRECT - Assessment: outcome desired; clients with depression may have increased or decreased sleep time
2) Assessment: outcome not desired; lack of appetite is a frequent sign of depression
3) Assessment: outcome not desired; lack of concentration is sign of depression
4) Assessment: outcome not desired; is a sign of anxiety
The nurse on the maternity unit must accept a transfer client from a medical/surgical unit. The nurse considers which transfer client appropriate?
1. A 38-year-old client with a diagnosis of systemic lupus erythematosus.
2. A 45-year-old client receiving daily external radiation therapy treatments for breast cancer.
3. A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg.
4. A 74-year-old client who has received intravenous antibiotics for 7 days. - ANSWER 1) CORRECT - Implementation: outcome desired; autoimmune disease; not infectious
2) Implementation: outcome not desired; possible skin damage and suppression of bone marrow with decreased white-blood-cell levels; increased risk for infection
3) Implementation: outcome not desired; generalized skin infection of deeper connective tissue; usually caused by Streptococcus or Staphylococcus; increased risk for infection
4) Implementation: outcome not desired; elderly clients receiving long-term antibiotic therapy are at risk for Clostridium difficile infection; highly contagious; increased risk for infection
The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is MOST important for the nurse to make which of these statements?
1. "Your parents are going to leave a half hour before the surgery."
2. "You're going to talk with some other children who had this surgery."
3. "If you have this surgery, your parents will buy you a new toy."
4. "Take this doll and show me where the operation will be done." - ANSWER 1) Implementation: outcome not desired; parents are encouraged to remain with child
2) Implementation: outcome not desired; appropriate only for school-aged and adolescent children
3) Implementation: outcome not desired; not appropriate
4) CORRECT - Implementation: outcome desired; encourage expression of feelings (e.g., anger); fear mutilation; allow child to play with models of equipment
The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused and incontinent of urine. What is the MOST important action for the nurse to take?
1. Insert an indwelling urinary drainage catheter.
2. Perform intermittent catheterization every 4 hours.
3. Offer the bedpan to the client every 2 hours.
4. Assist the client to a bedside commode every 2 hours. - ANSWER 1) Implementation: outcome not desired; increases risk of infection; catheter-related infections are most common hospital-acquired infection
2) Implementation: outcome not desired; increases chance of infection
3) Implementation: outcome appropriate but not priority; does not keep client independent and active
4) CORRECT - Implementation: outcome desired; keeps client active and independent
The nurse cares for a client with a history of type 1 diabetes mellitus who has just returned to the surgical acute-care unit after a right below-knee amputation. The client's capillary blood glucose is 480 mg/dL. The postoperative orders indicate 6 units of regular insulin subcutaneously should be administered. Which of the following is the FIRST action the nurse should take?
1. Check the client records to see if insulin was given prior to surgery.
2. Administer the 6 units of regular insulin subcutaneously.
3. Administer the insulin when oral fluids are tolerated.
4. Contact the healthcare provider. - ANSWER 1) Assessment: outcome desired but not priority; client needs insulin coverage now
2) CORRECT - Implementation: outcome desired; sliding scale-receives predetermined amount of insulin according to glucose level; surgery and infection increase insulin needs
3) Implementation: outcome not desired; needs insulin regardless of oral intake due to elevated blood glucose
4) Implementation: outcome not desired; no reason to contact healthcare provider; order is valid and appropriate for situation
During the admission interview, the client reports a red, itchy raised rash on the chest and lip swelling after use of aspirin and penicillin. The admission orders include bed rest, soft diet as tolerated, naproxen (Naprosyn), and cefaclor (Ceclor). Which is the BEST description of expected breath sounds heard during auscultation?
1. Administer the Ceclor as ordered; do not administer the naproxen.
2. Administer the naproxen as ordered; do not administer the Ceclor.
3. Administer both the Ceclor and naproxen as ordered; document the client's response.
4. Do not administer the Ceclor or naproxen; notify the healthcare provider. - ANSWER 1) Implementation: outcome not desired; cephalosporins have cross-allergies with penicillins
2) Implementation: outcome not desired; NSAIDs should be used cautiously with aspirin allergies
3) Implementation: outcome not desired; both medications should be withheld due to allergies
4) CORRECT - Implementation: outcome desired; both medications should be withheld; risk of hypersensitivity reaction
The nurse teaches a client about how to care for an ileostomy. Which comment, if made by the client to the nurse, indicates further teaching is needed?
1. "The skin around the stoma should be cleaned with warm water and thoroughly dried."
2. "The appliance should fit snugly around the ileostomy opening."
3. "I should take polyethylene glycol (MiraLax) with a large glass of water."
4. "I will continue to take a daily multi-vitamin." - ANSWER 1) Implementation: outcome desired; standard of care for ileostomy
2) Implementation: outcome desired; ileostomy drainage is liquid and very alkaline; great risk of skin irritation
3) CORRECT - Implementation: outcome not desired; osmotic laxative and is contraindicated; avoid enteric-coated or capsule medication, which may not be absorbed through GI tract
4) Implementation: outcome desired; inform healthcare provider and pharmacist about ileostomy
The nurse cares for a client diagnosed with chronic bronchitis and peripheral vascular disease. The nurse expects to assess which of these breath sounds?
1. Continuous, high-pitched musical sounds heard on expiration.
2. Soft, high-pitched interrupted sounds heard on inspiration.
3. Deep, low-pitched rumbling sounds are heard mainly on expiration.
4. Harsh, grating sounds heard best during inspiration. - ANSWER 1) Assessment: outcome not expected; sibilant wheezes, heard with asthma, caused by narrow bronchioles
2) Assessment: outcome not expected; crackles, heard with pneumonia and CHF, caused by fluid in the alveoli
3) CORRECT - Assessment: outcome expected; sonorous wheezes or rhonchi, caused by mucus in the airways; excessive mucous production is primary symptom
4) Assessment: outcome not expected; pericardial friction rub, caused by inflamed pleura or pericarditis
The nurse prepares to administer gentamicin (Garamycin) to the 65-year-old client. Which is the MOST important action for the nurse to take prior to administration of the medication?
1. Request a daily hemoglobin and hematocrit test.
2. Monitor the serum BUN and creatinine.
3. Request a highly-sensitive C-reactive protein (hs-CRP) test.
4. Monitor the erythrocyte sedimentation rate (ESR). - ANSWER 1) Assessment: outcome not priority; may cause anemia, but not usually seen
2) CORRECT - Assessment: outcome priority; nephrotoxic; will see proteinuria, oliguria, hematuria, thirst, increased BUN, decreased creatine clearance
3) Assessment: outcome not priority; will be increased in inflammation and rheumatoid arthritis
4) Assessment: outcome not priority; will be increased with any inflammatory process
The nurse cares for the client in the labor unit. During the transitional phase of labor, the umbilical cord becomes prolapsed. It is MOST important for the nurse to take which action?
1. Place the client on her back with thighs flexed on her abdomen.
2. Place the client on her left side with legs flexed.
3. Place the client supine with the head of the bed elevated 30°.
4. Place the client supine with the foot of the bed elevated. - ANSWER 1) Implementation: outcome not desired; lithotomy position; will not decrease pressure on umbilical cord
2) Implementation: outcome not desired; position used to remove weight of fetus from vena cava to prevent maternal hypotension; will not help with prolapsed cord
3) Implementation: outcome not desired; would aggravate prolapsed cord pressure
4) CORRECT - Implementation: outcome desired; Trendelenburg or knee chest position desired to decrease pressure on umbilical cord
The nurse cares for the client diagnosed with lung cancer. The family states that the client has become confused and that urinary output has decreased during the previous 24 hours. Which finding MOST concerns the nurse?
1. 2+ pitting pretibial edema.
2. Sodium 128 mEq/L.
3. Weight gain of 2 kg in 24 hours.
4. Urine specific gravity 1.008. - ANSWER 1) Assessment: outcome desired but not priority; edema not seen with SIADH even though water is retained; needs to be monitored
2) CORRECT - Assessment: outcome desired and priority; normal sodium range is 135-145 mEq/L, dilutional hyponatremia due to SIADH; client is neurologically depressed with increased risk of seizures
3) Asssessment: outcome desired but not priority; indicates fluid retention, not as important as hyponatremia; important to watch trends in weight
4) Assessment: outcome not desired; 1.008 indicates that urine is very dilute; with SIADH, urine will have high concentration and specific gravity due to excess ADH secretion
The home care nurse cares for a client who is diagnosed with hypertension and mild depression. The client's daughter states that her mother has been falling frequently. WWhich response by the nurse is BEST?
1. "Let's get your mother a walker."
2. "Do you think it's time to put your mother in a nursing home?"
3. "When does your mother fall?"
4. "Does your mother seem to be more confused lately?" - ANSWER 1) Implementation: outcome not desired; need to assess first
2) Assessment: outcome not priority; "yes/no" question; doesn't help determine the problem
3) CORRECT - Assessment: outcome priority; nurse needs to determine what the problem is before implementing; recent history of falling is most important contributor to increased risk of falls
4) Assessment: outcome not priority; "yes/no" question is non-therapeutic; need to assess; may be a contributing factor
A femoral angiogram is scheduled for a client. It is MOST important for the nurse to take which action prior to the angiogram?
1. Clean and shave the catheter insertion-site area.
2. Locate and note the presence of peripheral pulses.
3. Encourage the client to increase oral fluid intake.
4. Teach coughing and deep-breathing exercises. - ANSWER 1) Implementation: outcome not desired; cleansing may be done according to facility policy; shaving may not be recommended due to possible abrasions and increased risk of infection
2) CORRECT - Assessment: outcome desired and priority; pulse location may be marked according to facility policy; important to get baseline assessment of color, motion, temperature and sensitivity of extremities as well as strength and equality of pulses
3) Implementation: outcome not desired; NPO 8 hours prior to test; dye may cause possible nausea; fluid intake should be increased after procedure to clear dye and reduce risk of renal toxicity
4) Implementation: outcome desired but not highest priority; not at greatly increased risk for atelectasis
A child sustains a crushing chest injury in a car accident. In the emergency room, an endotracheal tube is inserted. Several hours later the nurse enters the client's room and finds the child in respiratory distress. It is MOST important for the nurse to take which action prior to the angiogram?
1. Observe the color of the client's fingernail beds.
2. Assess the client's blood pressure in both arms.
3. Listen to the client's breath sounds.
4. Assess for intercostal retractions. - ANSWER 1) Assessment: outcome desired but not priority; cyanosis is a late sign of respiratory distress; central cyanosis will occur later than peripheral cyanosis
2) Assessment: outcome not desired; priority is to assess respiratory status; blood pressure may change due to decreased arterial oxygen levels; priority is to correct underlying problem
3) CORRECT - Assessment: outcome priority; will give early and clearest indication of respiratory status, will hear changes with narrowed airways, fluid in alveoli or pneumothorax
4) Assessment: outcome desired but not priority; late indication of respiratory distress; intercostal muscles are accessory muscles
The nurse cares for an elderly man diagnosed with Alzheimer's disease. It is MOST important for the nurse to take which action?
1. Leave the television on all day in the client's room.
2. Frequently inform the client of the room and bathroom location.
3. Provide the client with newspapers and magazines.
4. Assign a staff member to check on the client every 15 minutes. - ANSWER 1) Implementation: outcome not desired; does not address orientation needs; risk of overstimulation; television should be on intermittently
2) CORRECT - Implementation: outcome desired; provides for safety needs and frequent orientation
3) Implementation: outcome not priority; does not address safety needs or orientation
4) Implementation: outcome desired not priority; addresses safety but not orientation or stimulation needs
The nurse is responsible for triage of injured residents of an apartment building that collapsed during a tornado. Which client should the emergency personnel see FIRST?
1. A 38-year-old client with potential fracture left femur. Blood pressure 110/78, pulse 92/minute, shallow respirations at 16/minute.
2. A 42-year-old client with ecchymotic areas on the left anterior and posterior chest. Blood pressure 142/90, pulse 88/minute, shallow respirations at 20/minute.
3. A 48-year-old client with severe head trauma. Blood pressure 168/52, pulse 58 per minute, irregular respirations at 12/minute.
4. A 64-year-old client complaining of left hand and wrist pain asking, "Where am I?" Blood pressure 128/72, pulse 88/minute, respirations unlabored at 16/minute. - ANSWER 1) Potential for hemorrhage or fatty embolism; eliminate second
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