D D Nursing Educators - Physiological integrity

50 terms by jespinosa1984 

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When caring for a client with head trauma, the nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do?

a) Test the nasal drainage for glucose.
b) Look for a halo sign after the drainage dries.
c) Have the client blow his nose.
d) Keep the client in a supine position.

a) Test the nasal drainage for glucose.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention would reduce the client's risk of increased intracranial pressure (ICP)?

a) Encouraging oral fluid intake
b) Suctioning the client once each shift
c) Elevating the head of the bed 90 degrees
d) Administering a stool softener as prescribed

d) Administering a stool softener as prescribed

A child has been diagnosed with a brain tumor, but surgery cannot be scheduled for several days. The mother asks what she can do to ease her child's headaches. The nurse suggests that the mother:
a) Help the child to drink plenty of liquids.
b) Discourage the child from having a bowel movement.
c) Encourage the child to sleep in a semi-Fowler's position.
d) Encourage the child to blow the nose when headaches become severe.

c) Encourage the child to sleep in a semi-Fowler's position.

The nurse planning care for a client who suffered a cerebrovascular accident (CVA) with residual dysphagia would write on the care plan to avoid doing which of the following during meals?

a) Feed the client slowly.
b) Give the client thin liquids.
c) Give foods with the consistency of oatmeal.
d) Place food on the unaffected side of the mouth.

b) Give the client thin liquids.

Which of the following statements made by the client with migraine headaches would indicate to the nurse that she has understood client teaching regarding migraine medication?
a) "I will be keeping a diary of my headaches to see if there is a pattern."
b) "I will be able to stop my exercise program since it has not helped my headaches."
c) "I will take my headache medication every 4 hours."
d) "I will never be able to drive again due to my headaches."

a) "I will be keeping a diary of my headaches to see if there is a pattern."

A client is scheduled for an electroencephalogram (EEG) early in the morning. The nurse working the night shift prior to the procedure would write a note to do which of the following per protocol in the early morning on the day of the test?

a) Instruct the client to refrain from washing the hair.
b) Hold the daily dose of anticonvulsant.
c) Place the client on NPO status.
d) Reinforce client teaching that the test is only mildly uncomfortable.

b) Hold the daily dose of anticonvulsant.

After a magnetic resonance imaging (MRI) to rule out an expanding brain lesion, the nurse prepares the client for a lumbar puncture. Client teaching would include:

a) The risk of paralysis because the needle is inserted through the spinal cord.
b) Maintaining a full bladder for better visualization.
c) Keeping his or her head flat to avoid a headache.
d) Directions to straighten the legs slowly.

c) Keeping his or her head flat to avoid a headache.

When teaching a client about home management following cataract removal with lens implant surgery, the nurse should include which of the following? Select all that apply.
a) Take a stool softener and/or laxative daily to prevent constipation.
b) No lifting or bending over for at least 6 weeks.
c) Shampoo the hair daily with mild soap.
d) Stay on strict bedrest until you return to the doctor in 3 weeks.
e) Wash the face and around the eyes 3 times daily.

a) Take a stool softener and/or laxative daily to prevent constipation.
b) No lifting or bending over for at least 6 weeks

In the client with right lung pneumonia, the nurse should encourage which of the following positions to facilitate optimal oxygenation?

a) Prone position
b) Supine position with head elevated 30 degrees
c) Positioned with the right side dependent
d) Positioned with the left side dependent

d) Positioned with the left side dependent

A client has a chest tube inserted for a pneumothorax. The nurse monitors the drainage system for adequacy. Which of the following signifies that the system is working correctly?

a) There is no fluctuation in the water-seal compartment.
b) Constant bubbles are noted in the water-seal without fluctuation.
c) There are no bubbles noted in the water-seal compartment.
d) There is fluctuation in the water-seal compartment coinciding with respirations.

d) There is fluctuation in the water-seal compartment coinciding with respirations.

The nurse is caring for a client who has just had a cardiac catheterization. The client insists on getting up to go to the bathroom to urinate immediately when brought back to the room. Which of the following would be the nurse's best response?
a) "You can't walk yet. You may be too weak after the procedure and may fall."
b) "If you bend your leg, you will risk bleeding from the insertion site. It is an artery, and it could lead to complications."
c) "If you get out of bed, you may have an arrhythmia from the catheterization. Your heart has to rest after this procedure."
d) "The doctor has ordered that you stay on bed rest for the next 6 hours. It is important that you follow these orders."

b) "If you bend your leg, you will risk bleeding from the insertion site. It is an artery, and it could lead to complications."

A client has just received a Holter cardiac monitor to wear for the next 24 hours. The nurse determines that the client understands its use when the client makes which of the following statements?
a) "I should write in the diary what I am doing every half hour."
b) "I should only take a bath, not a shower, for the next 24 hours."
c) "I can continue with my usual activity and exercise pattern while wearing the monitor."
d) "I need to try to walk a total of 3 miles over the next 24 hours while wearing the monitor."

c) "I can continue with my usual activity and exercise pattern while wearing the monitor."

The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client is developing pulmonary edema after observing which change in the client?

a) Bradycardia
b) Increased urination
c) Cough with pink, frothy sputum
d) Increased sleepiness

c) Cough with pink, frothy sputum

A client has been admitted to the hospital with chest pain. The client's symptom has not been relieved after 1 dose of nitroglycerine (NTG) sublingually. The nurse monitors the vital signs (VS) and notices they are stable. Which of the following indicates the next appropriate action?
a) Notify the physician.
b) Obtain an electroencephalogram (EEG).
c) Give another dose of nitroglycerine.
d) Add a dose of nitroglycerine paste.

c) Give another dose of nitroglycerine.

A client has just received a Holter cardiac monitor to wear for the next 24 hours. The nurse determines that the client understands its use when the client makes which of the following statements?
a) "I should write in the diary what I am doing every half hour."
b) "I should only take a bath, not a shower, for the next 24 hours."
c) "I can continue with my usual activity and exercise pattern while wearing the monitor."
d) "I need to try to walk a total of 3 miles over the next 24 hours while wearing the monitor."

c) "I can continue with my usual activity and exercise pattern while wearing the monitor."

The client had abdominal surgery 5 weeks ago, and now is having leg pains. What activities could the nurse have performed when the client was hospitalized that would have minimized this complication's risk? Select all that apply.
a) Turn the client every 2 hours.
b) Increase the fluid intake to at least 8 ounces per hour.
c) Tell the client to avoid crossing the legs.
d) Instruct the client to wear pneumatic compression devices while in bed.

a) Turn the client every 2 hours
c) tell the client to avoid crossing the legs
d) instruct the client to wear pneumatic compression devices while in bed.

A client receiving a unit of packed red blood cells (RBCs) begins to complain of chills, temperature is 101.4º F, pulse is 185, and blood pressure is 80/50. The nurse should do which of the following first?

a) Call the physician.
b) Send the blood bag to the laboratory.
c) Stop the transfusion and flush the line.
d) Continue to record the VS and monitor the client every 5 minutes.

c) Stop the transfusion and flush the line.

A client with acute leukemia is admitted for a bone marrow transplant. The nurse concludes that the client understands teaching based on which of the following statements?

a) "The bone marrow will be transplanted into my iliac crest."
b) "The bone marrow is given to me through an intravenous line."
c) "The bone marrow will be transplanted into my sternum."
d) "The bone marrow is injected into my muscle."

b) "The bone marrow is given to me through an intravenous line."

A client receiving chemotherapy is experiencing mild stomatitis. Based on an understanding of this complication, the nurse will teach the client which of the following measures?

a) Brush teeth with a soft toothbrush before and after meals.
b) Rinse mouth with mouthwash before and after meals.
c) Rinse mouth with warm hydrogen peroxide twice daily.
d) Drink hot liquids regularly.

a) Brush teeth with a soft toothbrush before and after meals.

Which diagnostic results would you expect to find in the client who has been newly diagnosed as having acquired immunodeficiency syndrome (AIDS)?

a) T cell count of 400
b) Negative enzyme-linked immunosorbent assay (ELISA)
c) Platelet count of 500,000/mm3
d) CD 4/CD 8 test of 1.5

a) T cell count of 400

A client with hypocalcemia has been started on intravenous (IV) corticosteroids. Which of the following findings would indicate to the nurse a further decrease in calcium level in the client?

a) Absence of Trousseau's sign
b) Positive Chvostek's sign
c) Muscle weakness
d) Frequent urination

b) Positive Chvostek's sign

A diabetic client tells the nurse that he has some early signs of hypoglycemia. The nurse recommends to the client to:

a) Take an extra injection of regular insulin.
b) Drink a glass of orange juice.
c) Skip the next dose of insulin.
d) Start exercising.

b) Drink a glass of orange juice.

The client who has a long history of type 1 diabetes mellitus is being treated for bronchitis and sinusitis. The nurse observes deep, rapid, unlabored respirations, fruity odor on the client's clothes, and dry skin. Which of the following actions should the nurse take next?

a) Auscultate breath sounds for additional signs of response to treatment of the infection.
b) Measure blood glucose level for hyperglycemia and check urine for ketones.
c) Measure blood glucose level for signs of hypoglycemia.

b) Measure blood glucose level for hyperglycemia and check urine for ketones.

A client with a total hip replacement is concerned about dislocation of the prosthesis. What can the nurse say to reassure this client?

a) "Avoiding activities that cause adduction of the hip to prevent dislocation."
b) "Use of elevated toilet seats alone will prevent dislocation."
c) "Perform bending exercises as often as able to prevent dislocation."
d) "Remove the foam abduction pillow as soon as possible postoperatively."

a) "Avoiding activities that cause adduction of the hip to prevent dislocation."

A client is taking epoetin alfa (Epogen) for treatment of anemia related to chronic renal disease. What clinical finding reveals to the nurse that this medication is working effectively?
a) The client is not experiencing any related bone pain when the medication is being administered.
b) The client's hemoglobin and hematocrit levels are rising rapidly based on the latest two daily blood draws.
c) The client's hematocrit is in the established target range at 33%.

c) The client's hematocrit is in the established target range at 33%.

A child with a confirmed diagnosis of appendicitis has been scheduled for an emergency appendectomy. Suddenly, the child states his pain is much less. The best interpretation of this is that:

a) He is tolerating the pain much better.
b) There is a possibility the appendix has ruptured.
c) His level of consciousness has decreased.
d) Perhaps the problem has been resolved.

b) There is a possibility the appendix has ruptured.

The nurse should anticipate the client with a gastric ulcer to have pain:

a) two to three hours after a meal.
b) at night.
c) relieved by ingestion of food.
d) one-half to one hour after a meal.

d) one-half to one hour after a meal.

The nurse is caring for a male patient with a colostomy. When teaching the patient how to care for his colostomy, the nurse would instruct the patient that the MOST important intervention is to:

a) avoid gas-producing foods that will produce painful flatus
b) use a catheter with a shield
c) clear all air from tubing before irrigation
d) keep skin around the stoma area free of feces

d) keep skin around the stoma area free of feces

The nurse in the outpatient clinic teaches a client with right-sided weakness to walk down stairs using a cane. What behavior, if demonstrated by the client, would indicate that teaching was successful?
a) The client puts her right leg on the step, then the cane, followed by her left leg.
b) The client leads with the cane, followed by her right leg, and then her left leg.
c) The client advances her right leg, followed by her left leg and the cane.

b) The client leads with the cane, followed by her right leg, and then her left leg.

An intravenous pyelogram (IVP) is ordered for a client who is scheduled to have his left kidney removed because of hypertension and renal disease. Which of the following nursing actions has the highest priority the evening prior to the IVP?
a) Administer a cathartic enema to cleanse the bowel.
b) Obtain information about client allergies.
c) Instruct the client to be NPO after midnight.
d) Teach the client that x-rays will be taken at multiple intervals.

b) Obtain information about client allergies.

The nurse is admitting a client with a history of grand mal seizures. As a precaution in case a seizure occurs, what equipment should the nurse ensure is placed in the room?

a) Oxygen with a nasal cannula and a padded tongue blade
b) Linens to pad the bed rails and a suction machine
c) A crash cart and oxygen with a nasal cannula
d) Emergency seizure medications and a padded tongue blade

b) Linens to pad the bed rails and a suction machine

The client is being observed for the risk of increasing intracranial pressure (ICP) after a closed head injury. Because of his decreased level of consciousness, he is not clearing copious pulmonary secretions on his own. What fact is most important for the nurse to recall when planning care for this client?

a) Suction through the nose is not recommended for clients who have head injuries.
b) Suction pressure should be limited to 80 to 100 mm water pressure.
c) A vagal response may be elicited during suctioning.
d) Suctioning should be avoided in clients with a closed head injury.

a) Suction through the nose is not recommended for clients who have head injuries.

After experiencing a transient ischemic attack (TIA), a client is prescribed aspirin, 325 mg P.O. daily. The nurse should teach the client that this medication has been prescribed to:

a) control headache pain.
b) enhance the immune response.
c) prevent intracranial bleeding.
d) reduce the chance of blood clot formation.

d) reduce the chance of blood clot formation.

Clients with COPD are usually in low levels of oxygen via nasal cannula. What problem would occur if these clients received too high an oxygen concentration?

a) Increased sputum production with decreased oxygen exchange
b) Respiratory rate greater than 30 breaths/minute
c) Decrease in rate and depth of respirations
d) Increased wheezing and irritability

c) Decrease in rate and depth of respirations

The nurse is caring for a client with pneumonia. Which of the following nursing observations would indicate a therapeutic response to the treatment?
a) Oral temperature of 101°F (38.3°C), increased chest pain with nonproductive cough.
b) Cough, productive of thick green sputum, client reports feeling tired.
c) Respirations at 20 with no complaints of dyspnea, moderate amount of thin white sputum.
d) White cell count of 10,000 mm3, urine output at 40 cc per hour, decreasing amount of sputum.

c) Respirations at 20 with no complaints of dyspnea, moderate amount of thin white sputum.

The home care nurse is instructing a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan?
a) During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes.
b) The client will be required to take prescribed medication for a duration of 6-9 months.
c) The family should support the client to help reduce feeling of low self-esteem and isolation.

b) The client will be required to take prescribed medication for a duration of 6-9 months.

Which of the following is true of purified protein derivative (PPD) and tuberculosis?

a) It is used to detect current infection.
b) It is used to prevent tuberculosis.
c) It is used to detect previous exposure of mycobacterial infection.
d) It is used to neutralize toxins produced by the tuberculosis bacillus.

c) It is used to detect previous exposure of mycobacterial infection.

An adult client is receiving oxygen at 6 liters/min. The client asks the nurse why the oxygen is running through bubbling water. What should be included in the nurse's reply?

a) The water cools the oxygen and makes it more comfortable.
b) Oxygen is very drying to tissues; the water humidifies it.
c) The water prevents fires when oxygen is in use.
d) The water helps to prevent infections from developing in the tubing.

b) Oxygen is very drying to tissues; the water humidifies it.

Which of the following indicates to the nurse a need for further teaching for a postoperative client using the incentive spirometer?

a) The client exhales with the spirometer in his mouth.
b) The client inhales with the spirometer in his mouth.
c) The client splints his incision before using the spirometer.
d) The client raises the head of his bed before using the spirometer.

a) The client exhales with the spirometer in his mouth.

The supervisor observes a new graduate nurse suctioning a client who has a tracheostomy. Which of the following techniques indicates that the graduate nurse is carrying out the procedure correctly?

a) Suction is applied until all secretions are removed
b) Suction is applied when the catheter is inserted
c) Suction is applied for 10 seconds
d) Suction is applied while rotating the catheter 180 degrees

c) Suction is applied for 10 seconds

The client has a chest tube attached to a portable chest drainage system. Four hours after the chest tube is inserted the nurse notes there is no bubbling in the water seal compartment. What is the most likely explanation for this?

a) The lung has re-expanded.
b) There is an obstruction in the tubing coming from the pleural cavity.
c) There is an air leak in the drainage system.
d) The suction is not turned on.

b) There is an obstruction in the tubing coming from the pleural cavity.

The nurse enters the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube is dislodged from the chest. The most appropriate nursing intervention is to:

a) notify the physician.
b) instruct the client to breathe deeply until help arrives.
c) cover the insertion site with petroleum gauze.
d) insert a new chest tube.

c) cover the insertion site with petroleum gauze.

The water-seal chamber of the patient's chest drainage set-up has stopped fluctuating. The chest tube has been in place for 4 days, and the patient is resting comfortably. What is the most probable cause for this development?

a) The patient's lung has reexpanded.
b) The tube is dislodged.
c) The suction has been turned too high.
d) A kink has occurred in the tubing.

a) The patient's lung has reexpanded.

The nurse is to obtain pedal pulses on a client following a cardiac catheterization. Which is the proper procedure?

a) Place the fingertips against the wrist bone.
b) Place the stethoscope over the apex of the heart.
c) Place the fingertips against the side of the neck.
d) Place the fingertips on top of the foot.

d) Place the fingertips on top of the foot.

A patient is admitted with severe, crushing chest pain. The medical diagnosis is possible myocardial infarction. Which data would be MOST important to collect in the initial assessment?

a) Ask the patient if there is a history of hypertension
b) Administer oxygen stat
c) Ask the patient if rest relieves the pain
d) Administer morphine stat

c) Ask the patient if rest relieves the pain

The client in the Emergency Department was diagnosed with acute myocardial infarction (MI). He asks the nurse to explain what this is. The nurse should tell him that an MI usually results from which of the following?
a) Obstruction of a coronary artery with death of tissue distal to the blockage
b) Spasm of a coronary artery causing temporary decreased blood supply
c) A slow heart rate leading to decreased blood supply to myocard
d) Dilation of the ventricular wall causing decreased blood supply

a) Obstruction of a coronary artery with death of tissue distal to the blockage

A client is receiving chemotherapy for cancer and develops thrombocytopenia. What should the nurse include in the client's plan of care because of the thrombocytopenia?

a) Place the client in a semi-upright position.
b) Limit the client's intake of fluids.
c) Administer no injections.
d) Exercise the client's lower extremities.

c) Administer no injections.

The nurse is caring for a client with type 1 diabetes mellitus. In developing a teaching plan, which of the following signs and symptoms of hypoglycemia should be included?

a) Shakiness
b) Increased thirst
c) Fever
d) Fruity breath

a) Shakiness

One of the campers at summer camp sprains his ankle. What action can the nurse take to help reduce the pain?

a) Encourage the camper to gently exercise the ankle several times every hour.
b) Apply an ice pack to the ankle.
c) Keep the leg down to encourage blood flow.
d) Apply a topical steroid ointment.

b) Apply an ice pack to the ankle.

The nurse is collecting data on a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?

a) Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg
b) Urine output of 20 ml/hour
c) White pulmonary secretions
d) Rectal temperature of 100.6° F (38° C)

b) Urine output of 20 ml/hour

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