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Evolve: Comprehensive Exam 2

Terms in this set (124)

1. A parent whose 12-year-old child has been inhaling paint fumes asks the nurse, "Can he become addicted to paint fumes?" What is the best response for the nurse to provide?

A. Any time you use an illegal substance, you are abusing drugs.
B. Tell me what you think may have caused him to start inhaling paint fumes.
C. Only hard drugs like cocaine and heroin can cause problems with addiction.
D. Abuse of any of the inhalants can eventually lead to addiction.
D. Abuse of any of the inhalants can eventually lead to addiction.

Any inhalant can become addictive. Any substance that is used to alter perception can be addictive and is not limited to the common street drugs.
2. A young adult female is brought to the emergency room by family members who report that she ingested a large quantity of acetaminophen (Tylenol). The nurse should prepare for which treatment to be implemented?

A. Gastric lavage with normal saline.
B. IV administration of Narcan.
C. Syrup of ipecac per nasogastric tube.
D. Acetylcysteine (Mucomyst) 140 mg/kg.
- Acetylcysteine (Mucomyst) 140 mg/kg.

Mucomyst (D) is the antidote for acute acetaminophen (Tylenol) poisoning and is the treatment of choice for an overdose. (B) is used for an overdose of narcotics. (C) is used for ingestion of non-corrosive products such as iron tablets. (A) might also be implemented, depending on the amount of drugs ingested and the time elapsed since ingestion.
3. An 8-year-old male client with nephrotic syndrome is in remission following treatment with prednisone (Deltasone). The nurse should teach the child to check his urine for which finding?

A. Ketones.
B. Protein.
C. White blood cells.
D. Glucose.
B. Protein.

Children should be taught to check for protein (albumin) (B) in the urine daily, because a positive reading for protein in the urine is often the only indicator of a relapse of nephrotic syndrome. (C) is an indication of infection. (A and D) should be assessed while the child is receiving corticosteroid therapy, since corticosteroids increase blood glucose.
4. When making a home visit to a family with a teething 4-month-old, what information is most important for the nurse to provide the parents?

A. No action is required for the common symptoms associated with teething, which include drooling, irritability, and poor sleeping.
B. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention.
C. Though child development is characterized by individual differences, first teeth usually erupt during the seventh month.
D. Providing cooled teething toys can help decrease the discomfort associated with tooth eruption.
B. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention.

A slight fever that persists longer than three days is likely to be associated with a pathological process, not teething, and the parents should seek the attention of their healthcare provider if it occurs (B). (A, C, and D) provide useful information about teething, but do not have the priority of (B).
5. To treat cystitis, a 14-day course of treatment with cephalexin (Ceclor) is prescribed for a client residing in a long-term care facility. Which action is most important for the nurse to take prior to administering the first dose of this medication?

A. Take the client's vital signs prior to the first dose and once daily for 14 days.
B. Determine if the client has ever had a hypersensitivity reaction to penicillins.
C. Review the client's fasting blood glucose levels for a hyperglycemic trend.
D. Restrict the use of dairy products in the client's diet for the next 3 weeks.
B. Determine if the client has ever had a hypersensitivity reaction to penicillins.

Most individuals who have an allergy to penicillins (B) are at risk of hypersensitivity to cephalosporins. To prevent a potential hypersensitivity reaction that could cause a life-threatening episode of anaphylactic shock, the nurse must determine if the client has a known penicillin allergy before giving the client a cephalexin (Ceclor) dose. (A, C, and D) are not required interventions for the administration of cephalexin (Ceclor).
6. A staff member tells the charge nurse that a float nurse assigned to work on the unit has made several medication errors in the past, but is currently working with the education department to improve this skill. What action is best for the charge nurse to take?

A. Arrange for someone to be available to assess and assist the float nurse.
B. Assign the float nurse to function as a UAP for the day.
C. Dismiss the staff nurse's report about the float nurse because it may be just gossip.
D. Call the nursing supervisor and request a different employee be sent to the unit.
A. Arrange for someone to be available to assess and assist the float nurse.

The float nurse is receiving education, but careful assessment of her or his skills and assistance, as needed, is still warranted, so (A) is the best choice. Though the staff member's report may indeed be gossip, failure to pay attention to the information could constitute negligence on the part of the charge nurse (C). (D) is not the best way to manage the unit. (B) is not the best use of a licensed person and would also eliminate the float nurse's opportunity to improve medication administration skills.
7. The blood pressure readings obtained by a unlicensed assistive personnel (UAP) are consistently different from those obtained by other staff members. What action should the charge nurse take first?

A. Ask the education department to provide additional training for the UAP.
B. Observe the UAP performing blood pressure measurements.
C. Make staff members aware of the possible errors in blood pressure readings.
D. Counsel the UAP about the inaccurate blood pressure readings.
B. Observe the UAP performing blood pressure measurements.

The charge nurse should first observe the UAP's performance (B), then take appropriate action, which might include (A, C and D).
8. A client at 13-weeks' gestation is scheduled for an amniocentesis in one week. The nurse knows that the primary reason for conducting this procedure is to obtain what information?

A. Quantification of alpha-fetoprotein levels.
B. Level of fetal lung maturity.
C. Presence of genetic disorders.
D. Determination of gestational age.
C. Presence of genetic disorders.

Amniocentesis is done at 14 to 16 weeks' gestation to determine chromosomal, genetic, and metabolic disorders (C). Amniocentesis in the third trimester assesses fetal lung maturity (B) by evaluating the lecithin/sphingomyelin (L/S) ratio and the presence of phosphatidylglycerol (PG). Amniocentesis is performed to quantify alpha-fetoprotein levels (A) after abnormal maternal serum alpha-fetoprotein levels (done at 15 to 18 weeks) are found. While specific levels of creatinine, bilirubin, and lipid cells are present in amniotic fluid only after 35 to 36 weeks' gestation, gestational age (D) is commonly evaluated by ultrasound.
9. A hospitalized 5-year-old boy recovering from surgery refuses to drink fluids. Which intervention is best for the nurse to implement?

A. Ask the parents to participate in encouraging the child's fluid intake.
B. Offer the child a popsicle and allow him to pick the flavor he prefers.
C. Tell the child he can go outside after he drinks a full glass of water.
D. Make a game of seeing who can finish a glass of water first--the nurse or the child.
B. Offer the child a popsicle and allow him to pick the flavor he prefers.

Fluids in popsicle form (B) are an excellent choice for a child, and small children react best when they are provided with possible choices, such as choosing a flavor. (D) is a good intervention, but (B) is better. (C) is manipulative and the nurse must be careful not to make promises that may not be possible. Although (A) may be useful, it may also be manipulative and is not as likely as (B) to obtain the ultimate goal of increasing fluids.
10. An overweight adolescent girl has been to the school nurse three times in the last two months complaining of vaginal and urinary tract infections. What action should the nurse take first?

A. Counsel the girl regarding hygiene.
B. Ask if she is going to the bathroom frequently.
C. Teach the girl the importance of practicing safe sex.
D. Encourage the girl to see the school counselor.
B. Ask if she is going to the bathroom frequently.

All actions might be implemented, depending on further assessment findings. However, based on the data presented, the nurse should ask questions directed toward symptoms of diabetes (B). Recurrent vaginal and urinary tract infections are often an early sign of IDDM. (A, C, and D) require further assessment data to support their implementation.
11. About mid-morning, a 10-year-old child reports to the school nurse complaining of nausea, dizziness, and chills. Further assessment reveals that this child is sweating profusely and has a blood glucose level of 57 mg/dl. Based on these assessment findings, which food is best for the nurse to encourage the child to eat?

A. A piece of bubble gum.
B. Peanut butter crackers.
C. A chocolate bar.
D. A soft drink.
B. Peanut butter crackers.

Peanut butter crackers (B) provide a complex carbohydrate, plus protein and fat. This child is exhibiting signs and symptoms of mild to moderate hypoglycemia and needs to eat about 15 grams of carbohydrates to increase the blood sugar level. Complex carbohydrates are broken down more slowly and are slower acting than simple sugars, so they prevent the blood glucose level from peaking and then dropping precipitously. (A, C, and D) contain only simple sugars.
12. When examining the wound of a client who had abdominal surgery yesterday, the nurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take?

A. Observe closely for possible dehiscence.
B. Increase the IV fluid rate and encourage the client to eat more ice chips.
C. Notify the healthcare provider that the client's wound is producing a sanguineous drainage.
D. Record these findings in the client's record.
D. Record these findings in the client's record.

These are normal findings for one-day postoperative and indicate that the wound is healing by primary intention (D). Dehiscence (A) is separation of a surgical incision, and there is no indication that this is a possibility at this time. Serosanguineous drainage is thin and red and is composed of serum and blood, and this client is not exhibiting this finding, and even if the wound was producing this drainage, the finding does not warrant (C). There is no indication of dehydration, so (B) is not indicated at this time.
13. When culturing a wound, the nurse should obtain the sample from which part of the wound?

A. Any particularly painful area of the wound.
B. All necrotic sections of the wound.
C. Areas containing purulent or pooled exudates.
D. The outer edges of the wound.
C. Areas containing purulent or pooled exudates.

To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions (C), then return the swab to the culturette tube, cap the tube, and crush the inner ampoule so that the medium for the organism growth coats the swab. The culture should not be collected from (A, B, or D).
14. The nurse administers dopamine (Intropin) IV infusion at 3 mcg/kg/min to a critically ill, hypotensive client. What is the intended effect of this treatment? To increase

A. urine output to 55 mL/hr.
B. pulse to 132 beats/min.
C. respirations to 24 breaths/min.
D. blood pressure to 140/80.
A. urine output to 55 mL/hr.

The expected outcome of this treatment is an increase in urine output due to increased renal perfusion (A). Dopamine, a catecholamine, provides renal and mesenteric vasodilation at a low dosage level, such as the 3 mcg/kg/minute infusion that was prescribed for this client. A higher dose of dopamine is needed to affect (B or C) to the levels indicated in a critically ill client who is hypotensive. (D)'s effect would be minimal.
15. Yesterday a female client who is delusional told the nurse that her healthcare provider needs to be released from her case because they are going to get married on her birthday. Which statement made by the client today indicates that the client is less delusional?

A. I think I should talk about this in group.
B. I really wish that my birthday wasn't so soon.
C. The doctor won't talk with me about this.
D. I don't talk about things like that anymore.
D. I don't talk about things like that anymore.

When the client states that she doesn't want to talk about things like that anymore (D), she is likely less delusional, because when a client begins to question the delusional belief or stops talking about it, the client is becoming less delusional. (A, B and C) lack evidence that the client no longer maintains the delusion.
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