Practice Qs Flashcards
(41 cards)
The adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse’s first response?
A. “It is important that you continue your medication while learning to meditate”
B. “Spiritual meditation requires a time commitment of 15 to 20 minutes daily.”
C. Obtain your HCP permission before starting meditation.
D. Complementary therapy and western medicine can be effective for you.
A.
The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued.
A client receiving supplemental oxygen needs to be suctioned to remove excess secretions from the airway. Which intervention should the practical nurse implement to maximize the client’s oxygenation?
A. Encourage deep breathing prior to suctioning.
B. Increase the oxygen flow rate during suctioning attempts.
C. Provide oxygen during rest periods between suctioning.
D. Limit suctioning attempts to five second intervals.
C. Provide oxygen during rest periods between suctioning.
When a client is unable to effectively clear respiratory tract secretions with coughing, suctioning with oxygen during rest periods of 10 to 15 seconds between suction attempts should be provided to ensure maximal oxygenation.
A young woman, who is the primary caregiver for her mother who has Alzheimer’s disease, tells the practical nurse (PN), “Sometimes I hate my mother for living this long and my Dad for dying and not caring for her.” What response should the PN offer?
A. What you do to cope with these feelings?
B. Have you told your family how you feel?
C. It’s normal feel these emotions when you are stressed.
D. Don’t worry, at least you can talk about your angry
A. What you do to cope with these feelings?
A response that invites the client to share feelings and perceptions is the most therapeutic communication.
Which action should the practical nurse (PN) follow when applying an elasticized bandage to a client’s leg?
A. Secure the end with metal clips.
B. Overlap turns of the bandage equally.
C. Adjust the tension as needed.
D. Wrap from the proximal to distal end.
B. Overlap turns of the bandage equally.
The practical nurse (PN) obtains an elevated blood pressure reading for an older male client who is alert. When the PN offers the client his morning blood pressure medication, he refuses to take it. What action should the PN take?
A. Mixed the crushed medication in his breakfast oatmeal.
B. Explain the importance of routine use of antihypertensives.
C. Tell the client that he should not refuse his prescriptions.
D. Document that the client refused to take the medication.
B. Explain the importance of routine use of antihypertensives.
A client has the right to refuse any medication but should be informed of the therapeutic value of routine compliance with taking antihypertensive medications.
The practical nurse (PN) hears breath sounds that are short, popping, and discontinuous on inspiration when auscultating a client’s lungs. Which description should the PN document in the client’s record?
A. Wheezes present.
B. Crackles auscultated.
C. Pleural friction rub noted.
D. Bronchovesicular sounds heard.
B. Crackles are short, popping, discontinuous sounds heard on inspiration.
The practical nurse (PN) is obtaining information for a male client’s psychosocial assessment. Which action should the PN implement first?
A. Determine the value the client places on his health
B. Establish a therapeutic relationship
C. Determine is he has abnormal behaviors
D. Ask the client to share info about his past
B. Establish a therapeutic relationship
A client is prescribed a medication that is labeled as a sustained released (SR). What action should the practical nurse (PN) implement when administering this drug form?
A. Instruct the client to chew the medication.
B. Do not crush or dissolve the tablet or capsule contents.
C. Obtain a different drug form for administration.
D. Delay giving the medication until the stomach is empty.
B. Sustained-release tablets or capsules are drug forms that are coated and delay dissolution over a period of time and should not be crushed or dissolved for administration
The nurse is instructing a client with high cholesterol about diet and lifestyle modification. What comment from the client indicates that the teaching has been effective?
A. “If i exercise at least two times weekly for one hour, I will lower my cholesterol.”
B. “I need to avoid eating proteins, including red meat.”
C. “I will limit my intake of beef to 4 oz per week.”
D. “My blood level of low density lipoproteins.”
C.
Limiting saturated fat from animal food sources to no more than 4 oz per week is important diet modification for lower cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4-6 times per week.
What nutritional assessment data should the nurse collect to best reflect total muscle mass in the adolescent?
A. Height in Inches or centimeters.
B. Weight in kilograms or pounds.
C. Triceps skin fold thickness
D. Upper arm circumference
D.
Upper arm circumference is an indirect measure of muscle mass. A and B do not distinguish between fat and muscularity. C is a measure of body fat.
The client who is in the hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic Q4H as needed. Which action should the nurse implement?
A. Give an around the clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities
A.
The most effective management of pain is achieved using an around the clock schedule that provides analgesic medication on a regular basis and in a timely manner.
An unlicensed assistive personnel (UAP) places a client in the left lateral position prior to administration a soap suds enema. Which instruction should the nurse provide the UAP?
A. Position the client on the right side of the bed in reverse Trendelenburg.
B. Fill the enema container with 1000 ml of warm water and 5 ml of Castile soap.
C. Reposition in a Sims position with the clients weight on the anterior ilium
D. Raise the side rails on both sides of the bed and elevate the bed to waist level.
C.
The left sided sims position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results.
A client who is 5’5 tall and wieghs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse t0 include during the preoperative assessment?
A. What is your daily caloric consumption?
B. What vitamin and mineral supplements do you take?
C. Do you feel that you are overweight?
D. Will a clear liquid diet be okay after surgery?
B.
Vitamin and mineral supplements may impact medications used during the operative period.
What action should the nurse implement when accessing the implanted infusion port for a client who receives long term IV medications?
A. Cleanse the site with iodine solution
B. Insert a Huber-point needle into the port
C. Flush the tubing with 5 ml of NS
D. Place a sterile dressing over the port
B.
An implanted infusion port needs to be accessed using a huber-point needle to prevent damage to the self sealing septum of the port
A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline with potassium chloride 20 meq at 83 ml/hr. The clients eight hour urine output is 400 ml, BUN is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl and the serum potassium is 3.7 meq/L. Which action is most important for the nurse to implement?
A. Notify the HCP and request to change the IV infusion to hypertonic D10W
B. Decrease the infusion rate of the current IV and report to the HCP
C. Document in the medical record that these normal findings are expected outcomes
D. Obtain potassium chloride 20 meq in anticipation of a prescription to add to present IV
C.
The results are all within normal range
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint
B. Apply a pulse oximeter to the right hand
C. Compare hand color bilaterally
D. Palpate the right radial pulse
A.
The priority nursing action is to restore circulation by loosening the restraint, because blue fingers indicates decreased circulation.
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?
A. Infuse normal saline at a keep vein open rate.
B. Discontinue the IV and flush the port with heparin.
C. Infuse 10 percent dextrose and water at 54 ml/hr.
D. Obtain a stat blood glucose level and notify the healthcare provider.
TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation.
Correct Answer: C
Which action is most important for the nurse to implement when donning sterile gloves?
A. Maintain a thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above elbows.
D. Put the glove on the dominant hand first.
C
Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D).
The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer.
A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation.
Correct Answer: B
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first?
A. Reaffirm the client’s desire for no resuscitative efforts.
B. Transfer the client to a hospice inpatient facility.
C. Prepare the family for the client’s impending death.
D. Notify the healthcare provider of the family’s request.
The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented.
Correct Answer: D
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?
A. Adequate venous blood flow to the lower extremities.
B. Estimated amount of body fat by an underarm skinfold.
C. Degree of flexion and extension of the client’s knee joint.
D. Change in the circumference of the joint in centimeters.
The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D).
Correct Answer: C
When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices?
A. Complimentary healing practices interfere with the efficacy of the medical model of treatment.
B. Conventional medications are likely to interact with folk remedies and cause adverse effects.
C. Many complimentary healing practices can be used in conjuntion with conventional practices.
D. Conventional medical practices will ultimately replace the use of complimentary healing practices.
C
Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D).
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes.
Correct Answer: C
An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers?
A. Generalized dry skin
B. Localized dry skin on lower extremities
C. Red flush over entire skin surface
D. Rashes in the axillary, groin and skin fold regions.
D
Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown and teh development of pressure ulcers (A, B, and C) do not address the concepts of inflammation and tissue integrity.