PRACTICE TEST 4 Flashcards
A client has cancer of the liver. The nurse should be most concerned about which nursing diagnosis? ❍ A. Alteration in nutrition ❍ B. Alteration in urinary elimination ❍ C. Alteration in skin integrity ❍ D. Ineffective coping
Answer A is correct. Cancer of the liver frequently leads to severe nausea and vomiting, thus the need for altering nutritional needs. The problems in answers B, C, and D are of lesser concern and, thus, are incorrect in this instance.
The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?
❍ A. Inspection of the abdomen for enlargement
❍ B. Bimanual palpation for hepatomegaly
❍ C. Daily measurement of abdominal girth
❍ D. Assessment for a fluid wave
Answer C is correct. Daily measuring of the abdominal girth is the best method of deter- mining early ascites. Measuring with a paper tape measure and marking the measured area is the most objective method of estimating ascites. Inspection and checking for fluid waves, in answers A and D, are more subjective and, thus, are incorrect for this question. Palpation of the liver, in answer B, will not tell the amount of ascites.
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client’s most appropriate priority nursing diagnosis?
❍ A. Alteration in cerebral tissue perfusion
❍ B. Fluid volume deficit
❍ C. Ineffective airway clearance
❍ D. Alteration in sensory perception
Answer B is correct. The vital signs indicate hypo- volemic shock or fluid volume deficit. In answers A, C, and D, cerebral tissue perfusion, airway clearance, and sensory perception alterations are not symptoms and, therefore, are incorrect.
The home health nurse is visiting a 15-year-old with sickle cell disease. Which information obtained on the visit would cause the most concern? The client:
❍ A. Likes to play baseball
❍ B. Drinks several carbonated drinks per day
❍ C. Has two sisters with sickle cell trait
❍ D. Is taking Tylenol to control pain
Answer A is correct. The client with sickle cell is likely to experience symptoms of hypoxia if he becomes dehydrated or lacks oxygen. Extreme exercise, especially in warm weather, can exacerbate the condition, so the fact that the client plays baseball should be of great concern to the visiting nurse. Answers B, C, and D are not factors for concern with sickle cell disease.
The nurse on oncology is caring for a client with a white blood count of 600. During evening visitation, a visitor brings a potted plant. What action should the nurse take?
❍ A. Allow the client to keep the plant
❍ B. Place the plant by the window
❍ C. Water the plant for the client
❍ D. Tell the family members to take the plant home
Answer D is correct. The client with neutropenia should not have potted or cut flowers in the room. Cancer patients are extremely susceptible to bacterial infections. Answers A, B, and C will not help to prevent bacterial invasions and, therefore, are incorrect.
The nurse is caring for the client following a thyroid- ectomy when suddenly the client becomes nonres-ponsive and pale, with a BP of 60 systolic. The nurse’s initial action should be to:
❍ A. Lower the head of the bed
❍ B. Increase the infusion of normal saline
❍ C. Administer atropine IV
❍ D. Obtain a crash cart
Answer B is correct. Clients who have not had surgery to the face or neck would benefit from lowering the head of the bed, as in answer A. However, in this situation lowering the client’s head could further interfere with the airway. Therefore, the best answer is answer B, increasing the infusion and placing the client in supine position. Answers C and D are not necessary at this time.
The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incidence, he should take which initial action?
❍ A. Order a chest x-ray
❍ B. Reinsert the tube
❍ C. Cover the insertion site with a Vaseline gauze
❍ D. Call the doctor
Answer C is correct. If the client pulls the chest tube out of the chest, the nurse should first cover the insertion site with an occlusive dressing, such as a Vaseline gauze. Then the nurse should call the doctor, who will order a chest x-ray and possibly reinsert the tube. Answers A, B, and D are not the first priority in this case.
A client being treated with sodium warfarin has an INR of 8.0. Which intervention would be most important to include in the nursing care plan?
❍ A. Assess for signs of abnormal bleeding
❍ B. Anticipate an increase in the coumadin dosage
❍ C. Instruct the client regarding the drug therapy
❍ D. Increase the frequency of neurological assessments
Answer A is correct. An INR of 8 indicates that the blood is too thin. The normal INR is 2.0–3.0, so answer B is incorrect because the doctor will not increase the dosage of coumadin. Answer C is incorrect because now is not the time to instruct the client about the therapy. Answer D is not correct because there is no need to increase the
neurological assessment.
Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease? ❍ A. A granola bar ❍ B. A bran muffin ❍ C. Yogurt ❍ D. Raisins
Answer C is correct. The food indicating the client’s understanding of dietary management of osteoporosis is the yogurt, with approximately 400mg of calcium. The other foods are good choices, but not as good as the yogurt; therefore, answers A, B, and D are incorrect.
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate IV. Which action by the nurse indicates a lack of understanding of magnesium sulfate?
❍ A. The nurse places a sign over the bed not to check blood pressures in the left arm.
❍ B. The nurse obtains an IV controller.
❍ C. The nurse inserts a Foley catheter.
❍ D. The nurse darkens the room.
Answer A is correct. There is no need to avoid taking the blood pressure in the left arm. Answers B, C, and D are all actions that should be taken for the client receiving magnesium sulfate for preeclampsia.
The nurse is caring for a 12-year-old client with appendicitis. The client’s mother is a Jehovah’s Witness and refuses to sign the blood permit. What nursing action is most appropriate?
❍ A. Give the blood without permission
❍ B. Encourage the mother to reconsider
❍ C. Explain the consequences without treatment
❍ D. Notify the physician of the mother’s refusal
Answer D is correct. If the client’s mother refuses the blood transfusion, the doctor should be notified. Because the client is a minor, the court might order treatment. Answer A is incorrect because the mother is the legal guardian and can refuse the blood transfusion to be given to her daughter. Answers B and C are incorrect because it is not the primary responsibility of the nurse to encourage the mother to consent or explain the consequences.
A client is admitted to the unit 2 hours after an injury with second-degree burns to the face, trunk, and head. The nurse would be most concerned with the client developing what? ❍ A. Hypovolemia ❍ B. Laryngeal edema ❍ C. Hypernatremia ❍ D. Hyperkalemia
Answer B is correct. The nurse should be most concerned with laryngeal edema because of the area of burn. Answer A is of secondary priority. Hyponatremia and hypokalemia are also of concern but are not the primary concern; thus, answers C and D are incorrect.
The nurse is evaluating nutritional outcomes for an elderly client with anorexia nervosa. Which data best indicates that the plan of care is effective?
❍ A. The client selects a balanced diet from the menu.
❍ B. The client’s hematocrit improves.
❍ C. The client’s tissue turgor improves.
❍ D. The client gains weight.
Answer D is correct. The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet is useless if the client does not eat the diet, so answer A is incorrect. The hematocrit, in answer B, might improve by several means, such as blood transfusion, but that does not indicate improvement in the anorexic condition, so B is incorrect. The tissue turgor indicates fluid, not improvement of anorexia, so answer C is incorrect.
The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor? ❍ A. Pain beneath the cast ❍ B. Warm toes ❍ C. Pedal pulses weak and rapid ❍ D. Paresthesia of the toes
Answer D is correct. Paresthesia of the toes is not normal and can indicate compartment syndrome. At this time, pain beneath the cast is normal and, thus, would not be reported as a concern. The client’s toes should be warm to the touch, and pulses should be present. Answers A, B, and C, then, are incorrect.
The client is having a cardiac catheterization. During the procedure, the client tells the nurse, “I’m feeling really hot.” Which response would be best?
❍ A. “You are having an allergic reaction. I will get an order for Benadryl.”
❍ B. “That feeling of warmth is normal when the dye is injected.”
❍ C. “That feeling of warmth indicates that the clots in the coronary vessels are dissolving.”
❍ D. “I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing.”
Answer B is correct. The best response from the nurse is to let the client know that it is normal to have a warm sensation when dye is injected for this procedure. Answers A, C, and D indicate that the nurse believes that the hot feeling is abnormal and, so, are incorrect.
Which action by the healthcare worker indicates a need for further teaching?
❍ A. The nursing assistant wears gloves while giving the client a bath.
❍ B. The nurse wears goggles while drawing blood from the client.
❍ C. The doctor washes his hands before examining the client.
❍ D. The nurse wears gloves to take the client’s vital signs.
Answer D is correct. It is not necessary to wear gloves when taking the vital signs of the client, thus indicating further teaching for the nursing assistant. If the client has an active infection with methicillin-resistant staphy-lococcus aureus, gloves should be worn, but this is not indicated in this instance. The actions in answers A, B, and C are incorrect because they are indicative of infection control not mentioned in the question.
The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective?
❍ A. The client loses consciousness.
❍ B. The client vomits.
❍ C. The client’s ECG indicates tachycardia.
❍ D. The client has a grand mal seizure.
Answer D is correct. During ECT, the client will have a grand mal seizure. This indicates completion of the electroconvulsive therapy. Answers A, B, and C are incorrect because they do not indicate that the ECT has been completed.
The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:
❍ A. Place tape on the child’s perianal area before putting the child to bed
❍ B. Scrape the skin with a piece of cardboard and bring it to the clinic
❍ C. Obtain a stool specimen in the afternoon
❍ D. Bring a hair sample to the clinic for evaluation
Answer A is correct. An infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs, causing intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be evaluated in a lab. There is no need to scrape the skin, collect a stool specimen, or bring a sample of hair; therefore, answers B, C, and D are incorrect.
The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?
❍ A. Treatment is not recommended for children less than 10 years of age.
❍ B. The entire family should be treated.
❍ C. Medication therapy will continue for 1 year.
❍ D. Intravenous antibiotic therapy will be ordered.
Answer B is correct. Erterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated, to ensure that no eggs remain. Because a single treatment is usually sufficient, there is usually good compliance. The family should then be tested again in 2 weeks, to ensure that no eggs remain. Answers A, C, and D are inappropriate for this treatment and, therefore, incorrect.
The registered nurse is making assignments for the day. Which client should not be assigned to the pregnant nurse?
❍ A. The client receiving linear accelerator radiation therapy for lung cancer
❍ B. The client with a radium implant for cervical cancer
❍ C. The client who has just been administered soluble brachytherapy for thyroid cancer
❍ D. The client who returned from an intravenous pyelogram
Answer B is correct. The pregnant nurse should not be assigned to any client with radioactivity present, and the client with a radium implant poses the most risk to the
pregnant nurse. The clients in answers A, C, and D are not radioactive; therefore, these answers are incorrect.
