Post Test 2 Rationales

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Post Test 2

Which client would be the highest risk for injury?a.

A 3-month-old in an infant seat sitting on a coffee tableb.

A 2-year-old playing in the living room unattended by an adultc.

A 2-1 /2-year-old with a tracheostomy playing outside in the backyardd.

A 7-year-old who goes to after school care in a 38-year-old home

This age of child puts everything in their mouth so they could put an object in the tracheostomy. This creates a risk for airwayobstruction. Option #1 is not a priority to Option #3 due to the possibility of airway obstruction. Option #2 is a concern but nota priority. Option #4 is incorrect because while this home may have older paint which would present a risk with lead poisoning,this age of child does not have a tendency to put objects in the mouth.

A client is admitted to a general medicine unit and the lab technician arrives to draw the lab blood tests that were ordered.After the technician leaves, the nurse enters the room to find drops of blood on the floor and on the wall by the needlecontainer. When considering the safety of the hospital clients, what is the best nursing action?a.

Call the laboratory supervisor and report the poor technique used by the technician.b.

Make a note for the unit manager to discuss the break in technique with the laboratory supervisor.c.

Call housekeeping to come immediately to clean and disinfect the area where the blood was dropped.d.

Have the laboratory technician return to the unit and clean up the area contaminated with the blood.

It is everyones responsibility to maintain a safe environment. This break in universal precautions should be reportedimmediately to the laboratory supervisor so the technician can be identified and the problem corrected. The unit managermay also be notified in order to follow up regarding how the lab supervisor corrected the problem. The area can be cleaned byblotting the blood with paper towels and spraying the area with disinfectant spray designated for body fluid spills.

A client has colon cancer and a descending colostomy was done. How is the best way for the nurse to determine if theclient understands .and can perform her own care?a.

Have the client explain to the nurse all of the steps necessary to carry out the colostomy irrigation.b.

With the nurse performing the irrigation, have the client direct the nurse regarding how to do it.c.

Construct a written test and have the client complete it. Then discuss with the client the questions missed.d.

With the nurse present, have the client independently carry out the colostomy irrigation herself.

The best way to determine if the client understands the teaching is to encourage the client to perform a return demonstrationof the procedure. Option #1 is correct to do prior to the procedure. However, it does not determine if the client can carry outthe procedure correctly.

An important assessment to obtain in a client who requires home oxygen therapy is:a.

amount of oxygen required within a 24-hour period.b.

maintenance of the equipment.c.

the clients knowledge base about home oxygen therapy.d.

adequate personnel to monitor the oxygen therapy.

It is important that the client on home oxygen therapy demonstrate an adequate knowledge base about oxygen. This willprevent any, injury to the client.

A client was admitted yesterday to the trauma intensive care unit (ICU) with a gunshot wound of the neck. He has a cervicallevel (C4) spinal cord injury. He is tearful and constantly complains of discomfort and needing to be suctioned. The nurseunderstands that his attention-seeking behaviors may be due to:a.

anger and frustration.b.

awareness of vulnerability.c.

increased social isolation.d.

increased sensory stimulation.

The client is experiencing an increased awareness of physical vulnerability due to the spinal cord injury. The client is trying todetermine who is consistent and trustworthy for meeting his significant physical needs. Options #1, #3, and #4 may come later.

After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a 5-year-old is admittedto the ER. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessmentsshould the nurse report to the physician 3 hours after admission?a.

The obtunded state she is inb.

Clear fluid draining from her right earc.

The characteristics of the lacerationsd.

Slight withdrawal of extremities in response to painful stimuli

Clear fluid from the ear indicates a rupture of the meninges and presents a potential complication of meningitis. Option #1 isno change. Option #3 is not a priority over Option #2. Option #4 is not an assessment change.

To promote safety, the nurse would implement which action in obtaining a blood specimen from a client with hepatitis B?a.

Clean area with antiseptic solutionb.

Wear a pair of clean gloves.c.

Apply pressure to site for 5 seconds.d.

Recap needle to avoid carrying exposed needle.

Clean gloves should be worn at all times when handling any clients body fluids. Option #1 is correct but not a higher priorityover Option #2. Option #3 is incorrect because venipuncture sites of clients with hepatitis B should be held for a longer periodof time due to possibility of increased bleeding associated with an impaired liver. Option #4 is unsafe.

Which observation would be most important during the first 48 hours after the admission of a client with severe anxiety?a.

What is important to the client?b.

How does the client view self?c.

In what situations does the client get anxious?d.

Who in the clients family has had mental problems?

This will provide necessary information in the baseline assessment of the clients anxiety. Options ^l, #2, and #4 are helpfuldata which can be collected during treatment, but do not take priority during the first 48 hours.

A 72-year-old client has an order for digoxin(Lanoxin) 0.25 mg PO in the morning. At 7:00 a.m., the nurse reviews thefollowing information:

• apical pulse, 68

• respirations, 16

• plasma digoxin level, 2.2 ng/ml

Based on this assessment, which nursing action is appropriate?a.

Give the medication on time.b.

Withhold the medication, notify the physician.c.

Administer epinephrine 1:1000 stat.d.

Check the clients blood pressure.

Withhold the medication and notify the physician because the therapeutic plasma level of digoxin is 0.5-2.0 ng/ml. Option #3 isnot necessary at this time. Option #4 is not a priority.

10.

A client is ordered cefoxitin (Mefoxin) 2 gm. IV piggyback in 100 cc 5% Dextrose in water. The primary IV is 5% Dextrose inlactated ringers infusing by gravity. Which safety measure should be included in the administration of this medication?a.

The medication should be administered slowly at 20-25 cc/hr.b.

The primary IV solution should be changed.c.

The piggyback infusion bag should be hung higher than the primary infusion.d.

An infusion pump must be obtained prior to administration.

When using a gravity drip, the piggyback fluid level should be higher than the primary infusion. Option #1 is incorrectbecause the antibiotic should be administered within one hour. Options #2 and #4 are not necessary for safe infusion.

11.

When exploring ways to effectively manage the budget, the nurse will most likely find that she will have to set goals for theunit. What would be an appropriate goal for the unit?a.

Decrease overhead by limiting supplies utilized to operate the unit.b.

Stabilize the total work force by utilizing only part-time employees with limited working hours.c.

Develop an incentive program that will demonstrate cost-effective measures to maintain the overall budget.d.

Participate in open-forums to discuss the issues of budget management on a consistent basis.

Developing an incentive program to maintain revenue will involve the whole unit. This will also give accountability andresponsibility back to the staff on the unit. Option #1 may be counterproductive. Option #2 may de crease quality of care.Option #4 may be useful and secondary to Option #3.

12.

A client is to be taking the tricyclic antidepressant medication imipramine (Tofranil) at home following discharge. The nurseshould instruct the client to report which symptoms immediately?a.

Sore throat, fever, increased fatigue, vomiting, diarrheab.

Dry mouth, nasal stuffiness, weight gainc.

Rapid heartbeat, frequent headaches, yellowing of eyes or skind.

Weakness, staggering gait, tremor, feeling of being drunk

These are possible side effects of Tofranil which can be resolved by changing the dosage or changing the medication. Option #2describes side effects of antidepressants which the client can learn to manage at home without changing the medication.Options #3 and #4 describe side effects of a different category of medications.

13.

The physician has just informed a client that an amputation of the leg is needed. The client is crying as you enter the room.Which technique that the nurse can utilize is the most therapeutic?a.

Sit with client quietly until crying stops; then inquire about feelings.b.

Ask what is causing client to feel so badly.c.

Comfort by hugging and tell client not to worry.d.

Try to distract by talking about her family.

Being with the client as acknowledgement and dealing with impending loss demonstrates the nurses acceptance of the clients .need to grieve. Allowing the client time to cry and then asking to describe feelings demonstrates the nurse is willing to listenand validate the clients feelings. Option #2 is not acknowledging the situation requiring an amputation. Option #3 might besomewhat premature and uncomfortable unless both participants in the relationship find touching acceptable. It isinappropriate to tell her not to worry. Option #4 is avoidance of the situation.

14.

The client is admitted with cerebrovascular accident (CVA) and has facial paralysis. Nursing care should be planned toprevent which complication?a.

Inability to talkb.

Inability to swallowc.

Inability to open the affected eyed.

Corneal abrasion

The client will be unable to close his eye voluntarily. When the facial nerve (cranial nerve VII) is affected, the lacrimal gland

will no longer supply secretions that protect the eye. Options #1, #2, and #3 may occur, but nursing care cannot prevent them.

15.

Which statement by a client indicates an understanding of the cause of herpes zoster?a.

"I will avoid exposure to children with German measles."b.

"I had the chickenpox in grammar school."c.

"Using a condom during intercourse will be necessary."d.

"I will bathe more often than in the past."

Herpes zoster (shingles) is a reactivation of latent varicella (chickenpox) which has an ^increased frequency rate amongadults with weakened immune systems. Option #1 is not correlated with measles. Option #3 is incorrect because this is not asexually-transmitted disease. Option #4 is incorrect because the problem is not related to hygiene.

16.

The nurse has been caring for a schizophrenic client receiving haloperidol (Haldol) IM. She notices the following newsymptoms in the client:

• high fever

• tach

ycardia

• muscle rigidity

• incontinence

These findings suggest that the client is experiencing:a.

tardive dyskinesia.b.

Parkinsons syndrome.c.

acute dystonic reaction.d.

neuroleptic malignant syndrome.

This severe reaction to antipsychotic medication occurs in clients who are severely ill as a result of dopamine blockage in thehypothala-mus. Option #1 would be characterized by abnormal facial and tongue movements. Option #2 would becharacterized by tremors, rigidity, and shuffling gait. Option #3 would be characterized by severe muscle contractions of thehead and neck.

17.

Which technique is best for obtaining a urine specimen for a culture and sensitivity from a client with an existing indwellingcatheter?a.

Clean the drain of the collection bag with an antiseptic before filling the specimen container.b.

Obtain the specimen from the drainage bag in the morning.c.

Using a sterile syringe with a small gauge needle, aspirate urine from the catheter port.d.

If the catheter has been in place for 48 hours, replace it before obtaining the specimen.

Indwelling catheters have a port for the withdrawal of sterile urine specimens. Options #1 and #2 will not provide a sterilespecimen from the collection bag. Option #4 is not necessary

18.

A client is ordered to take metronidazole (Flagyl) PO TID at home. Which client statement indicates a knowledge deficit andneed for teaching?a.

"I'll be sure to take this medication with meals."b.

"I'll call my physician if my skin becomes itchy."c.

"I'll limit my, alcohol intake to two drinks per day."d.

"I understand that my urine may become brown-colored and is normal."

Metronidazole (Flagyl) will produce a disulfiram-like (Antabuse) reaction if any form of alcohol is used. Options #1, #2, and #4indicate an understanding of the concepts related to taking this medication.

19.

The nurse's assessment of a client who abuses cocaine includes:a.

bradycardia, miosis, hypertension.b.

mydriasis, abdominal cramps, excessive salivation.c.

hypotension, bradycardia, abdominal cramps.d.

hypertension, tachycardia, tremor.

Cocaine elevates the blood pressure and pulse along with causing a fine tremor. Cardiac arrhythmias can occur, especiallywith the use of crack cocaine. Excessive salivation and bradycardia are not found with cocaine abuse.

20.

Which technique should be used in the administration of heparin sodium (Heparin)?a.

Gently massage the injection site.b.

Do not aspirate after inserting the needle.c.

Use a 1-inch, 18-20 gauge needled.

Administer the medication at the deltoid muscle.

Aspirating the syringe with a subcutaneous heparin solution can cause bruising.Option #1 is incorrect because the heparininjection site should not be rubbed. Option #3 is incorrect because the needle is too long. Option #4 is incorrect because themedication should be given subcutaneously.

21.

A nursing unit is implementing a project involving changes in the way the unit is managed. The nursing manager on the unitcontinues to have problems with a team member that has been very disruptive regarding the implementation of the project.What is the best approach for the nurse manager in handling this situation?a.

Call the unit supervisor and advise her of the problems with the team member and ask her how to handle thesituation.b.

Privately meet with the team member, review her behavior, and determine if she is aware of the impact herbehavior has on he unit.c.

Involve the other members of the team in attempting to discourage the disruptive team members behavior.