Q&A Random Selection #5 Rationale

1 B: The nurse would be concerned about all of these comments, however the most life threatening is option B.
Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism.
Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require
immediate attention. Option C may indicate a urinary tract infection. Although option D requires further investigation, it
is not life threatening.

2 C: Inspiratory grunt. Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.

3 A: Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood
pressure must be within normal range (HR 60-100 BPM; systolic B/P over 100) in order to safely administer both
medications.

4 C: Bed wetting. In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child
for evaluation. Bed wetting in a school age child is readily detected by the parents.

5 C: Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart
rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate
vasoconstrictor mechanisms, and autonomic insufficiency.

6 B: Spinal column manipulation. The theory underlying chiropractic is that interference with transmission of mental
impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the
vertebrae. Manipulation reduces the misalignment (subluxation).

7 C: Manage pain. The immediate goal of therapy is to alleviate the client’s pain, which can be quite severe with
kidney stones.

8 A: the muscles. Rhabdomyosarcoma is the most common children''s soft tissue sarcoma. It originates in striated
(skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word -- “myo” --which
typically means muscle.

9 B: A teenager who got a singed beard while camping. This client is in the greatest danger with a potential of
respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have
caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will
not be aware of swelling.

10 C: "I understand our child’s need to use those new skills." Erikson describes the stage of the toddler as being the
time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.

11 C: Gravida 3 para 1. Gravida is the number of pregnancies and Parity is the number of pregnancies that reach
viability (no t the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1
viable birth (twins).

12 A: Should be taken in the morning. Thyroid supplement should be taken in the morning to minimize the side effect
of insomnia.

13 A: Decrease in level of consciousness. A further decrease in the level of consciousness would be indicative of a
further progression of the CVA.

14 D: School age children gain about 5.5 pounds each year and increase about 2 inches in height.

15 B: The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be
accomplished with proper nutrition. The other interventions are appropriate, but without proper nutrition, they would
be of little help.

16 D: No special orders are necessary for this examination. No special preparation is necessary for this examination.

17 D: Have the client empty bladder. The first step in the process is to have the client void prior to administering the
pre-operative medication. The other actions follow this initial step in this sequence: D, C, B, A. Note: It is much easier
to administer IM meds with the side rails down, and then raising them when the nurse is done. Other activities can
then be carried out more safely.

18 B: This client requires immediate evaluation. A delay in treatment could result in further deterioration of his
condition and possibly permanent harm. Home care nurses must prioritize interventions based on assessment
findings that are in the client's best interest.
19 B: Chlamydia. Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory
disease.

20 D: Decreased appetite. Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of
hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, and dysrhythmias.

21 D: For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.

22 A: 45 year-old African American attorney. The incidence of hypertension is greater among African Americans than
other groups in the US. The incidence among the Hispanic population is rising.

23 A: The best candidate for discharge is one who has a chronic condition and has an established plan of care. The
client in option A is most likely stable and could continue medication therapy at home.

24 B: left heart function. The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the
left side of the heart. It can provide hemodynamic information such as intracardiac pressure readings and oxygen
saturation data, and even transvenous pacing. Information about left ventricular function is important because it
directly affects tissue perfusion. Right sided heart function is assessed through the evaluation of the central venous
pressure (CVP).

25 C: A tall peaked T wave is a sign of hyperkalemia. The provider should be notified regarding discontinuing the
medication.

26 D: These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of
an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform
intubation or a tracheostomy in the event of further or complete obstruction.

27 C: Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are positive
statements, however safety is most important to reinforce.

28 C: Moist, productive cough. Option C is a later sign. Noisy respirations and a dry non-productive cough are
commonly the first of the respiratory signs to appear in a newly diagnosed client with CF. The other options are the
earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and
digestive juices. Normally, these secretions are thin and slippery, but in CF a defective gene causes the secretions to
become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways,
especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.

29 C: avoiding very heavy meals. Eating large, heavy meals can pull blood away from the heart for digestion, which is
dangerous for the client with coronary artery disease.

30 B: Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac
catheterization. A falling BP occurs along with hemorrhage of the insertion site which is within the first 12 hours after
the procedure.

31 A: Feedback is most useful when given immediately. Positive behavior is strengthened through immediate
feedback, and it is easier to modify problem behaviors if what constitutes appropriate behavior is clearly understood.

32 A: Gastric lavage PRN. Removing as much of the drug as possible is the first step in treatment for this drug
overdose. This is best done by gastric lavage. The next actions to complete would be to administer activated
charcoal, then Mucomyst and lastly the IV fluids.

33 C: The minimal dose is 10 ml per hour, which would mean 40 mls are given in a 4 hour period. Only 60 mls should
be left at noon. The pump is not functioning when more than expected medicine is left in the container.

34 C: Establishing an open airway is always the primary objective in a cardiopulmonary arrest.

35 A: verify correct placement of the tube. Proper placement of the tube prevents aspiration.

36 B: lead to dehydration. The client must take in adequate fluids before and during exercise periods.

37 D: The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term
effects may be related to hypoxia.

38 A: The blood pressure reading is moderately high with the need to have it rechecked in a few days. Although the
client states it is usually much lower,’ a concern exists for complications such as stroke. An immediate check by the
provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.
39 B: There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should
form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care
providers.

40 C: Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate
complications of their problem. The client in option C exhibits opioid toxicity with the pinpoint pupils and has the least
risk of complications occurring in the near future.