RNSG 2331 EXAM 2 CAPSTONE 1 QUESTIONS AND ANSWER 2022

Question: The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best? You answered this question Correctly 1. Ham and vegetable casserole 2. Cheese and crackers 3. Caffeine free tea 4. Packaged sugar free Jell-O  Rationale  Strategies 4. Correct: A client who is suspicious of others needs foods that are packaged and can see them opened. 1. Incorrect: A client who is suspicious of others needs to be able to identify the ingredients in the food that is being eaten. A casserole contains many ingredients and the client may fear that something has been added to the food. 2. Incorrect: Finger foods are best for clients that are manic. 3. Incorrect: Drinks and foods with no caffeine are okay for the confused and suspicious client but this menu choice is not the best choice from the list here. Question: Two days after a myocardial infarction, a client begins reporting orthopnea and dyspnea. Further assessment reveals bi-basilar crackles, jugular venous distension, an S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90 beats per minute. The urine output has steadily declined over the past 12 hours. What should the nurse do first? You answered this question Correctly 1. Notify the primary healthcare provider. 2. Increase the IV rate. 3. Elevate the head of the bed. 4. Observe for cardiac arrhythmias.  Rationale  Strategies 3. Correct: Elevate the head of the bed first. The client is reporting inability to breathe. (Orthopnea means the client needs to sit up to breathe better.) With ANY RNSG 2331 EXAM 2 CAPSTONE 1 client having difficulty breathing, the first intervention for the nurse is to sit the client up. This client is showing s/s of heart failure. 1. Incorrect: Your next step is to call the primary healthcare provider after you do something to try to fix the problem. 2. Incorrect: Increasing the IV rate is contraindicated and would make the problem worse. 4. Incorrect: After an MI, all clients are observed for cardiac arrhythmias. This, however, does not fix the problem. Question: Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of proper diet was understood? You answered this question Correctly 1. Pancakes with whipped butter, syrup, bacon, apple juice 2. Scrambled eggs, sliced turkey, biscuit, whole milk 3. Grits, fresh fruit, toast, coffee 4. Bagel with jelly, hash browns, tea  Rationale  Strategies 2. Correct: Client needs low sodium and increased proteins. 1. Incorrect: This selection is too high in sodium and fats. 3. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine. 4. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine. Question: The nurse assesses a multigravida who is four hours postpartum. Findings include that fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority? You answered this question Correctly 1. Massage the fundus. 2. Administer intravenous oxytocin. 3. Document these normal findings. 4. Assist the client up to void.  Rationale  Strategies 4. Correct: These findings are caused by a full bladder, which prevents the uterus from contracting down and achieving homeostasis. Once the bladder is empty, the fundus will contract adequately and return to its normal location at level of umbilicus or 1 finger breadth below the umbilicus and in the midline. A distended bladder will displace the uterus, usually to the right. 1. Incorrect: The nurse may check fundus after client voids to ensure that this fixes the problem. 2. Incorrect: Administering oxytocin is not the first intervention for this issue. 3. Incorrect: These are not normal findings so this would be incorrect information for the nurse to document. Question: What risk factors should the nurse include when conducting a class about type 2 diabetes mellitus? You answered this question Correctly 1. Fat distribution greater in abdomen than in hips. 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 5. Polycystic ovary syndrome.  Rationale  Strategies 1., & 5. Correct: If the body stores fat primarily in the abdomen, risk of type 2 diabetes is greater than if body stores fat elsewhere, such as hips and thighs. Women with polycystic ovary syndrome have increased risk of diabetes. 2. Incorrect: Being overweight is a primary risk factor for type 2 diabetes. The more fatty tissue, the more resistant cells become to insulin. 3. Incorrect: A type 1 diabetic will remain a type 1 diabetic. 4. Incorrect: Blacks, Hispanics, American Indians, and Asian Americans are more likely to develop type 2 diabetes than Caucasians are. Question: What should the nurse include when providing education to a client receiving tetracycline? You answered this question Correctly 1. Wear long sleeves when going outside. 2. Take tetracycline on a full stomach. 3. Wait at least two hours after taking tetracycline prior to taking iron supplements. 4. Tetracycline can decrease the effectiveness of birth control pills. 5. Do not take this medicine after the expiration date on the label has passed.  Rationale  Strategies 1., 3., 4., & 5. Correct: Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Tetracycline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun. Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective. Tetracycline can make birth control pills less effective. Use a second method of birth control while you are taking this medicine to keep from getting pregnant. Throw away any unused tetracycline when it expires or when it is no longer needed. Do not take this medicine after the expiration date on the label has passed. Expired tetracycline can cause a dangerous syndrome resulting in damage to the kidneys. 2. Incorrect: Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective. Question: A 72 year old client admitted with a diagnosis of bleeding ulcers has been prescribed ranitidine 50 mg IVPB every 8 hours and omeprazole 10 mg po every morning. Based on this data what intervention should the nurse take first? Exhibit You answered this question Correctly 1. Stop the infusion of ranitidine. 2. Send the client for a CT scan of the head. 3. Provide oxygen at 2L/NC. 4. Notify the primary healthcare provider.  Rationale  Strategies 1. Correct: Ranitidine can cause confusion in the elderly as well as agitation. Stop the infusion, then notify the primary healthcare provider. 2. Incorrect: Confusion is a side effect of ranitidine, so the medication should be stopped and then the healthcare provider notified. 3. Incorrect: The oxygen saturation is not low at 95%. Providing oxygen will not correct the confusion. 4. Incorrect: The primary healthcare provider should be notified after stopping the ranitidine. Question: A nurse invites a friend home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch and begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What should the nurse do first? You answered this question Correctly 1. Stay with the friend until the friend feels better. 2. Have the friend breathe into a paper bag. 3. Remove the cat from the room. 4. Dim the lights in the room.  Rationale  Strategies 3. Correct: Remove the source of the panic attack first, then continue to assess the person for symptoms. Removing the cat "fixes" the problem. 1. Incorrect: This is a correct answer, but remove the cat first. 2. Incorrect: This will help hyperventilation if it occurs, but the stem of the question said the client was having "shortness of breath" related to seeing the cat. Remove the cat first as this will fix the problem and alleviate the symptoms. 4. Incorrect: This is a correct answer, but remove the cat first. Question: A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect? You answered this question Correctly 1. Stop taking the medication and call the primary healthcare provider. 2. Drink plenty of water with the medication. 3. Take the medication before bedtime. 4. Take antacids when taking the medication.  Rationale  Strategies 2. Correct: Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet. 1. Incorrect: Slight heartburn does not warrant primary healthcare provider report. Extreme pain or difficulty swallowing should be reported, as should heartburn that increases despite suggestions listed above. 3. Incorrect: The client should take in the morning, thus preventing prolonged contact with the esophagus. 4. Incorrect: The absorption of the medication is decreased when it is taken with calcium, iron, and magnesium, or antacids containing calcium, aluminum, or magnesium. Thirty minutes should elapse before taking the antacid following administration of the alendronate. Question: The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client? You answered this question Incorrectly 1. Document the client's statement in the client's own word