Hurst Practice Exam 2 with Complete Solutions

A client has been prescribed vancomycin 1 gram IV every 12 hours for the treatment of methicillin-resistant staphylococcus aureus (MRSA). Which action by a new nurse when administering this medication would require intervention by the charge nurse? - ANSWER This dose of medication should be delivered over at least 60 minutes to prevent hypotension and ototoxicity. The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider? - ANSWER Weight gain of 5 pounds in one week is a s/s of an adverse effect of ACE inhibitor use. Weight gain is a sign of fluid retention. Angioedema is an adverse effect of ACE inhibitors and can be life threatening. This should be reported immediately to the healthcare provider. The potassium level is too high. Hyperkalemia is an adverse effect of an ACE inhibitor and needs to be reported. The nurse is caring for a client taking spironolactone. Which dietary change should the nurse teach the client to make when starting treatment with this medication? - ANSWER Spironolactone is a potassium sparing diuretic. Salt substitutes have potassium instead of sodium and should be avoided. When assessing a client, the nurse finds that in response to painful stimuli the upper extremities exhibit flexion of the arm, wrist, and fingers with adduction of the limb, while the lower extremity exhibits extension, internal rotation, and plantar flexion. How would the nurse accurately document this finding? - ANSWER This describes decorticate posturing because they are moving towards the core of the body. Decerebrate posturing - ANSWER when the client is stimulated, and teeth clench and the arms are stiffly extended, adducted, and hyperpronated. The legs are stiffly extended with plantar flexion of the feet. Abnormal extension occurs with lesions in the area of the brain stem. 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? - ANSWER 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. What precautions should be taken with computer monitors that display client health information to ensure client's confidentiality? - ANSWER 2. Have the screen placed facing away from any visitor or client care area where information could be viewed by unauthorized persons. The nurse receives new healthcare provider prescriptions on a client diagnosed with Addison's disease. Which prescriptions should the nurse recognize as being inappropriately written and requiring clarification from the prescriber? - ANSWER Use "daily" or "every day". QD is an unapproved abbreviation. T.I.W. stands for three times a week; however, it is an unapproved abbreviation. Use "three times a week". The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice for the nurse to place the client in until full consciousness is regained? - ANSWER When someone is very sedated and not fully conscious, we want them on their side so the airway remains open and the secretions can drain. A client is hospitalized because of severe malnutrition related to anorexia nervosa. What is the most important goal for this client? - ANSWER Until appropriate weight is gained, the client continues to be at risk for major health complications including hypotension, cardiac arrhythmias, poor muscle tone, increased risk for infection, abnormal liver function, and damaged kidneys. A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client? - ANSWER Flushing, nausea and vomiting, palpitations, tachycardia, psychosis are signs of disulfiram-type reaction seen when using products containing alcohol (cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking metronidazole. Antibiotic: take metronidazole on an empty stomach What should a community health nurse include when planning a presentation on prevention and early detection of colon cancer? - ANSWER A diet high in vegetables, fruits, and whole grains has been linked with a decreased risk of colorectal cancer; exercise regularly The guaiac-based fecal occult blood test detects blood in the stool through a chemical reaction. This test is done yearly. The nurse is searching for information about the nursing care of a client receiving an experimental drug for the treatment of obesity. Which database is most likely to address this issue? - ANSWER The Cumulative Index for Nursing and Allied Health Literature (CINAHL) is a source for reviewing nursing and allied health information. Which assignments would be most appropriate for the RN to delegate to an LPN/VN? - ANSWER 1. child with pneumonia admitted two days ago 2. the child admitted for developmental studies. 3. The twelve year old with post op wound infection taking oral antibiotics is also stable. Which symptoms would the nurse be likely to observe in the client who overdosed on diazepam? - ANSWER Benzodiazepines are central nervous system (CNS) depressants. Diazepam is a benzodiazepine. They will slow respirations (bradypnea) and the heart rate (bradycardia). Somnolence (extreme, prolonged drowsiness) would be seen. Benzodiazepines - ANSWER drugs that lower anxiety and reduce stress A long-term care nurse is planning care for a newly admitted client diagnosed with Alzheimer's disease. What should the nurse include in the plan of care? - ANSWER Assess the client's ability to perform activities of daily living and allow client to perform alone if capable. Maintain stimuli such as a clock, newspaper, calendar, and/or weather status. Encourage family to visit to maintain socialization. Plan for staff to spend some time talking and listening to the client. The home health nurse is assessing the home environment for possible irritants that could increase/precipitate symptoms of respiratory problems. Which assessment questions would be important to determine level of risk? - ANSWER 1. What type of heat do you use in the home? 2. Does anyone in the home have hobbies that involve sanding of wood or use of chemicals? 3. Is there anyone in the home who smokes? 4. Do you routinely use aerosol sprays for personal care or cleaning? Presence of wood smoke could increase respiratory problems. Poorly vented gas heaters could increase carbon monoxide in the environment. Use of solvents or other agents that produce irritating fumes could increase risk. The particles from the sanding could irritate the respiratory tract as well. Second-hand smoke is irritating to the respiratory tract. Aerosols could trigger respiratory problems. 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? - ANSWER 1. Document the client's statement in the client's own words. 2. Provide information on advance directives to the client. 3. Inform the client that personnel are available to assist with completing an advance directive. Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of proper diet was understood? - ANSWER Client needs low sodium and increased proteins. ex.Scrambled eggs, sliced turkey, biscuit, whole milk A client is diagnosed with new onset grand mal seizures. Which nursing interventions should the nurse implement for this client? - ANSWER 2. Pad the side rails with blankets. 3. Place the bed in low position. 5. Instruct client to call for help when ambulating. A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who will need assistive devices upon discharge. Which devices should the case manager include for this client - ANSWER 1. Dinner plate food guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip eating utensils The goal is to promote self-care by the client as much as possible. The case manager should evaluate the need for assistive devices to help with eating, bathing, dressing, and ambulating. The dinner plate food guard will prevent food from being pushed off the plate. The transfer belt will provide safety for the client to get into a chair or back in bed. A raised toilet seat makes it easier for the client to sit on the toilet without falling. The long-handled shoe horn allows the client to put on shoes without assistance. Wide grip utensils accommodate a weak grip. The nurse is providing post-operative care to the craniotomy client. Hourly urinary output increases from 100 mL last hour to 500 mL this hour. What action by the nurse takes priority? - ANSWER we are "worried" this client is going into SHOCK due to diabetes insipidus. So, you better be checking a BP. This is a time where checking the BP is appropriate. If we "assume the worst" I better check a blood pressure. It could have dropped out the bottom. A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. Which intervention takes priority? - ANSWER Activate the community emergency response team. Which statement by a student nurse indicates to the nurse educator that teaching regarding witnessing consent signatures has been successful? - ANSWER Signing as a witness implies that the witness has observed the client personally signing the consent form with no coercion. Only one signature is required as a witness. The witness does not have to be an RN. A witness is required to be over the age of 18. Ranitidine - ANSWER Antihistamine and Antacid treats: heartburn.,stomach ulcers, gastroesophageal reflux disease (GERD), and conditions that cause too much stomach acid. Ranitidine can cause confusion in the elderly as well as agitation. A primary healthcare provider informs the nurse to prepare for an amniotomy on a client who's labor has not progressed. What should the nurse assess for prior to the primary healthcare provider performing this procedure? - ANSWER Fetal engagement is important prior to rupturing the membranes so that the umbilical cord cannot prolapse. Fetal engagement is when the fetus is at station 0 (level of mom's ischial spines). The nurse is working with the parents of a preschooler to help promote healthy sleep patterns of approximately 8-12 hours per night. Which intervention should assist the parents to achieve adequate sleep for their preschooler? - ANSWER 3. Spend about 30 minutes with the preschooler prior to bedtime for stories, prayers, etc. Following surgery, a client refuses to ambulate as prescribed. What action should the nurse take? - ANSWER The nurse should educate the client about complications that can be prevented with ambulation, such as constipation, pneumonia, or deep vein thrombosis (DVT). A nurse attaches a client to continuous cardiac monitoring due to a potassium level of 2.8 mEq (2.8 mmol). The nurse should monitor for which dysrhythmia? - ANSWER Hypokalemia is reflected by the EKG. The earliest EKG change is often premature ventricular contractions (PVCs) which can deteriorate into ventricular tachycardia or fibrillation (VT/VF) without appropriate potassium replacement. A client has been on the mental health unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do? - ANSWER Protocols on the unit must be followed when someone is requesting to leave AMA. The first step is to call the primary healthcare provider about the client's desire to leave AMA. wrong: 2. Make arrangements for a commitment hearing, as soon as possible. 3. Tell the client the primary healthcare provider must discharge the client prior to leaving. 4. Call the primary healthcare provider and request a discharge order. 2. Incorrect: The client is not suicidal; however, the primary healthcare provider needs input into their decision to leave AMA. It is not appropriate to prepare for a commitment hearing. 3. Incorrect: If the client is not a threat or potential threat to self or others, the client may leave. The nurse may discuss the decision to leave; however, this statement is not accurate. 4. Incorrect: The nurse should call the primary healthcare provider and discuss the situation. The primary healthcare provider should have input into this decision. In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last. - ANSWER 1. apply clean gloves. Second, remove soiled dressings. Third, discard soiled dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean surgical wound with moistened sterile 4x4's. Sixth, clean around Penrose drain using circular pattern inside to outside. Seventh, place dry, sterile 4x4's over surgical wound and Penrose drain. Eighth, apply abdominal dressing pad. Which foods should the nurse teach a client to avoid when prescribed a diet limiting purine rich foods? - ANSWER Meats: liver, bacon, veal, and venison are high in purine and should be avoided. Seafood: sardines, mussels, codfish, scallops, trout, and haddock are high in purine and should be avoided. Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? - ANSWER Check client's vital signs after ambulating. Obtain a stool specimen.