NCSBN Practice Questions 121-131

NCSBN Practice Questions 121-131 It is the start of the shift and the nurse has just finished listening to a report on four clients. Which client should the nurse assess first? A. A client with a diagnosis of an acute traumatic brain injury who has a blood pressure of 88/58 B. A client with a diagnosis of a concussion and who doesn't remember the motor vehicle accident C. A client diagnosed with viral meningitis and has signs of meningeal irritation D. A client diagnosed with generalized seizures who complains of a headache following an observed seizure Ans- A Hypotension adversely affects cerebral perfusion following a traumatic brain injury. Both hypotension and hypoxia are the greatest threats to functional outcomes in brain injury and must be corrected early, taking priority over other interventions for brain injury. Headache after a seizure is expected, amnesia is common with a concussion, and meningeal irritation is an expected finding with viral meningitis, making these clients a lower priority at this point. The nurse discovers that a chest tube has become disconnected from the main connection site of a closed chest drainage unit (CDU). What immediate action should be taken by the nurse? A. Cover the insertion site with a sterile petroleum gauze pad B. Submerge the distal end of the tube in 2 - 4 centimeters of sterile water C. Reconnect the drainage tube to the chest tube D. Clamp the chest tube nearest to the client with a rubber-tipped hemostat Ans- B If the tube becomes disconnected from the main connection site of a CDU, the nurse should place the end of the chest tube in a bottle of sterile water (or saline solution) while someone else prepares a new CDU setup. The health care provider should be called (the nurse should expect an order for a chest Xray.) To prevent the chest tube from coming apart, it's important to spiral-tape the main connection site and not to let loops of tubing hang down the side of the bed. If there is an air leak from the chest, do not clamp the chest tube as this will cause air to accumulate in the pleural cavity, potentially leading to a collapsed lung or tension pneumothorax. Only if the chest tube becomes dislodged from the client does the nurse need to cover the insertion site with a sterile gauze dressing. The client states to the nurse: "I am ready to stop all of these treatments. I just want to go home and enjoy my family for the little bit of time I have left." Which action is most appropriate? A. Call in a referral to a social worker and explain that the request will need to be discussed in more detail at a later time B. Encourage the client to discuss this decision with the health care provider and family C. Tell the family members that the client's preference is to go home to die D. No action is needed at this time unless the client repeats the statement to another caregiver Ans- B The client has the right to stop treatment and should be supported in clearly communicating this decision with the health care provider and family. The nurse needs to act as an advocate for the client. It is factually incorrect to wait until the request is repeated; clients should not need to express their wishes repeatedly before caregivers listen to them. The nurse should not be the one to share sensitive information with the family; the client controls that information. Social services may get involved but time is of the essence for those who are terminally ill. A client who is newly diagnosed with hypertension is prescribed benazepril. What is the most important point to make when teaching the client about this medication? A. "Notify the health care provider if there is a change in your voice." B. "Monitor your blood pressure and pulse regularly." C. "Take medication as directed at the same time each day, even if you feel well." D. "Call your health care provider if you develop a dry cough." Ans- A Benazepril (Lotensin) is an angiotensin converting enzyme (ACE) inhibitor. Even if you don't know this drug, remember that the spelling of ACE inhibitors usually end with "pril." One of the side effects of ACE inhibitors is a dry cough; sometimes the cough is severe enough to require discontinuation of the drug. But the most important point to make is that if the client's voice changes or "sounds funny" or there is any swelling of the lips, tongue or throat, the client should contact the health care provider because this could indicate angioedema, a potentially fatal condition. A client's admission urinalysis shows the specific gravity value of 1.039. Which of these findings would the nurse expect to find during the physical assessment of this client? A. Above normal heart rate B. Moist mucous membranes C. Poor skin turgor D. Increased blood pressure Ans- C The specific gravity value is high, which would indicate dehydration. Specific gravity measures urine density and an average urine specific gravity value is around 1.020. Poor skin turgor, as seen with tenting of the skin, is consistent with this problem. A male client is preparing for discharge after an acute myocardial infarction. The client asks the nurse about sexual activity once the client is home. What should be the nurse's initial approach? A. Answer the questions accurately in a private environment B. Schedule a private, uninterrupted teaching session with both the client and the partner C. Assess the client's knowledge about the current health problems D. Give the client written material from the American Heart Association about sexual activity with heart disease Ans- C The nursing process is continuous and cyclical in nature. When a client expresses a specific concern, the nurse should perform a focused assessment to gather additional data prior to planning and implementing nursing interventions. A nurse is caring for a 2 year-old child who is being treated for lead poisoning by chelation therapy. The nurse should be alert for which side effect of chelation therapy? A. Hepatomegaly B. Ototoxicity C. Neurotoxicity D. Hypocalcemia Ans- D Injections of ethylenediaminetetraacetic acid (EDTA) or other chemicals bind, or chelate, to iron (and some other metals), which are then eliminated from the body. Since chelation therapy removes minerals from the body, there is a risk of developing low calcium levels (hypocalcemia) and bone damage. After four electroconvulsive treatments over two weeks, a client is very upset and states, "I am so confused. I lose my money. I just can't remember telephone numbers." The most therapeutic response for the nurse to make is which of these statements? A. "Don't get upset. The confusion will clear up in a day or two." B. "You were seriously ill and needed the treatments." C. "I can hear your concern and that your confusion is upsetting to you." D. "It is to be expected since most clients have the same results." Ans- C Communicating caring and empathy with the acknowledgement of feelings is the initial response. Afterwards, teaching about the expected short-term effects would be discussed with a movement to the problem-solving stage. A 10 year-old child is recovering from a splenectomy after a traumatic injury. The child's laboratory results show a hemoglobin of 8.8 g/dL and a hematocrit of 26%. What is a priority approach that the nurse should include in the plan of care? A. Promote a diet rich in iron and lean red meats B. Restrict the consumption of carbonated beverages C. Plan for regularly scheduled rest periods D. Encourage bed activities and games for the next five days Ans- C The initial priority for this client is rest due to the lack of sufficient red blood cells to carry oxygen. The normal hemoglobin is between 10.0 and 15.0 g/dL, and the normal hematocrit is 35% to 45% for a child this age. Note that all of the options are correct actions that may be used for various reasons. A client is NPO and receiving total parenteral nutrition (TPN). The nurse recognizes which of the following laboratory values is important to monitor regularly while the client is receiving the TPN? A. Cholesterol level B. White blood cell count C. Glucose D. Hemoglobin Ans- C The nurse recognizes that the glucose level should be monitored regularly while the client is on TPN because it is common to develop hyperglycemia. The white blood count, cholesterol and hemoglobin don't directly relate to the TPN infusion. A child presents in the emergency department with a documented acetaminophen poisoning event. In order to provide counseling and education for the parents, what information should the nurse understand? A. Hepatic problems may occur and may be life-threatening B. Full and rapid recovery can be expected in most children C. This poisoning is usually fatal because no antidote is available D. The problem occurs in stages with recovery within 12 to 24 hours Ans- A Clinical manifestations associated with acetaminophen poisoning occur in four stages. The third stage is hepatic involvement, which may last up to seven days and be permanent. Clients who do not die in the hepatic stage gradually recover. The antidote for acetaminophen overdose is N-acetylcysteine (NAC). It is most effective when given within eight hours of the event and can prevent liver failure if given early enough. The nurse is administering a vesicant intravenous chemotherapeutic agent to a client. Which assessment should alert the nurse to take immediate action? A. Complaints of pain at the site of the infusion