NUR 111 Quiz Summary Questions and Answers

The nurse is preparing to perform an abdominal assessment on a client. Which position would best accommodate this assessment? A) SIMS B) Supine C) High Fowler's D) Prone B) Supine What is the best practice for the nurse to use to promote infection control in the hospital? A) Practice hand hygiene by washing with soap and water and/or alcohol-based rubs. B) Avoid touching any object in the hospital, including door knobs. C) Avoid contact with soiled linen by asking the family to perform all client care. D) Take prescribed antibiotics to remain infection-free while working. A) Practice hand hygiene by washing with soap and water and/or alcohol-based rubs During an assessment, the nurse uses the method of inspection. What is needed to perform this skill? A) Electronic thermometer B) Senses of hearing and sight C) High quality stethoscope D) Documentation skill checklist B) Senses of hearing and sight When auscultating an apical pulse, what is the site to be used? A) Left fifth intercostal space midclavicular line B) Right third intercostal space C) Right fifth intercostal space midclavicular line D) Left third intercostal space A) Left 5th intercostal space midclavicular line The nurse has weighed a new client during the admission assessment. How does this action best contribute to safe medication administration? A) Provides baseline for changes in fluid balance B) Confirms appropriate use of subcutaneous or intramuscular injections C) Allows the care team to prescribe the correct medication dose D) Identifies nutritional deficiencies that may affect drug dosage C) Allows the care team to prescribe the correct medication dose Rationale: Dosage of medication is often calculated based on the client's weight, so getting the client's weight wrong could cause a medication error The nurse should consider teratogenic effects when caring for what clients? Select all that apply. A) 50-year-old post-menopausal female being treated for acute renal failure B) 37-year-old female taking fertility drugs C) 81-year-old with chronic heart failure D) 41-year-old male who is post-bone marrow transplant E) 29-year-old receiving prenatal care during first trimester of pregnancy B) 37-year-old female taking fertility drugs Rationale: Teratogenic effects are harmful to the fetus E) 29-year-old receiving prenatal care during first trimester of pregnancy Rationale: Teratogenic effects are harmful to the fetus A client was prescribed a 10-day course of antibiotics to treat a sinus infection. With symptom relief after 3 days of medications, the client stopped taking the antibiotic. What is a priority nursing diagnosis for this client? A) Chronic confusion B) Risk for injury C) Knowledge deficit D) Non-compliance D) Non-compliance Rationale: The priority is the client's non-adherence to the treatment/ drug regime When documenting subjective client data, the nurse should: A) verify the information with the client's family prior to documentation. B) use the client's own words placed in quotation marks. C) record the information using generic wording. D) document everything that was said by the client in an unstructured manner B) use the client's own words placed in quotation marks Which is a correctly written client outcome? A) The client understands what foods are low in sodium. B) The client correctly self-administers the morning dose of insulin. C) The client will ambulate 10 ft (3 m) with a walker by October 12. D) The client will eliminate a soft, formed stool. C) The client will ambulate 10 ft (3 m) with a walker by October 12 When a client achieves their expected outcome in the care plan, which action should the nurse do first? A) Continue the care plan. B) Create a new care plan. C) Modify the care plan. D) Terminate the care plan. D) Terminate the care plan The nurse is caring for an older adult client who is prescribed a benzodiazepine. When planning the client's assessment, the nurse should be aware of what possible adverse effect? A) Acute renal failure B) Dysuria (painful urination) C) Epistaxis (nosebleeds) D) Unpredictable reactions D) Unpredictable reactions Rationale: Use benzodiazepines with caution in elderly or debilitated clients because of the possibility of unpredictable reactions and in clients with renal or hepatic dysfunction, which may alter the metabolism and excretion of these drugs, resulting in direct toxicity. Dosage adjustments usually are needed for such clients. Acute renal failure, dysuria, and epistaxis are not commonly related to therapy with these medications in the elderly. The nurse is caring for a client who does not have a respiratory disorder but has been prescribed acetylcysteine. What is an additional indication for acetylcysteine? A) Antidote for acetaminophen poisoning B) Conversion of cardiac rhythm irregularities C) Treatment of bronchospasm D) Treatment of stomach ulcers A) Antidote for acetaminophen poisoning Rationale: Acetylcysteine is used orally to protect liver cells from being damaged during episodes of acetaminophen toxicity because it normalizes hepatic glutathione levels and binds with a reactive hepatotoxic metabolite of acetaminophen. Acetylcysteine is not used for the conversion of cardiac dysrhythmias, for treatment of peptic ulcer disease, or for decreasing bronchospasm. Karch Ch 54 Acetylcysteine is used orally to protect liver cells from being damaged during episodes of acetaminophen toxicity because it normalizes hepatic glutathione levels and binds with a reactive hepatotoxic metabolite of acetaminophen. Acetylcysteine affects the mucoproteins in the respiratory secretions by splitting apart disulfide bonds that are responsible for holding the mucus material together. The result is a decrease in the tenacity and viscosity of the secretions. Karch pg 955 A client has taken a benzodiazepine for one year following a divorce. During an annual physical, the client states, "I decided it was time to move on, so I stopped this drug three days ago." The nurse then assesses the client for what symptoms of withdrawal? A) Trembling. muscle cramps, and sweating B) Sedation and drowsiness C) Decreased libido (sex drive) and urinary hesitancy D) Dry mucous membranes and constipation A) Trembling, muscle cramps, and sweating Rationale: Taper dose gradually after long-term therapy, especially in epileptic patients. Acute withdrawal could precipitate seizures in these patients. It may also cause withdrawal syndrome. Karch, pg 346 A client with a persistent, dry, non-productive cough has been diagnosed with chronic pharyngitis (sore throat). The client should benefit the most from what medication category? A) Mucolytics B) Oral decongestants C) Antitussives D) Nasal sprays C) Antitussives Rationale: Antitussives are drugs that suppress the cough reflex. Many disorders involving the respiratory tract, including the common cold, sinusitis, pharyngitis, and pneumonia are accompanied by an uncomfortable, nonproductive cough. Persistent coughing can be exhausting and can cause muscle strain and further irritation of the respiratory tract. Nasal sprays, oral decongestants, and mucolytics are not generally prescribed for chronic pharyngitis. Karch 8e pg 940 What client education would the nurse include following administration of a sublingual medication? A) "Swallow this tablet with a full glass of water." B) "Chew the pill so it will dissolve faster." C) "Allow the tablet to slowly dissolve beneath your tongue." D) "Avoid dairy products while taking this medication." C) "Allow the tablet to slowly dissolve beneath your tongue." A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure? A) Reduces need for prn pain medications B) Prolongs expiration reducing airway resistance C) Replaces use of incentive spirometry D) Assists in moving upper chest muscles B) Prolongs expiration reducing airway resistance Rationale: Pursed-lip breathing can help clients with dyspnea and feelings of panic gain control of their respirations. This exercise trains the muscles to prolong expiration, increasing airway pressure during expiration, and reducing the amount of airway trapping and resistance. Taylor, Ch 39 pg The nurse is preparing to complete a head to toe assessment on a client. The most important intervention immediately prior to beginning the assessment would be ? A) Ask the client about an appropriate time to complete the assessment. B) Have the client remove all clothing and don a patient gown. C) Provide privacy without environmental distractions when performing the assessment. D) Always involve family members in collecting information about the client. C) Provide privacy without environmental distractions when performing the assessment Rationale: The nurse and client should be in a room (or area) that is private, quiet, and warm enough to prevent chilling, and it should have adequate lighting, either by sunlight or overhead fixtures. Family members may remain, especially if they are needed to explain activities to the client. A nursing assessment does not require a primary care provider's order. Time for the assessment should be mutually agreed upon but the priority is that the space be accommodating for the nurse and client. Taylor, ch 26 The nurse noted that a client just received bad news, was crying, and did not want to speak to anyone. What is the correct term for this response to this news? A) Defense mechanism B) Homeostasis C) Adaptation D) Coping mechanism D) Coping mechanism Rationale: When a person is in a threatening situation, immediate responses occur. Those responses, which are often involuntary, are called coping responses. The change that takes place as a result of the response to a stressor is adaptation. (Taylor, ch 42) A nurse uses the ISBARR method to hand off the communication to the health care team. Which of the following might be listed under the "B" of the acronym? A) Vital signs B) Mental status C) Further testing D) Client request B) Mental status Rationale: ISBARR stands for Introduction, Situation, Background, Assessment, Recommendation, and Readback. ISBARR provides a consistent method for hand-off communication that is clear, structured, and easy to use. Vital signs would fall under the category of situation; mental status: background; client request: assessment; further testing: recommendations. Your client is a recent college graduate working at a fast paced engineering firm for approximately 4 months. The client recognizes there have been many stressful days on the job and makes a decision to participate in activities to reduce stress. What activities would you recommend to reduce stress for your client? Select all that apply. A) Take a sleeping pill to ensure getting at least 7 hours sleep. B) Participate in an enjoyable hobby, such as painting. C) Practice meditation. D) Drink two to three ounces of alcohol each night after work. E) Walk in neighborhood for 3 to 4 days/week. B) Participate in an enjoyable hobby, such as painting C) Practice meditation E) Walk in neighborhood 3 to 4 days/week The wristband is an important safety component used during client stays. Which organization's guidelines require the nurse to accurately identify a client using the wristband when providing care? A) ANA (American Nurses' Association) B) TJC (The Joint Commission) C) NANDA ( North American Nursing Diagnosis Association) D) HIPAA (Health Insurance Portability and Accountability Act) B) TJC (The Joint Commission) When nurses use the principle of _________ during client care, avoidance of all harm is priority. A) Justice B) Nonmaleficence C) Fidelity D) Autonomy B) Nonmaleficence The nurse has donned a sterile glove on one hand and is preparing to don the other sterile glove. What would be the next step? A) Use the fingers and thumb to grasp the edges of the cuff of the second glove. B) Hold the second glove in the palm of the gloved hand. C) Use the thumb and index finger to grasp the cuff of the second glove. D) Place the fingers of the gloved hand under the cuff of the second glove. D) Place the fingers of the gloved hand under the cuff of the second glove A wound and ostomy care nurse (WOCN) is teaching a client to care for a new colostomy. The client's understanding of teaching is verified when the client states? A) "It is normal if the stoma is beefy red and moist." B) "I need to call my provider if the peristomal skin is intact." C) "I should change the wafer every am at 1000." D) "I should call my surgeon if the stoma is not drying out." A) "It is normal if the stoma is beefy red and moist." Rationale: Beefy red and moist is an expected finding. A student is collecting a sterile urine specimen from an indwelling catheter. Which of the following is the correct way to obtain the specimen? A) Remove the catheter and ask the client to void. B) Aspirate urine from the collection bag. C) Obtain urine from the collection bag. D) Aspirate urine from the collection port on the catheter tubing. D) Aspirate urine from the collection port on the catheter tubing The nurse is aware that some clients have difficulty swallowing solid preparations of medications. What nursing intervention would be the most appropriate to assist a geriatric client with difficulty swallowing? A) Break a scored tablet. Give first half then give the second half 30 sec. to a min. later. B) Crush a prolonged-release tablet into fine powder. C) Open a sustained-release capsule and mix the contents with applesauce. D) Crush an enteric-coated tablet and give with milk. A) Break a scored tablet. Give first half then give the second half 30 seconds to 1 minute later Rationale: Scored tablets can be broken and administered separately. This make swallowing the pill easier because it is not as large. Waiting before giving the second half allows time for the first half to move downward into the stomach via peristalsis. A client is to receive metoclopramide (Reglan) for nausea. What statement by the client leads the nurse to believe that the client has understood the nurse's teaching? A) "This medication should be taken on a full stomach." B) "During episodes of nausea, I will drink lots of water." C) "I will take OTC minerals while I am taking this medication." D) "I may be drowsy as a result of taking this medication." D) "I may be drowsy as a result of taking this medication." Rationale: Adverse effects include drowsiness, fatigue, restlessness, extrapyramidal symptoms, and diarrhea. A client with acid reflux has an order for pantoprazole (Protonix), 40 mg po daily. In order to achieve maximum therapeutic effect, the nurse schedules the medication for which of the following times? A) 1000 hours B) One hour after breakfast C) One hour before breakfast D) 2200 hours C) One hour before breakfast The provider instructs the client to take psyllium (Metamucil) 1 tablespoon daily in 8 oz of water. Which client outcome would be the best measure of a therapeutic response from this medication? A) Client bowel sounds progress from hypoactive to absent within 3 hours B) Client produces soft, formed bowel movement within 2 days C) Client reports nausea followed by projectile vomiting within 1 hour D) Client complains of 3 liquid stools within 8 hours B) Client produces soft, formed bowel movement within 2 days Rationale: Psyllium is a natural substance that forms a gelatin-like bulk of the intestinal contents. This agent stimulates local activity. It is considered milder and less irritating than many other bulk stimulants. Clients must use caution and take it with plenty of water because psyllium absorbs large amounts of water and produces stools of gelatin-like consistency. As anti-infectives continue to be an area of concentration for pharmaceutical manufacturers and as providers are encouraged to prescribe these medications, nurses are caring for an increasing number of clients who have developed antibiotic resistance. What principles should the nurse and the other members of the health care team follow in attempts to prevent antibiotic resistance? Select all that apply. A) Teach clients not to save antibiotics for self-medication in the future. B) Perform culture and sensitivity testing immediately after starting a course of antibiotics. C) Use narrow-spectrum agents if they are likely to be effective. D) Avoid broad-spectrum antibiotics when treating trivial or viral infections. E) Treat all infections with antihelminthic or antivirals whenever possible. A) Teach clients not to save antibiotics for self-medication in the future. Rationale: It is vital to complete the full course of treatment to increase the chances of eradication of the organism. Incomplete treatment can promote repeated prescriptions of antibiotics (when symptoms persist or return) which can promote antibiotic resistance. C) Use narrow-spectrum agents if they are likely to be effective Rationale: Use of narrow spectrum antibiotics treat fewer types of bacteria. As long as this is a therapeutic option for the client, it can be a better choice of treatment. Treating fewer bacteria prevent such a large number of bacteria to mutate and develop resistance to antibiotics. D) Avoid broad-spectrum antibiotics when treating trivial or viral infections. A nurse has administered an intramuscular injection. What will the nurse do with the syringe and needle? A) Recap the needle; place it in a puncture-resistant container. B) Take off the needle and throw the syringe in the client's trash can. C) Break off the needle, place it in the barrel, and throw it in the trash. D) Do not recap the needle; place it in a puncture-resistant container. D) Do not recap the needle; place it in a puncture-resistant container Rationale: After use, needles and syringes are placed in a puncture-resistant container without being recapped. This prevents needlestick injuries, because most occur during recapping. A client is currently taking medications for chronic pain management secondary to rheumatoid arthritis. At an urgent care facility, the client presents with reports of dizziness, mental confusion, and difficulty hearing. What assessment is most appropriate by the nurse based upon these symptoms? A) Allergy status B) Use of salicylates C) Use of acetaminophen D) Exacerbation of rheumatoid arthritis B) Use of salicylates Rationale: Salicylism can occur with high dosage of aspirin. Dizziness, ringing in the ears, difficulty hearing, nausea, vomiting, diarrhea, mental confusion, and lassitude can occur. This combination of adverse effects is not associated with acetaminophen toxicity or an exacerbation of rheumatoid arthritis itself. This constellation of symptoms is not suggestive of an allergic reaction. (Taylor ch. 35) A nurse is preparing to administer a prescribed antibiotic and is aware that the medication is selectively toxic. What does the nurse understand about this medication? A) It eliminates bacteria by interrupting protein synthesis and damaging the pathogen's cell wall. B) It interferes with a biochemical reaction common to many different organisms. C) It kills invading bacteria by interfering with the pathogens' ability to reproduce. D) It is able to kill foreign cells without causing significant harm to the client's own body cells. D) It is able to kill foreign cells without causing significant harm to the client's own body cells Rationale: The choice of antibiotics in a clinical situation is determined by assessing which drug will affect the causative organism and lead to the fewest adverse effects. Selective toxicity is the ability of the drug to kill foreign cells without causing harm to the human body cells. How the antibiotic works to kill bacteria varies by drug type and may reduce the ability to reproduce, damage the cell wall, or interfere with a biochemical reaction, but this is a description of how the antibiotic works and does not describe selective toxicity. A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which agent is most likely the cause of the infection? A) Spores B) Fungi C) Bacteria D) Virus C) Bacteria Rationale: Some of the more prevalent agents that cause infection are bacteria, viruses, and fungi. Bacteria are the most significant and most commonly observed infection-causing agents in health care institutions. A client is on isolation because she acquired a MRSA infection after hospitalization for hip replacement surgery. What name is given to this type of infection? A) Healthcare-associated (HAI) B) Septicemia C) Antimicrobial D) Viral A) Healthcare-associated (HAI) Rationale: For various reasons and sometimes despite best efforts, certain clients in health agencies develop infections that were not noted to be present on admission. The term healthcareassociated infection is used to describe a hospital-acquired infection. A nurse is performing a sterile dressing change. If new sterile items or supplies are needed, how can they be added to the sterile field? A) With clean forceps that touch only the outermost part of the item B) By carefully handling them with clean hands C) By clean hands wearing clean latex gloves D) With sterile forceps or hands wearing sterile gloves D) With sterile forceps or hands wearing sterile gloves Rationale: Once a sterile field is established, objects on a field may only be handled by using sterile forceps or with hands wearing sterile gloves. The other choices would contaminate the sterile field.