Question 1

When administering drugs during CPR, what would be a priority for the nurse?

Accepted Answer

When administering drugs during CPR, the nurse should use a saline flush between medications to prevent drug interactions. The nurse must also document all drugs, dosages, and the time and route of administration. Other options, although important, are not the highest priority during CPR.

Question 2

Which initial nursing assessment finding would best indicate that a client has been successfully resuscitated after a cardio-respiratory arrest?

Accepted Answer

Palpable carotid pulse. Presence of a palpable carotid pulse indicates the return of cardiac function which, together with the return of breathing, is the primary goal of CPR. Pulsations in arteries indicate blood flowing in the blood vessels with each cardiac contraction. Signs of effective tissue perfusion will be noted after.

Question 3

A 20-year-old client is being treated for pneumonia. He has a persistent cough and complains of severe pain on coughing. What type of instruction could be given to help the client reduce the discomfort he is having?

Accepted Answer

"Splint your chest wall with a pillow for comfort." Showing this client how to splint his chest wall will help decrease discomfort when coughing. Holding in his coughs will only increase the amount of pain he has. Placing the head of the bed flat may increase the frequency of his cough more efficiently and with less pain. Increasing fluid intake will help to clear them. Promoting fluid intake is appropriate in this situation.

Question 4

What is the expected outcome for a client with a nursing diagnosis of ineffective airway clearance related to inflammation?

Accepted Answer

Choice C is the only correct answer. The desired outcome addresses the client's response. Choice A and D are nursing interventions. Choice B is a client goal not relevant to the nursing diagnosis.

Question 5

Marcus, a 56-year-old miner, was diagnosed with lung cancer and requires a wedge resection. How much of the lung is removed?

Accepted Answer

A very small area of tissue close to the surface of the lung is removed in wedge resection. A segment of the lung is removed in a segmental resection, a lobe is removed in a lobectomy, and an entire lung is removed in a pneumonectomy.

Question 6

The nurse is preparing her plan of care for a patient diagnosed with pneumonia. Which is the most appropriate nursing diagnosis for this patient?

Accepted Answer

Impaired gas exchange. Pneumonia, which is an infection, causes lobar consolidation, thus impairing gas exchange between the alveoli and the blood. Because the patient would require adequate hydration, this makes him prone to fluid volume excess.

Question 7

Which of the following physiologic effects of a pulmonary embolism would initially affect oxygenation?

Accepted Answer

The blood clot blocks blood flow to a region of the lung tissue. That area remains ventilated, but because blood flow is blocked, no gas exchange can occur in that region and a ventilation-perfusion mismatch is present. Ventilation isn't initially affected by a blood clot because air can still move normally through the bronchial tree.

Question 8

A 60-year-old client develops acute shortness of breath and progressive hypoxia, requiring mechanical ventilation after repair of a fractured right femur. The hypoxia was probably caused by which of the following conditions?

Accepted Answer

Long bone fractures are correlated with fat emboli, which cause shortness of breath and hypoxia. It's unlikely the client has developed asthma or bronchitis without a previous history. He could develop atelectasis, but it typically doesn't produce progressive hypoxia.

Question 9

The nurse inspects the skin of Jamie, 11 years old, suspected of having scabies. Which assessment finding would the nurse note if this disorder was present?

Accepted Answer

Scabies can be identified by multiple straight or wavy, thread-like lines noted beneath the skin. The skin lesions are caused by the female mite, which burrows beneath the skin and lays her eggs. The eggs hatch in a few days and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Choices A, B, and D are not characteristics of scabies.

Question 10

The nurse prepares discharge instructions for Mayra, 27 years old, following cryosurgery for the treatment of a malignant skin lesion. Which of the following should the nurse include in the instructions?

Accepted Answer

Cryosurgery involves the local application of liquid nitrogen to isolated lesions and causes cell death and tissue destruction. The nurse informs the client that swelling and increased tenderness of the treated area can occur when the skin thaws. Tissue freezing is followed by hemorrhagic blister formation in 1 to 2 days. The nurse instructs the client to clean the treatment site with hydrogen peroxide to prevent secondary infection. A topical antibiotic also may be prescribed. Application of a warm, damp washcloth intermittently to the site will provide relief from any discomfort. Alcohol-soaked dressings will cause irritation. The client does not need to avoid showering.

Question 11

Shane, 12 years old, is an avid fan of skateboarding. She tried to learn the moves, but accidentally fell on her first try. Agonizing in pain, she was then brought to the Emergency Department. The X-ray film showed an incomplete fracture of the left tibia. The doctor ordered for a closed reduction and a cast was applied on her left leg. Which of the following is an incorrect intervention for Shane?

Accepted Answer

Creating a turning schedule every 3 hours for position changes is the incorrect intervention. Position changes should be scheduled every 2 hours to prevent the complications of immobility which are pneumonia, skin breakdown, or deep vein thrombosis. The rest of the choices are correct nursing actions for a client with closed reduction.

Question 12

The nurse should plan to include which of the following statements in client teaching for impetigo?

Accepted Answer

Good hygiene is recommended to prevent spreading the infection to other family members. Choice A is false. Impetigo is contagious and antibiotic therapy is the recommended treatment (Choices C and D).

Question 13

Forty-eight hours after a burn injury, the physician orders for the client 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:

Accepted Answer

The nurse should set the flow to provide 28 gtt/min. This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes).

Question 14

To promote the safety environment of a client with Von Willebrand's disease, which actions would the nurse take?

Accepted Answer

To promote the safety environment of a client with Von Willebrand's disease, the nurse would advise the client to wear gloves while doing household chores. In clients with Von Willebrand's disease (also known as hemophilia), trauma and bleeding occurrences need to be minimized.

Question 15

A school-age child has leukemia. Considering the diagnosis and health teaching needs, the nurse would be most correct in advising this child to:

Accepted Answer

Brushing the teeth with a soft toothbrush can prevent bleeding gums due to thrombocytopenia, which is common in children with leukemia; in addition, chemotherapy may also cause oral mucous membrane ulceration. Choice C is not applicable because it might cause a break in the gums, leading to infection. Rinsing the mouth only (Choice D) might also lead to infection, because this would not necessarily clean the gums and teeth adequately; likewise, infection might be caused by not brushing the teeth (Choice A).

Question 16

Ana, 55 years old, is admitted to the hospital to rule out pernicious anemia. A Schilling test is ordered for Ana. The nurse recognizes that the primary purpose of the Schilling test is to determine the client's ability to:

Accepted Answer

Absorb vitamin B12. Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach due to a lack of intrinsic factor in the gastric juices. In the Schilling test, radioactive vitamin B12 is administered and its absorption and excretion can be ascertained through the urine.

Question 17

Roxanne, a 32-year-old waitress, underwent a cerebral angiogram through the right femoral site. Which procedural nursing assessment(s) would justify calling the physician? Select all that apply.

Accepted Answer

Assessment findings warranting a call to the physician include signs and symptoms of bleeding and possible perfusion problems. In this case, the client's decreased blood pressure, increased heart rate, increased amount of blood drainage, and asymmetrical pulses would necessitate notification of the physician.

Question 18

The nurse reads in an admission note that the physical examination of a client revealed an impairment of cranial nerve II. The nurse instructs ancillary caregivers to do which of the following when caring for this client?

Accepted Answer

The optic nerve, which governs vision, is cranial nerve II. For this client it would be most helpful to clear the area of objects that may not be perceived by the client, but that could lead to falls. The actions described in the options are unnecessary.

Question 19

The nurse includes the important measures for stump care in the teaching plan for a client with an amputation. Which measure would be excluded from the teaching plan?

Accepted Answer

Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. The "shrinker" bandage is applied to prevent swelling of the stump. It should be applied at the distal end with the tighter arms. Applying the tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow.

Question 20

Which nursing action is the first priority during a generalized tonic-clonic seizure episode?

Accepted Answer

The first priority is to protect the client from injury. Do not restrain the client's arms or legs, but make sure he or she does not hit anything. Protect the head with the nurse's hand, a towel, or a jacket. During the initial tonic phase, the client usually stops breathing for up to minute. There is no cause for alarm, as spontaneous breathing will, in most clients, return with no harm. In the absence of breathing, airway patency by this position change (Choice B) is not the first priority. Muscle contraction will prevent "positioning" of the head. A padded tongue blade, once indicated during a seizure, is also no longer used. Choices A and D are appropriate nursing actions after the seizure has ended.

Quiz 1: Medical Surgical Nursing Practice