Question 1

A nurse develops a plan of care for a client at risk for autonomic dysreflexia. Which of the following nursing actions is not included in the care plan?
A)Administer pain medications as ordered
B)Straight catheterization every 8 hours
C)Adherence to bowel retraining program
D)Keeping the client's linen wrinkle-free

Accepted Answer

Autonomic dysreflexia is stimulated by a distended bladder, an impacted rectum, wrinkled linen, pain or another cause. Straight catheterization is done every 4 to 6 hours to prevent bladder distension. The other actions are appropriate.

Question 2

A complication of nasogastric tube insertion for decompression of gastric contents is "silent aspiration." This complication involves the accumulation of gastric contents over a period of time. The nurse should watch out for which one of the following manifestations of silent aspiration?
A)Sudden shortness of breath
B)Sudden hypotension and tachycardia
C)Restlessness and irritability
D)Sudden change in mental status

Accepted Answer

Restlessness and irritability are the manifestations of silent aspiration. When a nasogastric tube is not functioning well, it allows the accumulation of gastric contents in the stomach, causing silent aspiration. This condition results from reflux of gastric content into the air passage. Silent aspiration may occur unnoticed and not present outwardly. However, in some cases, restlessness and irritability may be noted. Sudden shortness of breath, sudden hypotension and tachycardia as well as abrupt changes in mental status are characteristic of fluid aspiration.

Question 3

A nurse is preparing to remove the nasogastric tube of Hannah, a 67-year-old client. The nurse should instruct the client to do which of the following just before removing the tube?
A)Slowly breathe out
B)Slowly breathe in
C)Quickly breath in and then breathe out
D)Hold her breath

Accepted Answer

When removing the nasogastric tube the nurse should instruct the client to hold her breath to avoid unintentional aspiration of gastric contents in the tube. The maneuver should be quick but gentle to reduce discomfort and tissue trauma and to avoid drainage of gastric contents.

Question 4

A nurse plans to attach the probe of a pulse oximeter on the client's right forefinger. Which of the following conditions could result in inaccurate reading by the probe, necessitating a change in the attachment site?
A)Artificial fingernails
B)Hypothermia
C)Client has chronic respiratory disease
D)Client has Parkinson's disease

Accepted Answer

Clients with Parkinson's disease usually develop hand tremors. Attaching the probe to any of the client's fingers would yield inaccurate readings. The other options are conditions that do not necessitate a change in attachment site. To avoid false readings, the client may remove the artificial nails. The nurse could also increase the temperature in the room to avoid hypothermia which can affect the probe's readings. In clients with chronic respiratory disease, the nurse would expect lower than normal O2 saturation.

Question 5

Tommy, a client diagnosed with diabetes mellitus type II, is asked by his physician to undergo hemoglobin A1c testing every three months. Tommy asks the nurse about the significance of this test. The nurse correctly responds that hemoglobin A1c testing does not:
A)Test the client's compliance with medications
B)Test the client's compliance with diet
C)Test the client compliance with his exercise regimen
D)Test the client's disease progression

Accepted Answer

Hemoglobin A1C does not determine disease progression. Hemoglobin A1C is a test used to determine glucose control. The results imply whether or not the client has been compliant with medications, diet and exercise regimen. An acceptable HbA1c is 4% - 6%. This test is repeated every three or six months.

Question 6

A nurse is assessing a client who is having a blood transfusion. The blood transfusion was ordered after the laboratory test revealed a hemoglobin level of nine g/dL While transfusing the first unit of blood, the client complained of flank pain. The client's blood pressure is dropping and the heart rate is racing. These symptoms indicate:
A)Delayed hemolytic reaction
B)Anaphylactic reaction
C)Febrile reaction
D)Acute hemolytic reaction

Accepted Answer

The presenting symptoms are most likely associated with an acute hemolytic reaction that usually results from ABO incompatibility. Delayed hemolysis occurs weeks or months after the blood transfusion. In the case of acute hemolysis, the transfusion should be terminated immediately and the unit rechecked for compatibility. The doctor may order the client catheterized in order to check for hematuria.

Question 7

A client has a serum calcium level of 5.0 mg/dL. As the nurse reviews the client's records, which information is the most likely cause of the laboratory result?
A)Over activity of parathyroid glands
B)Excessive vitamin D levels
C)Intake of furosemide
D)Renal failure

Accepted Answer

The normal serum calcium level is between 8.6 and 10.0 mg/dL. A calcium level of 5.0 mg/dL indicates hypocalcemia. Loop diuretics, such as furosemide, may increase the excretion of calcium, which increases the risk for hypocalcemia. The other options increase the risk for hypercalcemia.

Question 8

A client who had just undergone hemodialysis is ordered for a laboratory test. Which of the following parameters will show a significant improvement after dialysis?
A)Creatinine
B)Hemoglobin
C)Phosphorus
D)Calcium

Accepted Answer

The best indicator of client's response to dialysis is a decrease in creatinine level. Creatinine is used to measure how well the kidneys can filter fluids. On the other hand, dialysis will result in diminishing hemoglobin level (renal anemia), increased phosphorus and decreased calcium which are all part of disease process of CKD.

Quiz 4: Reduction of Risk

A nurse develops a plan of care for a client at risk for autonomic dysreflexia. Which of the following nursing actions is not included in the care plan?

A complication of nasogastric tube insertion for decompression of gastric contents is "silent aspiration." This complication involves the accumulation of gastric contents over a period of time. The nurse should watch out for which one of the following manifestations of silent aspiration?

A nurse is preparing to remove the nasogastric tube of Hannah, a 67-year-old client. The nurse should instruct the client to do which of the following just before removing the tube?

A nurse plans to attach the probe of a pulse oximeter on the client's right forefinger. Which of the following conditions could result in inaccurate reading by the probe, necessitating a change in the attachment site?

Tommy, a client diagnosed with diabetes mellitus type II, is asked by his physician to undergo hemoglobin A1c testing every three months. Tommy asks the nurse about the significance of this test. The nurse correctly responds that hemoglobin A1c testing does not:

A client has a serum calcium level of 5.0 mg/dL. As the nurse reviews the client's records, which information is the most likely cause of the laboratory result?

A client who had just undergone hemodialysis is ordered for a laboratory test. Which of the following parameters will show a significant improvement after dialysis?