RNSG 2331 - Exam-3-capstone-1 (100% correct answers)

Question: Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection? You answered this question Incorrectly 3. Places the top of the dia per just above the umbilicus. 4. Wraps sterile petroleum gauze around umbilical cord. 5. Submerges newborn in warm water up to the chest for first bath. 1., & 2. Correct: Cleaning from front to back will decrease the risk of infection by reducing the number of microorganisms at the urethral meatus. Keeping the umbilical cord clean and dry will decrease the risk of infection and will allow it to fall off. 3. Incorrect: The top of the diaper should be placed just below the umbilicus to prevent exposure to body waste and moisture. Placing the diaper above the umbilical cord will cause the diaper to rub the umbilicus, which will increase the risk of infection. 4. Incorrect: This would keep the umbilical cord moist and could lead to infection. Also a sterile dressing is not warranted. The umbilical cord needs to be kept dry so it will fall off. 5. Incorrect: The newborn should not be placed in water until after the umbilical cord falls off. Water submersion keeps the cord moist and at risk for infection. The umbilical cord should be kept dry so that it will fall off. Question: A client tells the nurse, “I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing.” What action should the nurse take first to assure that the client’s request is respected? You answered this question Incorrectly 2. Report client wishes during the end-of-shift report. 3. Have the client sign an advanced directive. 4. Ask the client who holds the durable power of attorney for health care decisions. 1. Correct: The nurse should check the medical record for a DNR order. By law, a person who does not have a do-not-resuscitate (DNR) prescription, must be provided CPR in the event of a cardiac/respiratory arrest. This action will ensure the client’s end- of-life wishes have been communicated and will honor the client’s wishes. 2. Incorrect: It is appropriate to report the client’s end-of-life wishes to other care givers, but not before ensuring a DNR order is in place. 3. Incorrect: If the client has advance directives, a copy should be placed in the medical record. However, a DNR prescription must also be in place to ensure the client is not resuscitated. 4. Incorrect: The client's request can be initiated by notifying the primary healthcare provider. It would be helpful for the client to have a durable power of attorney. Question: A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal? You answered this question Correctly 1. "I should wrap the needle in a paper towel and place in the trash." 2. "I should use a hospital issued biohazard container for all needles." 4. "I should take my needles to the nearest hospital for disposal. " 3. Correct: At home, an FDA approved sharps container is not needed, however, needles, syringes, and sharps may be disposed of in a hard plastic container. Clients should follow their community guidelines for sharps container disposal. This protects the sanitation engineers from injury by the sharps. 1. Incorrect: Syringes must be placed in a safe container in order to protect others from becoming injured by sharps. Wrapping the needle in a paper towel and placing in the trash increases the possibility of injury to someone. 2. Incorrect: The hospital is not involved in sharps disposal in the home. A hard plastic container with a screw on cap is an acceptable container to dispose of needles. 4. Incorrect: The hospital is not involved in sharps disposal in the home. The client can dispose of needles safely at home in a hard plastic container with a screw on cap. The needle should not be brought to the hospital for disposal. Question: A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse sees a medical alert bracelet stating “Diabetic”, and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and an attempt to call them has been unsuccessful. What action should the nurse take? You answered this question Correctly 1. Obtain consent from the social worker on duty in the emergency department. 3. Give glucogon IM and wait for the arrival of a parent to consent to further treatment. 4. Withhold treatment until a parent arrives to the emergency department. 2. Correct: In emergencies, if it is impossible to obtain consent from the client or an authorized person, a health care provider may perform a procedure required to benefit the client or save a life without liability for failure to obtain consent. In such cases the law assumes that the client would wish to be treated. Begin treatment for diabetic ketoacidosis (DKA). 1. Incorrect: Consent for a minor is not needed in the event of an emergency. The social worker does not give consent in this situation. 3. Incorrect: This client is exhibiting signs of DKA, so glucagon is not needed. Emergency treatment can be provided without parental consent. 4. Incorrect: Consent for a minor is not needed in the event of an emergency. This is an emergency, so begin treatment for DKA. Question: The nurse is caring for a client in the emergency department. The primary healthcare provider prescribed 1000 mL of D5 ½ NS. The IV is infusing at 25 gtts/min. (Drop factor is 60 gtts/mL). What is the infusion time in hours? Round your answer to the nearest whole number. You answered this question CorrectlyEnter the answer for the question below. Question: The nurse is caring for a client in an outpatient clinic. The client is being treated with warfarin for prevention of a stroke due to atrial fibrillation. The international normalized ratio (INR) was noted to be 4.6. What should the nurse do? You answered this question Correctly 2. Instruct the client to continue medication as ordered. 4. Inform the client to return to the clinic per routine monitoring schedule. 5. Take no action as this value is within target range. 1. & 3. Correct: The primary healthcare provider should be notified. The value of 4 is above the usual target range of 2-3. The client has a potential for decreased clotting and bleeding. The client should be told to watch for signs of bleeding. 2. Incorrect: The medication dosage is likely to be reduced. 4. Incorrect: The client should not leave the clinic until the primary healthcare provider has been notified. Further action is indicated and may include changing the usual warfarin dosage. 5. Incorrect: The normal range for a INR is 2-3. When a client is prescribed warfarin, the INR should increase to a therapeutic target range. The value of 4.6 is greater than the usual target range. Question: Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)? You answered this question Correctly 1. Tell a female client who has recurrent urinary tract infections how to wipe after urinating. 3. Collects a urine specimen from an indwelling catheter tubing. 5. Irrigate the foley catheter of a client who has had transurethral resection of the prostate (TURP). 2. , 4., & 6. Correct: These are all tasks that can be performed by the UAP. The UAP has received training for completing these tasks. 1. Incorrect: The UAP cannot provide teaching; that is planned and implemented by the RN. 3. Incorrect: This is out of the scope of practice for the UAP as it is requires entering a sterile system using sterile technique. 5. Incorrect: The UAP does not have the knowledge and skill to irrigate catheters of any kind. This is a skilled procedure. Question: A client was prescribed thioridazine hcl five days ago and presents to the emergency department with a shuffling gait, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication does the nurse suspect? You answered this question Correctly 1. Akinesia 2. Neuroleptic malignant syndrome 4. Oculogyric crisis 3. Correct: Pseudoparkinsonism may appear 1 to 5 days following initiation of antipsychotic medications: occurs most often in women, the elderly, and dehydrated clients. Symptoms include tremor, shuffling gait, drooling, and rigidity. 1. Incorrect: Akinesia is defined as muscle weakness. This client is not presenting with this symptom. 2. Incorrect: Neuroleptic malignant syndrome is a rare, but fatal complication of neuroleptic drugs. Symptoms include hyperpyrexia up to 107 degrees, tachycardia, tachypnea, fluctuations in BP, diaphoresis, coma. 4. Incorrect: Oculogyric crisis is uncontrolled rolling back of the eyes and may appear as part of dystonia (involuntary muscular movements of face, arms, legs, and neck). Oculogyric crisis is not a side effect of thioridazine. Question: A nurse is planning to teach a group of men about their sildenafil prescription. What information should the nurse include? You answered this question Correctly 2. This medication protects against sexually transmitted diseases. 4. This medication is most effective if taken with grapefruit juice. 1. , 3., & 5. Correct: Alpha-adrenergic blockers action is to dilate small muscles. The action of sildenafil is also to dilate specific small muscles. The combination of these medications can cause a hypotension event. Sildenafil is usually taken only when needed, 30 minutes to 1 hour before sexual activity. Do not take sildenafil more than once per day. The most common side effects are flushing, headache, and dyspepsia. 2. Incorrect: This medication does not protect against sexually transmitted diseases. Safe sex practices should be followed, such as use of latex condoms. 4. Incorrect: Grapefruit and grapefruit juice may interact with sildenafil and lead to unwanted side effects. Avoid the use of grapefruit products while taking sildenafil. Question: The charge nurse has received report from the emergency department about a client diagnosed with Cushing’s disease being admitted to the unit. Which client in a semi- private room would be appropriate for the charge nurse to have this client share? You answered this question Correctly 1. Client who has leukemia. 2. Client diagnosed with gastroenteritis. 4. Client diagnosed with bronchitis. 3. Correct: The client with Cushing’s disease could go in the room with the client who has a fractured hip, as this client does not have an infection. 1. Incorrect: Both of these clients are immunocompromised and should not share a room with each other. 2. Incorrect: The client with gastroenteritis poses a risk of infection to the client with Cushing’s disease because this client is immunosuppressed. 4. Incorrect: The client with bronchitis poses a risk of infection to the client with Cushing’s disease. Question: Which finding should a nurse expect when assessing a healthy 65 year old client? You answered this question Correctly 1. Anomia 3. BP 156/88 4. Apraxia 2. Correct: As the lens becomes less flexible, the near point of focus gets further away. This condition, presbyopia, usually begins in the 40s. Reading glasses to magnify objects are required. 1. Incorrect: Anomia (cannot name objects) is an early sign of Alzheimer’s disease. Anomia is not a normal assessment of a 65 year old client. 3. Incorrect: Blood pressure (BP) reading of 156/88 is not within normal BP range. The normal blood pressure range for the 65 to 79 year old is 140/90 or less. 4. Incorrect: Apraxia means client cannot perform purposeful movement. We would not expect to assess this in a healthy 65 year old. Question: The nurse will be admitting a client from the operating room following a left total pneumonectomy for adenocarcinoma. Which type of chest drainage should the nurse anticipate that the client will have? You answered this question Incorrectly 1. Bilateral chest tubes. 2. One chest tube on the operative side 3. Two chest tubes on the operative side 4. Correct: A total pneumonectomy means the excision of the entire lung. A drainage tube is not inserted, since the fluid and air must accumulate in the thoracic space. This is to prevent mediastinal shift to the left. 1. Incorrect: A total pneumonectomy is removal of entire lung. The presence of fluid and air in the left thoracic cavity decreases the incidence of left mediastinal shift. 2. Incorrect: The entire lung is removed. The left thoracic space should fill with fluid and air to prevent mediastinal shift. The insertion of a chest tube is not warranted. 3. Incorrect: Entire lung is removed and no chest drainage is needed. The insertion of two chest tubes is not required. Fluid and air should fill the left pleural space to reduce the risk of a mediastinal shift. Question: The nurse is performing the admission assessment on a client who is having a breast augmentation. Which client information would be most important for the nurse to report to the surgeon before surgery? You answered this question Correctly 1. Client is concerned about who will care for her two children while she recovers. 2. There is a history of postoperative dehiscence after a previous C-section. 4. Client is concerned over pain control postoperatively. 3. Correct: The client may be pregnant, so a pregnancy test will need to be completed prior to administering anesthetic agents. As you look at these options they are all possible but only one is a priority and in this case life threatening. 1. Incorrect: Adequate caregivers can be discussed with the client without contacting the primary healthcare provider. This is important but not the priority to report to the surgeon. 2. Incorrect: Every person who has a surgical wound is at risk for dehiscence especially in the first two weeks after surgery. Educate the client concerning signs and symptoms and causes of dehiscence but this is not your priority here. 4. Incorrect: The client’s postoperative pain control will be discussed both before and post surgery. Always discuss clients concerns prior to surgery and consult the primary healthcare provider if you are unable to satisfy the client. Question: A nurse has just inserted an indwelling urinary catheter in a client scheduled for surgery. What should the nurse document? You answered this question Correctly 6. Infusing rate of IV fluid 1., 2., 3., 4., & 5. Correct: Perineal skin assessment should be assessed prior to insertion of the indwelling catheter. The following documentation is appropriate after inserting an indwelling catheter: Client teaching, color of the urine, date and time of the insertion and the type of catheter inserted. 6. Incorrect: Documenting the IV rate is not relevant to inserting the catheter. The infusion rate may need to be documented, but the question is asking about the documentation of the insertion of the indwelling catheter. Question: A client arrives at the emergency department after sustaining partial and full-thickness burns over the anterior neck, chest, and right arm. Which interventions will the nurse initiate? You answered this question Correctly 5. Debride wounds 1., 2., 3., & 4. Correct: Burns over the anterior neck and chest mean that the client is likely to have inhalation burns, putting him/her at high risk for impaired gas exchange. The inhalation will cause edema of the airway. It goes back to Maslow’s Hierarchy of Needs. Administer oxygen and start two IVs so that fluid resuscitation can begin. Metal continues to burn and swelling will occur, so remove the necklace or any jewelry. Elevate the arm to decrease swelling. 5. Incorrect: Debridement of the wound occurs in the acute/intermediate phase. This phase starts 48-72 hours after the burn accident has happened. Question: A client with dementia has been admitted to the medical floor. The family informs the nurse that the client tends to wander at night. When planning client safety goals, which action by the nurse would take priority? You answered this question Incorrectly 1. Place client with a roommate who is able to notify staff when client wanders. 2. Discuss safety goals with family, encouraging them to spend time with client. 4. Reorient the client every shift regarding floor policies and safety procedures. 3. Correct: The family specifically informed the nurse that the client wanders at night. When preparing care plan safety goals, the nurse understands the priority is to ensure client safety and have staff personnel to stay with the client during those hours of wandering. This action does not require a licensed nurse; therefore, a unlicensed assistive personnel UAP is the most appropriate staff to sit with the client. 1. Incorrect: It is neither ethical nor legal to expect another client to be accountable for a roommate’s behavior or whereabouts. 2. Incorrect: The nurse would indeed discuss plans for client safety with the family and encouraging the family to spend time with the client can be helpful. However, this does not release the staff from the responsibility for the client’s safety. 4. Incorrect: This client is known to have dementia and re-explaining policies and safety procedures every shift would not ensure this client’s compliance, understanding or safety. Question: A nurse has responded to the scene of a natural disaster to triage clients. Which client should the nurse triage with a black disaster tag? You answered this question Correctly 1. Traumatic amputation to the left lower leg. 3. Fracture of the humerus. 4. Blood pressure of 90/40 and lethargic. 2. Correct: 2nd and 3rd degree burns over 60% of the body put the client in the triage category of black- expectant: injuries are extensive and chances of survival are unlikely even with definitive care. Persons in this group should be separated from other casualties but not abandoned. Comfort measures should be provided when possible. 1. Incorrect: This client is tagged red and needs immediate care. Injuries are life- threatening but survivable with minimal intervention. Individuals can move quickly to black-expectant if treatment is delayed. 3. Incorrect: This client is tagged green and placed in the minimal category. Injuries are minor and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area. 4. Incorrect: This client is tagged red and is immediate with signs of shock. Question: What should the nurse include in the post-op care of a client following the removal of the posterior pituitary gland? You answered this question Correctly 2. Restrict fluids to no more than 1500 ml/day. 1. , 3., 4., 5., & 6. Correct: Removal of the pituitary gland can lead to diabetes insipidus (DI) as a result of the reduced production of antidiuretic hormone (ADH). The nurse should monitor I & O closely and watch for an increase in output which would indicate diuresis as part of DI. Daily weights are an important part of monitoring the client’s fluid status. Monitoring the urine specific gravity is another good way of assessing the fluid status because, as the urinary output increases, the client’s urine is becoming more dilute, which would result in a lower urine specific gravity. If the client’s serum volume is decreasing from the excessive diuresis, the client can go into shock. The nurse should monitor for early signs of changes in the level of consciousness. To avoid disrupting the surgical site, the client should not blow the nose forcefully for at least one week post-op. 2. Incorrect: If the client is lacking ADH, the client may begin losing large amounts of fluid volume. Therefore, the fluid intake would need to be increased (not decreased) to avoid dehydration and shock. Question: What should a nurse teach a client who has been diagnosed with hepatitis A? You answered this question Incorrectly 1. Hepatitis A is spread through blood and body fluid. 2. Chronic liver disease is a common complication of hepatitis A. 4. Treatment includes alpha-interferon and ribavirin. 3. Correct: Symptoms of hepatitis A include fever, malaise, loss of appetite, diarrhea, nausea, abdominal discomfort, dark-colored urine, and jaundice. 1. Incorrect: Hepatitis A is spread when an uninfected person ingests food or water that is contaminated with the feces of an infected person. This disease is closely associated with unsafe water, inadequate sanitation, and poor personal hygiene. 2. Incorrect: Hepatitis A infection does not cause chronic liver disease and is rarely fatal, but it can cause debilitating symptoms and fulminant hepatitis, which is associated with high mortality. 4. Incorrect: Used for hepatitis C. Question: The nurse is caring for a client suffering from major depression. The client spends all day in bed. Which nursing action is appropriate? You answered this question Incorrectly 2. Frequently round at regular intervals. 3. Patiently wait for the client to come out of the room. 4. Question the client about reason for not getting out of the bed. 1. Correct: Be accepting of, and spend time with the client. The client may exhibit pessimism and negativism. The nurse should focus on strengths and accomplishments, and minimize failures. 2. Incorrect: During depressive episodes the client's judgment and problem solving skills are decreased. The nurse should round at frequent, irregular intervals so that the client does not know when to expect the nurse and then can attempt suicide. 3. Incorrect: The nurse should seek out the client. The client may exhibit psycho motor retardation such as lethargy and fatigue. The depressed client is not likely to come looking for someone. 4. Incorrect: Do not confront the client about lack of activity. This will not promote trust. The client may not know why. The client may also have decreased ability to comprehend the question and formulate an answer. Question: The nurse is teaching a class to primiparas on breastfeeding. How many extra kilocalories per day would the nurse instruct the class participants to consume post- delivery to compensate for the increased energy requirements of lactation? You answered this question Incorrectly 1. 1000 2. 300 4. 800 3. Correct: The client needs an extra 500 kcal/day above the usual allowance because the average woman will secrete between 425-700 kcals per day in her breast milk. By increasing the daily caloric intake by 500 kcal the client will offset these losses. 1. Incorrect: 1000 kcal/day is more calories than are needed to offset the caloric loss of breastfeeding. 2. Incorrect: 300 kcal/day is not enough calories to offset the caloric loss of breastfeeding. 4. Incorrect: 800 kcal/day is more calories than are needed to offset the caloric loss of breastfeeding. Question: The nurse observes a client at a follow-up appointment using correct cane walking technique but losing balance each time the quad cane is lifted off of the floor. The client reports a history of recent falls. What is the best action for the nurse to take? You answered this question Correctly 2. Inform client that there are only a few assistive devices available to help with ambulation. 3. Instruct the client on proper quad cane use. 4. Notify the primary healthcare provider after consulting with the neighbor. 1. Correct: Inform the primary healthcare provider of the observations made regarding the quad cane. The client can not maintain proper balance with the assistance of one sided support. This client would most likely benefit from a walker. 2. Incorrect: The word "only" in the answer indicates that the choices for the client are limited. There are other interventions to assist with balance control. Therefore, this is not correct information or action for the nurse to take. 3. Incorrect: The client was observed using proper technique. Instruction on proper technique is not necessary. The nurse needs to identify the client problem which is imbalance. 4. Incorrect: Discussing the nurse's observation of the client with a neighbor would be a breach of client confidentiality. The Health Insurance Portability and Accountability Act (HIPAA) protects the individual's personal health information. Question: A client is in the surgical suite to have a left total knee replacement. Prior to the surgeon initiating the first incision, what should the circulating nurse remind the surgical team to perform? You answered this question Correctly 1. Surgical scrub 3. Sponge and instrument count 4. Inspection of the surgical site 2. Correct: Time-out, done immediately before the procedure, is a final verbal verification of the correct client, procedure, site, and implant. Time-out is active communication among all members of the surgical/procedural team, initiated by a member of the team before surgery. 1. Incorrect: Surgical scrub should be done before entering the surgical suite. 3. Incorrect: The scrub nurse does instrument and sponge counts numerous times before, during, and after the procedure. 4. Incorrect: Simple inspection of the surgical site is not enough. The team must verbally communicate what is to be done, on what limb. Additionally, the limb should be marked as “This knee” or “yes”. Question: A charge nurse is planning care for several clients on the unit. Which activities can the nurse safely delegate to an unlicensed assistive personnel (UAP)? You answered this question Incorrectly 1. Administer a nebulizer treatment to a client diagnosed with pneumonia. 2. Obtain vital signs on a postoperative client who required naloxone 5 minutes ago. 5. Remove an indwelling urinary catheter from a client. 3. , & 4. Correct: A UAP can report the amount of UOP but cannot interpret it. A clean catch urine sample is a noninvasive procedure. The UAP can assist the client to obtain the clean catch urinary sample. Both activities are the right person and right task of delegation. 1. Incorrect: A UAP cannot administer medications. This is the wrong task for an UAP. 2. Incorrect: The client received naloxone to reverse the action of an opioid medication. A UAP should not be assigned to obtain vital signs on an unstable client. This is the wrong person to perform removal of an indwelling urinary catheter. 5. Incorrect: A UAP cannot remove an indwelling urinary catheter. Question: The nurse is caring for a client with hypothyroidism. Which dietary consideration is most important for the nurse to teach this client? You answered this question Correctly 1. Increase carbohydrate intake. 2. Decrease fluid intake. 3. Avoid shellfish. 4. Correct: A symptom of hypothyroidism is constipation due to the decreased mobility of the intestinal tract. Client's with hypothyroidism should increase their dietary fiber to prevent constipation. 1. Incorrect: No, they need fewer calories, not more. Their metabolism is slowed. A client with hypothyroidism may gain weight due to decreased metabolism. The client should decrease their intake of carbohydrates. 2. Incorrect: To decrease constipation the client should increase fluid intake. When the client is hydrated the stool will be softer. 3. Incorrect: Avoiding shellfish is not a consideration unless there is an iodine allergy. Question: A nurse is instructing a client who had a cesarean birth 2 days ago about adverse signs that should be reported to the primary health care provider. Which signs should the nurse include? You answered this question Correctly 2. Change in lochia from rubra to serosa. 6. Able to provide self care. 1. , 3., 4., & 5. Correct: Fever for 2 or more days can indicate infection. Calf pain, redness, and swelling could indicate thrombophlebitis. Burning on urination could indicate urinary tract infection (UTI). Feeling of apathy about the newborn could mean postpartum depression. All should be reported to the primary healthcare provider. 2. Incorrect: You would report change from serosa to rubra lochia. Also, report changes in vaginal discharge with increased amount, large clots, and change to a previous lochia color, such as bright red bleeding and a foul odor. 6. Incorrect: We want the client to be able to provide self care. This does not warrant a call to the primary healthcare provider. Question: The nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which complications? You answered this question Incorrectly 2. Diarrhea 4. Tetany 5. Fluid volume deficit 1. & 3. Correct: Yes, because too much calcium in the blood equals too much calcium in the urine and increased risk of kidney stones. Increased parathyroid hormone (PTH) is pulling the calcium from the bones, leaving them weak. 2. Incorrect: A clinical manifestation of hyperpararthyroidism is constipation. Diarrhea is not a clinical manifestation of hyperparathyroidism. 4. Incorrect: Tetany is a clinical manifestation of hypoparathyroidism. 5. Incorrect: Fluid volume deficit (FVD) is not a clinical manifestation of hyperparathyroidism Question: The nurse is teaching a newly diagnosed diabetic about proper foot care. Which statements by the nurse are correct? You answered this question Correctly 1. Cut the toenails in a rounded fashion. 2. Wash the feet with warm water and betadine. 3. , 4., & 5. Correct: Shoes should be worn at all times to prevent injury. The client may step on something and not know that the foot has been injured. Inspection should be done daily, since many diabetics cannot feel if their feet have been injured. Feet may not be sensitive to hot and cold, which could cause injury. 1. Incorrect: Toe nails should be cut straight across to avoid an ingrown toenail. Additionally any skin cuts on the toes may result in infection. 2. Incorrect: Do not put harsh chemicals, such as betadine, on the feet. Betadine will dry the skin which may lead to cracks in the skin. This creates potential portals for infection to occur. Question: A client diagnosed with pancreatitis becomes increasingly restless, confused and has pulled out the NG tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation = 90%. Skin is cool and clammy to touch. Prioritize the actions that the nurse should take. You answered this question Correctly The Correct Order Your Selected Order First, initiate oxygen. The client is anxious and has tachycardia, signs of hypoxia. The BP is also low, so the client might be bleeding internally. If there is a decreased circulating blood volume then there is less hemoglobin to carry oxygen, so increasing the available oxygen will help the client until the problem is corrected. Second, get the IV started so fluid resuscitation can continue.This increased volume will improve the blood pressure. More volume, more pressure. The IV will also provide a port for needed medications. Third, check the client’s blood sugar. Since the pancreas is sick, insulin production can be decreased so glucose can go up. This is next in the priority line of the available options. You have addressed air and circulation, so blood glucose would be next. Fourth, insert the NG tube so that the client can be kept empty and dry and you can prevent aspiration if the client starts vomiting. Last, recheck vital signs to assess effectiveness of your nursing actions. Question: The primary healthcare provider prescribes a combination of pyrazinamide and isoniazid to treat a client with tuberculosis. The client asks the nurse, "Why am I taking two drugs?" Which explanation should the nurse give the client? You answered this question Correctly 1. One diminishes the side effects of the other. 2. Hepatoxicity is reduced. 4. One kills the live bacteria, and the other the spores. 3. Correct: The CDC says that the initial phase of treatment for newly diagnosed cases of pulmonary TB should consist of a multiple-medication regimen because many cases of TB are caused by strains of the bacteria that are resistant to isoniazid or rifampin. This client has been prescribed the multiple medication regimen of pyrazinamide and isoniazid. 1. Incorrect: These drugs do not diminish the side effects of each other. In fact, they potentiate them. 2. Incorrect: Both drugs can cause hepatoxicity. 4. Incorrect: Isoniazid is bacteriostatic or bactericidal against susceptible bacteria. Pyrazinamide is also bacteriostatic against susceptible bacteria. Question: A teenage client is placed on life-support as a result of a motor vehicle accident (MVA). Following an electroencephalogram (EEG), the client has been declared brain dead. Which action by the nurse would take priority? You answered this question Incorrectly 1. Call the respiratory department to have the ventilator removed. 2. Notify the facility’s pastoral personnel. 4. Ask the family to select a funeral home. 3. Correct: The first priority is to notify the designated organ procurement team. These personnel are trained to determine if the client would be an appropriate donor, how to approach the grieving family and discuss options, and to make any necessary arrangements in such a situation. Time is of the essence in the case of organ donation. Even if the family refuses to donate organs, it is the Procurement Team that will deal with the situation. 1. Incorrect: Although the Respiratory department may be present at the time of extubation, removing the ventilator from the room is not a priority at this time. The client will most likely remain on the ventilator until the Procurement Team has talked with the family. 2. Incorrect: The facility pastoral staff may already be aware of the critical nature of this situation, and the family may have also gathered their own support group at this time. Though the nurse may notify hospital’s support personnel, this would not be the first priority action. 4. Incorrect: While the family will have to make many difficult decisions in this situation, the nurse must focus on the client first. Time is crucial for organ viability, and the Organ Procurement Team needs to mobilize appropriate personnel to deal with all issues. Question: Which findings would indicate to the nurse that a client with Addison's disease has received too much glucocorticoid replacement? You answered this question Incorrectly 1. Dry skin and hair 2. Hypotension 4. Decreased blood glucose level 3, & 5. Correct: Excessive drug therapy with glucocorticoids will cause rapid weight gain, round face, and fluid retention. Cholesterol and triglycerides in the blood are also increased by glucocorticoids. Long term use of high steroid doses can lead to symptoms such as thinning skin, easy bruising, changes in the shape or location of body fat (especially in your face, neck, back, and waist), increased acne or facial hair, menstrual problems, impotence, or loss of interest in sex. 1. Incorrect: Dry skin and hair would be seen with a decrease in sex hormones, not with a increase in glucocorticoids. An increase in glucocorticoids will result in an increase in oil production in the skin. 2. Incorrect: Hypotension is a sign of Addison's disease. The client loses sodium and water, causing the client's blood pressure to drop. This loss of sodium and water would come from a decrease in mineralocorticoids. This would have nothing to do with glucocorticoids. 4. Incorrect: An increase in glucocorticoids will result in glucose intolerance. The client will become resistive to insulin production. This will result in an increase in the serum blood glucose. Question: The nurse is caring for an adolescent client diagnosed with depression. The client is prescribed fluoxetine. What is the best response by the nurse when the client says, "What will this medicine do to me?" You answered this question Correctly 2. It will decrease the production of noradrenaline. 3. It will lower your level of the brain hormone norepinephrine. 4. It will balance blood glucose and dopamine levels in your head. 1. Correct: The action of fluoxetine is to increase the level of serotonin in the central nervous system. There is a correlation between a low level of serotonin and depression. The action of the drug should be explained to the adolescent in a manner that will be understood. 2. Incorrect: Fluoxetine does not selectively decrease the production of noradrenaline in the brain. 3. Incorrect: This action does not relate to fluoxetine. Fluoxetine may actually increase the level of norepinephrine in the brain. 4. Incorrect: This action does not relate to fluoxetine. Fluoxetine does not effect the balance of blood glucose and dopamine in the brain Question: The primary healthcare provider suspects the client has tuberculosis (TB) and prescribes a Mantoux test. What precautions should the nurse take when administering the Mantoux test? You answered this question Incorrectly 1. Don sterile gloves. 2. Place the client on reverse isolation. 4. Obtain a consent form. 3. & 5. Correct: A disposable particulate respirator that fits snugly around the face is needed. The client needs to be on acid-fast bacilli (AFB) isolation precautions, not reverse isolation. Airborne precautions include a private room with negative pressure and a minimum of 6 air exchanges per hour. Ultraviolet lamps and high efficiency particulate air filters are also needed. 1. Incorrect: Sterile gloves are not needed. Standard precautions indicate clean gloves. 2. Incorrect: The client needs to be on airborne isolation precautions, not reverse isolation. Airborne precautions include a private room with negative pressure and a minimum of 6 air exchanges per hour. Ultraviolet lamps and high efficiency particulate air filters are also needed. 4. Incorrect: A consent is not necessary. Question: A client has been prescribed chlorpromazine for the treatment of schizophrenia. The nurse makes afternoon rounds and finds the client’s temperature to be 104.7º F/40.4º C. The client has extreme muscle rigidity, and the vital signs have been fluctuating for the last four hours. What should the nurse do first? You answered this question Correctly 1. Provide a tepid sponge bath. 3. Administer an antipyretic immediately. 4. Administer the chlorpromazine as prescribed. 2. Correct: These symptoms are consistent with neuroleptic malignant syndrome (NMS), which is an adverse reaction to antipsychotic drugs. The symptoms of NMS are fever, altered mental state, muscle rigidity, and autonomic dysfunction. This is a medical emergency, and immediate action should be taken. 1. Incorrect: The symptoms indicate a medical emergency and the need for an immediate response. The nurse should notify the primary healthcare provider first. 3. Incorrect: The high temperature should be assessed, but the extreme muscle rigidity and fluctuating vitals are a medical emergency. The client needs further immediate attention. 4. Incorrect: The nurse should not administer another dose of the antipsychotic medication due to the client's presenting symptoms. Usually, the primary healthcare provider would discontinue the medication immediately. Question: The nurse is teaching the client about benzodiazepines. Which comments by the client indicate adequate understanding of the drug effects/side effects? You answered this question Incorrectly 3. I may need to double the dose if I continue to be anxious. 1., 2., 4. & 5. Correct: Benzodiazepines slow reaction time and may affect general alertness. The client should not operate machinery until effects of the medication are observed, and client can drive safely. Benzodiazepine medications are usually prescribed for short periods of time. Benzodiazepines are frequently abused. Clients develop tolerance and dependence on the drugs. 3. Incorrect: The client should not self-regulate dosage. There is a potential for tolerance and dependence to develop. Dosage should be monitored carefully by the primary healthcare provider. Question: A client has returned to the burn unit after an escharotomy of the forearm. What is the priority nursing intervention? You answered this question Correctly 1. Roll sterile q-tip over the wound 2. Elevate the affected arm 3. Ask the client to rate pain level 4. Correct: An escharotomy is an incision of the eschar of a burned arm to decrease the tension in the proximal tissue. This will result in increased circulation to the proximal tissue. The assessment of bilateral radial pulses needs to be compared for adequate circulation. 1. Incorrect: This is an intervention for a forearm with a graft. 2. Incorrect: After an escharotomy elevating the affected arm is an appropriate intervention. The evaluation of the circulation in the arm should be performed first. 3. Incorrect: Pain is also an indicator of adequate circulation. The assessment of distal pulses first will provide a more concise assessment of the circulation in both arms. Question: What is priority for the nurse to determine about a client who is scheduled for a tubal ligation in the outpatient surgical center? You answered this question Incorrectly 1. Client's prior experiences with outpatient surgery. 2. Medical plan and the extent of insurance coverage for outpatient surgery. 4. Client's plan to spend the night at the surgical center. 3. Correct: After outpatient surgery, the client should not be allowed to drive home. A driver and assistance at home are necessary prior to discharge. 1. Incorrect: The client’s prior experience would be a factor in the pre-operative phase. 2. Incorrect: The medical plan’s coverage would not be assessed by the business office in the planning phase. This is done several days or weeks prior to the scheduled surgery. 4. Incorrect: It would be atypical for the client to spend the night in a surgical clinic, as they are not generally open at night for overnight medical stay. Question: Based on the Parkland formula, the primary healthcare provider has determined that a burn victim needs 9,250 mL of LR intravenously over the first 24 hours. How many milliliters of LR should the nurse administer over the first eight hours? Round answer to the nearest whole number. You answered this question CorrectlyEnter the answer for the question below. Based on the Parkland formula the fluid resuscitation of a burn victim means that ½ of the fluid should be given within the first 8 hours. For this client 4,625 mL needs to be administered within the first 8 hours. The remaining ½ of the fluid is divided over the remaining 16 hours. Question: A child was diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the clinic one week ago. Today the child’s mother calls the clinic to tell the nurse, “My child has not been able to sleep since being put on methyphenidate.” What is the best response for the nurse to make? You answered this question Incorrectly 1. "I will discuss this with the primary healthcare provider. A different medication may be prescribed." 2. "The insomnia will get better over time. Just wait it out." 4. "Your child may have overdosed on the medication. Go to the emergency department now." 3. Correct: The last dose should be at least 6 hours before bedtime. This will decrease the child's difficulty in falling asleep. If the medication is sustained-released, administer the dose in the morning. 1. Incorrect: This is premature. The nurse should identify the problem and suggest an alternative response. Try changing the time to help with sleep. 2. Incorrect: The child may adjust to the medication, but this will not correct the problem of insomnia. An alternative intervention should be recommended. 4. Incorrect: The client has not overdosed based on the data presented. Telling the mother to take the child to the emergency room is not needed. Question: A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual? You answered this question Incorrectly 2. Allow the client to break an insignificant rule. 1. , 3., 4. & 5. Correct: Trust is demonstrated through nursing interventions that convey a sense of warmth and care to the client. These interventions are initiated simply, concretely, and directed toward activities that address the client’s basic needs for physiological and psychological safety and security. Concrete thinking focuses thought processes on specifics, rather than generalities, and immediate issues, rather than eventual outcomes. Examples of nursing interventions that would promote trust in an individual who is thinking concretely include such things as: providing a blanket when the client is cold, providing food when the client is hungry, keeping promises, being honest, providing a written, structured schedule of activities, attending activities with the client if he is reluctant to go alone, being consistent in adhering to unit guidelines, and taking the client’s preferences, requests, and opinions into consideration when possible in decisions concerning care. 2. Incorrect: The client should be informed of all rules, simply and clearly, with reasons for certain policies and rules. Be consistent and provide written, structured, scheduled activities. Allowing a client to break a rule would not encourage them to think about the outcomes of their actions. Question: A client has an order for two units of packed red blood cells (PRBCs) to be administered. The current IV prescribed is D5LR with 20 mEq KCL at 125 mL/hr infusing through a 22 gauge needle to the left hand. What action should the nurse take? You answered this question Correctly 1. Piggyback the PRBCs to the current IV fluid at the lowest port on the tubing. 2. Change the current IV fluid to NS so the blood can infuse through the IV tubing. 3. Disconnect the current IV fluid and connect NS with a y-tubing blood administration set. 4. Correct: Blood should be administered through a large bore IV needle such as an 18 gauge, but no smaller than a 20 gauge. Smaller needles can cause the PRBCs to lyse. 1. Incorrect: The PRBCs must be administered through a y-tubing blood administration set that has a filter. Do not infuse through a normal IV tubing. The current IV that is infusing has 20 mEq KCL added. PRBCs should not be infused with KCL. Also the current IV was initiated with a 22 gauge needle, and the PRBCs should be infused with a needle no smaller than 20 gauge. 2. Incorrect: The IV needle is too small, and the client has an order for the IV fluids and potassium. It is out of the scope of the RN to change the prescription for the D5LR with 20 mEq KCL. Also the client requires additional KCL. 3. Incorrect: The problem here is that the IV needle is too small. Question: A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the symptoms. The client tells the nurse, “The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can’t function!” What is the nurse's most appropriate response? You answered this question Correctly 2. "The primary healthcare provider is right. Your pain is not real." 3. "Let me get you an appointment with the psychiatrist." 4. "Don't worry. Everything will be ok." 1. Correct: Pain is real even if it is psychological pain. The client is experiencing anxiety, or stress through stomach pain. The nurse should use therapeutic communication technique that is client centered and empowers the client. 2. Incorrect: This is a example of nontherapeutic communication. The response is confrontational and does not address how the client feels. 3. Incorrect: This nontherapeutic communication of changing the subject ignores the client's feelings. This action invalidates the client. 4. Incorrect: This is a nontherapeutic communication technique, because the response is trite, with false reassurance. The nurse can not know if everything will be ok for the client. Question: Blood and urine samples are sent to the laboratory for a client who has had a spinal cord injury. After reviewing these results, the nurse would expect which finding? You answered this question Incorrectly 1. Gross hematuria 2. Septicemia 4. Anemia 3. Correct: The urinalysis results of red blood cells (RBC) of 2/hpf or greater and urine white blood cells (WBC) of greater than 4/hpf indicate a urinary tract infection (UTI). 1. Incorrect: The urinalysis results of 2 to 3/hpf RBCs is not indicative of gross hematuria 2. Incorrect: The blood WBCs are normal. In septicemia, the blood WBCs are elevated. 4. Incorrect: Blood RBCs of 5 million/mm3 (5 x 106 / mm3) (5 x 1012/ mm3) is a normal finding. Question: A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy to determine equipment needs upon discharge to home for hospice care. Which equipment should the case manager obtain for this client? You answered this question Incorrectly 3. Walker 1., 2., 4., & 5. Correct: An alternating pressure mattress will help to prevent pressure ulcers. A hospital bed is needed so that the head of the client’s bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. The unresponsive client may need suction equipment for suctioning if unable to clear secretions from the oropharynx. The client at the end stages of liver disease will be hypoxemic, so oxygen therapy is provided. 3. Incorrect: The unresponsive client will not need a walker. Question: What is most important for the nurse to have at the client’s bedside when inserting a large orogastric tube for rapid gastric lavage? You answered this question Incorrectly 1. Emesis basin 2. Portable x-ray machine 3. Oxygen 4. Correct: Insertion of a large orogastric tube designed for rapid lavage often causes gagging and vomiting, so suction equipment should be readily available to reduce the risk of aspiration. Maintaining the client's airway is the priority. 1. Incorrect: You would need an emesis basin because of the chance of vomiting, but suction equipment is the priority due to aspiration. 2. Incorrect: An x-ray is the preferred method to check initial placement, once the tubing is inserted. Suction equipment is the priority when inserting the tube due to risk of aspiration. 3. Incorrect: There are no key words in the question to suggest the client needs oxygen at this time. Question: A nurse is planning to provide an education class on preconception health care to a group of young women wishing to become pregnant. What points should the nurse include in this class? You answered this question Incorrectly 5. Maintain folic acid intake at 200 micrograms/day. 1., 2., 3., & 4. Correct: All of these actions are needed to promote the birth of a healthy baby. A preconception care visit or class can help women take steps for a safe and healthy pregnancy before they get pregnant. 5. Incorrect: Folic acid intake should be 400 micrograms per day in order to reduce neural tube defects by 70%. Question: The nurse is working at the triage station. Which client should the nurse triage first? You answered this question Correctly 1. A client with hepatitis A who states, "My arms and legs are itching." 3. A client with nausea and vomiting for two days states, "I am very weak and can't eat." 4. A client with hematuria and reports left flank pain. 2. Correct: The client who has a cast with unrelieved severe pain indicates compartment syndrome and requires immediate action. This client is at greatest risk for harm because untreated compartment syndrome can cause irreparable nerve, and muscle damage and can lead to amputation. 1. Incorrect: A client with hepatitis A is not the highest priority at this time. The itching is most likely caused by accumulation of bile salts under the skin. The client will need to be evaluated but is not the triage nurse’s highest priority. 3. Incorrect: This client would need to be seen and evaluated for dehydration. Of the clients listed here, this is not the triage nurse’s highest priority. 4. Incorrect: When you see hematuria it leads you to worry about bleeding. Remember that even though hematuria may seem that the client is losing a lot of blood, it is not a significant loss. Hematuria is probably due to a kidney stone, infection, trauma or even prostate problems. In this triage scenario it is the lowest priority. Question: The nurse is planning health promotion strategies for a single parent of young children who is trying to increase personal physical activity level but expresses a lack of time. Which interventions would help the client get more regular physical activity into the day? You answered this question Correctly 4. Suggest waking one hour earlier in the morning to go to the gym. 5. Suggest walking for 30 minutes with a buddy each afternoon before leaving work. 1., 2. & 3. Correct: This plan will allow the parent to stay home without adding further time demands to the day. Parking farther away is one plan to get more steps into the day without increasing time demands drastically. Walking with the children allows the parent to spend quality time with the children as well as offers them a good example. 4. Incorrect: Being a single parent, this plan would not be feasible. The demands of getting the children out earlier could impact the time schedule for the day in a negative way. 5. Incorrect: This plan would only increase time demands and possibly financial demands if the children have to be cared for by someone else at an extra charge each day. Question: Which interventions should the nurse include when planning care for a client diagnosed with paranoid personality? You answered this question Correctly 3. Encourage the client to participate in group therapy. 4. Encourage the client to clean the day room daily. 1., 2. & 5. Correct: This disorder is characterized by distrust and suspicion towards others. The nurse should use open communication techniques to increase the client's trust in the nurse. Clear explanations of procedures will decrease the anxiety of the client. 3. Incorrect: The client with paranoid personality is reluctant to share personal information with other people. They suspect everyone of causing problems for them. Group therapy would not be appropriate for this client. 4. Incorrect: The client with paranoid personality feels that others are using or exploiting them. The client may perceive that they are being exploited if they clean the dayroom. Question: Which actions by the nurse, working in the recovery room, should be performed to prevent injury from a needle stick? You answered this question Correctly 1. Recap the needle after use to prevent injury. 2. Reinsert the sylet if it becomes loose in the vascular assess device. 3. After drawing up saline to flush an intravenous (IV) line, place the syringe in a pocket to prevent possible injury. 4. & 5. Correct: Puncture resistant biohazard containers should be replaced when three-quarters full to prevent hand injury when disposing of sharps. Use of "needleless" devices reduces the risk of needle stick injuries. 1. Incorrect: For safety precautions and transmissions of infection, needles should never be recapped due to the possibility of injury while recapping. 2. Incorrect: Reinserting the stylet may cause injury to the nurse and client. 3. Incorrect: For safety precautions of the nurse or another person, a needle should never be placed in a pocket. The cap could come off and stick someone. Question: A child is being admitted to the hospital with a diagnosis of acute glomerulonephritis. In performing the history and physical, what would be a priority assessment that the nurse should include when questioning the child and caregivers? You answered this question Correctly 1. Types of contact sports played 2. Amount of acetaminophen intake 4. Recent exposure to salmonella 3. Correct: Acute post-streptococcal glomerulonephritis (APSGN) results from a group A beta-hemolytic streptococci infection that originates typically in the throat (strep throat) or the skin (impetigo). The strep bacterial infection can cause the filtering units of the kidneys (glomeruli) to become inflamed and results in a decreased ability of the kidneys to filter the urine. The disorder may develop 1-2 weeks after an untreated throat infection or 3-4 weeks after a skin infection. 1. Incorrect: Glomerulonephritis is not associated with trauma over the kidney region, so questioning about contact sports would not be relevant to glomerulonephritis. 2. Incorrect: Excessive acetaminophen intake can cause liver damage but is not associated with glomerulonephritis. 4. Incorrect: Salmonella is not an organism that is linked to the development of glomerulonephritis. Group A beta-hemolytic streptococci is the causative organism for acute glomerulonephritis. Question: A nurse has received the following arterial blood gas results on a client with a post bowel resection: pH 7.48; PCO2 30; HCO3 24. Which acid/base imbalance is the client experiencing? You answered this question Correctly 1. Metabolic alkalosis 2. Metabolic acidosis 4. Respiratory acidosis 3. Correct: The pH is high, indicating alkalosis. The PCO2 is low, which coordinates with a high pH, indicating a lung problem. This client is in respiratory alkalosis, not acidosis. The bicarbonate is normal. 1. Incorrect: The bicarbonate is normal. In metabolic alkalosis, the bicarbonate will be increased. A pH of 7.48 is an alkalosis. 2. Incorrect: Normal pH is 7.35-7.45. Anything less than 7.35 is an acidosis. Anything greater than 7.45 is an alkalosis. 4. Incorrect: The pH is high, indicating alkalosis. The PCO2 is low, which coordinates with a high pH, indicating a lung problem: Respiratory alkalosis, not acidosis. The bicarbonate is normal. Question: An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this? You answered this question Correctly 1. Encourage the family to accept nursing home placement as the best option for their loved one. 3. Ask the client what she wants and tell the family to abide by the client's wishes. 4. Realize that the nurse does not need to be involved in this decision. 2. Correct: The nurse should listen to the concerns of the family. The Asian culture tends to be opposed to nursing home placement and see it as their duty to care for their elders in the home. The nurse should listen and serve as an advocate. 1. Incorrect: The nurse should not impose personal values on the client and family. Cultures vary as to acceptance of nursing home placement. 3. Incorrect: The client may not be in a position to make this decision. 4. Incorrect: The nurse must serve as client advocate and intermediary between client/family and primary healthcare provider as decisions are made about this important issue. Question: Which tasks would be appropriate for the nurse to assign to an LPN/VN? You answered this question Incorrectly 3. Teach insulin self administration to a diabetic client. 4. Administer IV pain medication to a two day post op client. 1., 2., 5., & 6. Correct. These tasks are within the PNs practice scope. The PN can change a colostomy bag, administer antibiotics by IVPB, monitor for urinary retention and remove wound sutures. 3. Incorrect: The RN is responsible for teaching. The PN can reinforce teaching once taught by the RN. 4. Incorrect: The RN must give IV pain meds to clients. The PN can monitor the effectiveness of the medication after given by the RN and can report any problems if necessary. Question: A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions for at risk clients. What steps should the QA manager include in this evaluation? You answered this question Incorrectly 3. Poll staff to identify what fall precautions are implemented for at risk clients. 1., 2., 4 & 5. Correct: The QA manager is responsible for evaluating performance improvement plans to ensure that staff are providing appropriate care. The QA manager can do chart reviews to see if staff are documenting fall precaution for a client. Direct observation of unit staff will let the QA manager know if staff are performing proper precautions while caring for clients. The first step is to identify what clients are at risk for falls and then see if the staff have identified these clients as at risk as well. Monitoring should be at unpredictable intervals, so staff do not comply just for a scheduled evaluation. 3. Incorrect: Asking the staff does not ensure that they follow through. Question: Post thyroidectomy, the nurse assesses the client for complications by performing which assessment? You answered this question Correctly 1. Perform blood glucose monitoring every 6 hours 5. Administer desmopressin per nasal spray for urinary output (UOP) greater than 200 mL/hr 2. , 3., & 4. Correct: A positive Chvostek's and Trousseau's is indicative of tetany (low calcium). This can occur when one or more of the parathyroids are accidently removed when the thyroid is removed. A weak, raspy voice, swallowing difficulty, and impaired respiratory status can be caused by nerve injury. Change in fit and comfort of the dressing can indicate possible neck swelling, which can affect the airway. 1. Incorrect: A possible complication of a thyroidectomy is to remove one or more parathyroid glands. The parathyroids' action is to regulate the serum calcium levels. The parathyroid does not regulate the blood glucose levels. 5. Incorrect: The action of desmopressin is to increase the reabsorption of water in the kidney. A decrease in vasopressin, (antidiuretic hormone) is not a complication of a thyroidectomy. Question: During evening rounds, the nurse discovers that a violent client with a history of threats against a former girlfriend cannot be located. The client’s window is open and personal belongings missing. Based on recent threats of violence against the girlfriend, what is the nurse’s initial action? You answered this question Incorrectly 1. Look for the client quietly to maintain confidentiality. 2. Notify the local police to organize a search party. 4. Complete an “Against Medical Advice” (AMA) form on the client’s elopement. 3. Correct. Since the client is missing and is considered to be a risk to himself or others, the missing client protocol is immediately implemented. A organized and escalating search for the client will occur. 1. Incorrect. Although HIPAA is very precise on the issue of confidentiality, privacy is waived in specific, extreme situations that involve the life of a client, staff, or family. While the nurse may alert staff members to help search the building or facility grounds, this is not the initial action of the nurse. 2. Incorrect. Although local police may eventually be asked to assist in locating the client, this decision will be made by the facility’s administrative personnel. However, this is not the initial action under the stated circumstances. 4. Incorrect. An Against Medical Advice (AMA) form is signed by a client who decides to leave a facility without treatment, against the advice of the primary healthcare provider. That form does not apply in this situation since the client has already left. This event falls under the category of elopement. Question: Which client requires immediate intervention by the nurse? You answered this question Correctly 1. Client diagnosed with Crohn’s disease reporting frequent bloody diarrhea and abdominal cramping. 2. Client with renal calculi who reports no pain relief from ketorolac administered 30 minutes ago. 4. Client admitted with cholelithiasis reporting right-sided abdominal pain of 8/10. 3. Correct: Sharp chest pain after a fractured femur could indicate a pulmonary embolus (PE) or a fat embolus and requires immediate intervention by the nurse. 1. Incorrect: This is not the most life-threatening problem. The client with suspected PE or fat embolus takes priority, although this client would be closely monitored for fluid and electrolyte imbalances. 2. Incorrect: This is not the most life-threatening problem. The client with suspected PE or fat embolus takes priority. Just remember, pain never killed anybody. 4. Incorrect: This is not the most life-threatening problem. The client with suspected PE or fat embolus takes priority. Although this client's pain does not need to be ignored, it doesn't take priority over someone with an embolus. Question: What statements by a client diagnosed with a hiatal hernia would indicate to the nurse that the discharge teaching was effective? You answered this question Incorrectly 3. “Eating a grapefruit for breakfast will help digest the rest of my food.” 6. “I will avoid using laxatives.” 1., 2., 4., & 5. Correct: Clients with a hiatal hernia should eat small frequent meals, because large meals cause them to be symptomatic with heartburn and other symptoms. Sitting up after eating will keep the stomach down as much as possible. If they lie down, the stomach will go upward and cause regurgitation, heartburn, nausea, and fullness. Placing blocks under the bed also helps keep the stomach downward and reduces symptoms