SAUNDERS TEST YOURSELF 1
QUESTIONS AND ANSWERS
Axclientxisxbeingxdischargedxhomexafterxaxroutinexhipxreplacementxsurgery.xThexnursexisxi
nstructingxthexclientxonxhowxtoxpreventxpostoperativexcomplications.xWhatxstatementsxbyx
thexclientxwouldxindicatexthexneedxforxfurtherxteaching?xSelectxallxthatxapply.
"Limitingxfiberxisxnecessaryxtoxavoidxdiarrhea."
"IxshouldxemptyxmyxbladderxwhenxIxfeelxthexurge."
"Avoidingxpainxmedicationxwillxpreventxconstipation."
"Ixshouldxdrinkxplentyxofxliquidsxlikexicedxteaxorxcoffee."
"Ixshouldxcontinuexwithxmyxphysicalxtherapyxandxwalking."x-xans--A,xC,xD
Rationale:xConstipationxisxcommonxafterxsurgeryxduextoxpainxmedication,xdecreasedxmov
ement,xandxanesthesia.xFiberxintakexshouldxbexencouragedxasxitxpromotesxthexprevention
xofxstoolxretention.xAlthoughxpainxmedicationxcanxcausexconstipation,xitxshouldxnotxbexavoi
dedxinxthexpost-
operativexperiod.xDrinkingxplentyxofxfluidsxisxencouragedxforxbothxbowelxandxbladderxmain
tenance,xbutxthexclientxshouldxchoosexnon-
caffeinatedxoptions.xPhysicalxtherapy,xwalking,xandxexercisexwillxhelpxpreventxconstipatio
n.xEmptyingxthexbladderxwhenxthexurgexisxpresentxcanxhelpxpreventxurinaryxtractxinfection
s.
ThexnursexisxcaringxforxaxVietnamesexclientxdiagnosedxwithxtuberculosis.xThexclientxspeak
sxlimitedxEnglish.xWhatxshouldxthexnursexdoxtoxensurexthexclientxandxfamilyxreceivesxthex
mostxaccuratexinformation?xSelectxallxthatxapply.
Providexculturallyxsensitivexeducation.
Encouragexfamilyxmembersxtoxobtainxaxtuberculosisxskinxtest.
ProvidexwrittenxinstructionsxinxEnglishxforxthexclientxtoxreference.
Encouragexthexclientxandxfamilyxtoxwashxallxdishesxbyxhandxtoxpreventxthexspreadxofxinfec
tion.
Urgexallxfamilyxandxclosexcontactxcommunityxmembersxtoxseekxandxcompletextreatmentxto
xenhancexcompliance.x-xans--A,xB,xE
,Rationale:xAsxalways,xthexnursexmustxprovidexculturallyxsensitivexeducation.xBecausextub
erculosisxisxhighlyxcontagious,xallxfamilyxmembersxandxclosexcommunityxmembersxshould
xhave xaxtuberculosisxskinxtest,xseekxtreatment,xandxremainxcompliant.xAxfullxcoursexofx6xto
x9xmonthsxofxtreatmentxisxneededxtoxpreventxre-
infection.xInstructionsxwrittenxinxEnglishxarexnotxhelpfulxforxthexclientxwithxlimitedxEnglishxs
kills.xWashingxdishesxbyxhandxisxnotxthexbestxwayxtoxpreventxinfection;xratherxaxdishwashe
rxshouldxbexusedxifxavailable.
Axclientxwithxanxietyxhasxjustxbeenxseenxbyxthexhealthxcarexproviderxandxhasxbeenxprescri
bedxalprazolam.xAxweekxlater,xthexclientxisxbroughtxtoxthexemergencyxroom,xafterxconsumi
ngxaxlargexnumberxofxtabletsxinxanxattemptxtoxoverdose.xThexclientxisxunresponsivexandxh
asxgaspingxrespirations.xWhichxactionxshouldxthexnursextakexfirst?
Administerxthexantidotexnaloxone
Administerxthexantidotexflumazenil
Assistxwithxintubationxofxthexclient
Assistxwithxinsertionxofxaxcentralxvenousxlinex-xans--C
Rationale:xThexclientxrequiresximmediatexintubationxbecausexofxthexgaspingxrespirationsx
andxunresponsiveness.xFlumazenilxisxthexantidotexforxanxoverdosexofxbenzodiazepines;xh
owever,xthexpriorityxisxsecuringxthexairway.xNaloxonexisxthexantidotexforxanxopiatexoverdos
e.xAssistingxwithxinsertionxofxaxcentralxvenousxlinexisxnotxthexpriorityxandxwouldxinvolvexaxg
reatxdealxofxtimexwhilexthexclientxisxgaspingxtoxbreathe.
Thexnursexisxobservingxthexcardiacxmonitorxofxaxclientxandxnotesxthisxcardiacxrhythmx(refe
rxtoxfigure).xWhatxisxthexinitialxnursingxaction?
[V-Tach]
Checkxforxaxpulse
Notifyxthexhealthxcarexprovider
Obtainxax12xleadxelectrocardiogramx(ECG)
Beginxcardiopulmonaryxresuscitationx(CPR)x-xans--Ax
Rationale:xVentricularxtachycardiaxcanxbexstablexorxunstablexdependingxonxwhetherxthexcl
ientxhasxaxpulsexorxnot.xInxthisxcase,xassessingxthexclient'sxpulsexisxthexinitialxaction.xObtai
ningxax12xleadxECGxandxnotifyingxthexhealthxcarexproviderxmayxbexnecessaryxbutxarexnotxi
nitialxactions.xInitiatingxCPRxmayxbexnecessaryxofxthexventricularxtachycardiaxbecomesxu
nstablexandxcardiacxarrestxoccurs.
Axmotherxbringsxherx9-month-
oldxchildxtoxseexthexpediatricianxandxhasxconcernsxthatxthexchildxmayxhavexaxdevelopment
alxdelayxbecausexthexchildxcannotxrollxoverxyet.xforxthexnursexshouldxaskxthexmotherxabout
xwhichxriskxfactorsxassociatedxwithxaxdevelopmentalxdelay?xSelectxallxthatxapply.
Age
Race
, Income
Chronicxillness
Lowxbirthxweight
Environmentalxexposurextoxtoxinsx-xans--C,D,xE,xFx
Rationale:xDevelopmentalxdelaysxcanxoccurxatxanyxage;xhowever,xitxisxmostxcommonlyxse
enxinxinfancyxthroughxadolescence.xDevelopmentalxdelaysxcanxoccurxregardlessxofxrace.x
Childrenxlivingxinxpoverty,xthosexwithxchronicxillnesses,xlowxbirthxweight,xorxexposurextoxen
vironmentalxexposurextoxtoxinsxarexatxaxhigherxriskxforxdevelopmentalxdelays.
Thexnursexinxaxpediatricxunitxisxplanningxthexstaffxassignmentsxforxchildrenxwithxdevelopm
entalxdelays.xWhenxplanningxthexassignment,xthexnursexdecidesxtoxassignxthosexchildrenx
whoxhavexsocialxorxemotionalxdelaysxamongstxdifferentxnurses.xWhichxchildrenxshouldxbex
assignedxtoxdifferentxnurses?xSelectxallxthatxapply.
Axchildxwithxautism
Anxinfantxwithxfetalxalcoholxsyndrome
Axchildxwithxattentionxdeficitxdisorder
Axchildxwithxgeneralizedxanxietyxdisorder
Axchildxwithxexpressivexlanguagexdisorderx-xans--A,xD
Rationale:xAxdevelopmentalxdelayxisxdefinedxasxnotxmeetingxthexexpectedxdevelopmental
xlevel.xSocialxandxemotionalxdevelopmentalxdelaysxincludexthosexaffectingxpersonality, xe
motion,xorxbehaviors.xTwoxexamplesxarexautismxandxgeneralizedxanxietyxdisorder.xAttenti
onxdeficitxdisorderxandxfetalxalcoholxsyndromexarexclassifiedxasxcognitivexdevelopmentalx
delays,xandxexpressivexlanguagexdisorderxisxaxcommunicationxdevelopmentalxdelay.
Thexclientxhasxbeenxprescribedxamoxiciilinx250xmgxthreextimesxdailyxforxsinusitis.xThexme
dicationxisxsuppliedxinxax500xmgxtablet.xHowxmanyxtablet(s)xwouldxthexnursexpreparexever
yx8xhoursxtoxadministerxthexcorrectxdose?xFillxinxthexblank.xRecordxthexanswerxusingxonexd
ecimalxplace.x_____________xtablet(s)x-xans--0.5
Thexnursexisxcaringxforxaxclientxadmittedxtoxthexhospitalxforxshortnessxofxbreathxandxedem
axinxbothxlowerxextremities.xThexclientxisxprescribedxfurosemidex40xmgxbyxthexintravenous
xroutexoncexdaily.xWhatxinformationxinxthexchartxwouldxwarrantxthexnursextoxverifyxcontinui
ngxthexprescriptionxwithxthexhealthxcarexproviderx(HCP)?xReferxtoxchart.
Expiratoryxrales
Atorvastatinxprescription
Peripheralxvascularxdisease
Potassiumxlevelxofx3.5xmEq/Lx(3.5xmmol/L)x-xans--Dx
Rationale:xFurosemidexisxaxpotassium-
losingxdiuretic.xThexserumxpotassiumxlevelxofx3.5xmEq/Lx(3.5xmmol/L)xisxonxthexlowerxlimit
xofxnormal,xandxthexnursexshouldxanticipatexthatxthexpotassiumxlevelxwouldxdropxwithxthexa
dministrationxofxfurosemide.xTherefore,xthexnursexshouldxverifyxcontinuingxthexprescriptio
QUESTIONS AND ANSWERS
Axclientxisxbeingxdischargedxhomexafterxaxroutinexhipxreplacementxsurgery.xThexnursexisxi
nstructingxthexclientxonxhowxtoxpreventxpostoperativexcomplications.xWhatxstatementsxbyx
thexclientxwouldxindicatexthexneedxforxfurtherxteaching?xSelectxallxthatxapply.
"Limitingxfiberxisxnecessaryxtoxavoidxdiarrhea."
"IxshouldxemptyxmyxbladderxwhenxIxfeelxthexurge."
"Avoidingxpainxmedicationxwillxpreventxconstipation."
"Ixshouldxdrinkxplentyxofxliquidsxlikexicedxteaxorxcoffee."
"Ixshouldxcontinuexwithxmyxphysicalxtherapyxandxwalking."x-xans--A,xC,xD
Rationale:xConstipationxisxcommonxafterxsurgeryxduextoxpainxmedication,xdecreasedxmov
ement,xandxanesthesia.xFiberxintakexshouldxbexencouragedxasxitxpromotesxthexprevention
xofxstoolxretention.xAlthoughxpainxmedicationxcanxcausexconstipation,xitxshouldxnotxbexavoi
dedxinxthexpost-
operativexperiod.xDrinkingxplentyxofxfluidsxisxencouragedxforxbothxbowelxandxbladderxmain
tenance,xbutxthexclientxshouldxchoosexnon-
caffeinatedxoptions.xPhysicalxtherapy,xwalking,xandxexercisexwillxhelpxpreventxconstipatio
n.xEmptyingxthexbladderxwhenxthexurgexisxpresentxcanxhelpxpreventxurinaryxtractxinfection
s.
ThexnursexisxcaringxforxaxVietnamesexclientxdiagnosedxwithxtuberculosis.xThexclientxspeak
sxlimitedxEnglish.xWhatxshouldxthexnursexdoxtoxensurexthexclientxandxfamilyxreceivesxthex
mostxaccuratexinformation?xSelectxallxthatxapply.
Providexculturallyxsensitivexeducation.
Encouragexfamilyxmembersxtoxobtainxaxtuberculosisxskinxtest.
ProvidexwrittenxinstructionsxinxEnglishxforxthexclientxtoxreference.
Encouragexthexclientxandxfamilyxtoxwashxallxdishesxbyxhandxtoxpreventxthexspreadxofxinfec
tion.
Urgexallxfamilyxandxclosexcontactxcommunityxmembersxtoxseekxandxcompletextreatmentxto
xenhancexcompliance.x-xans--A,xB,xE
,Rationale:xAsxalways,xthexnursexmustxprovidexculturallyxsensitivexeducation.xBecausextub
erculosisxisxhighlyxcontagious,xallxfamilyxmembersxandxclosexcommunityxmembersxshould
xhave xaxtuberculosisxskinxtest,xseekxtreatment,xandxremainxcompliant.xAxfullxcoursexofx6xto
x9xmonthsxofxtreatmentxisxneededxtoxpreventxre-
infection.xInstructionsxwrittenxinxEnglishxarexnotxhelpfulxforxthexclientxwithxlimitedxEnglishxs
kills.xWashingxdishesxbyxhandxisxnotxthexbestxwayxtoxpreventxinfection;xratherxaxdishwashe
rxshouldxbexusedxifxavailable.
Axclientxwithxanxietyxhasxjustxbeenxseenxbyxthexhealthxcarexproviderxandxhasxbeenxprescri
bedxalprazolam.xAxweekxlater,xthexclientxisxbroughtxtoxthexemergencyxroom,xafterxconsumi
ngxaxlargexnumberxofxtabletsxinxanxattemptxtoxoverdose.xThexclientxisxunresponsivexandxh
asxgaspingxrespirations.xWhichxactionxshouldxthexnursextakexfirst?
Administerxthexantidotexnaloxone
Administerxthexantidotexflumazenil
Assistxwithxintubationxofxthexclient
Assistxwithxinsertionxofxaxcentralxvenousxlinex-xans--C
Rationale:xThexclientxrequiresximmediatexintubationxbecausexofxthexgaspingxrespirationsx
andxunresponsiveness.xFlumazenilxisxthexantidotexforxanxoverdosexofxbenzodiazepines;xh
owever,xthexpriorityxisxsecuringxthexairway.xNaloxonexisxthexantidotexforxanxopiatexoverdos
e.xAssistingxwithxinsertionxofxaxcentralxvenousxlinexisxnotxthexpriorityxandxwouldxinvolvexaxg
reatxdealxofxtimexwhilexthexclientxisxgaspingxtoxbreathe.
Thexnursexisxobservingxthexcardiacxmonitorxofxaxclientxandxnotesxthisxcardiacxrhythmx(refe
rxtoxfigure).xWhatxisxthexinitialxnursingxaction?
[V-Tach]
Checkxforxaxpulse
Notifyxthexhealthxcarexprovider
Obtainxax12xleadxelectrocardiogramx(ECG)
Beginxcardiopulmonaryxresuscitationx(CPR)x-xans--Ax
Rationale:xVentricularxtachycardiaxcanxbexstablexorxunstablexdependingxonxwhetherxthexcl
ientxhasxaxpulsexorxnot.xInxthisxcase,xassessingxthexclient'sxpulsexisxthexinitialxaction.xObtai
ningxax12xleadxECGxandxnotifyingxthexhealthxcarexproviderxmayxbexnecessaryxbutxarexnotxi
nitialxactions.xInitiatingxCPRxmayxbexnecessaryxofxthexventricularxtachycardiaxbecomesxu
nstablexandxcardiacxarrestxoccurs.
Axmotherxbringsxherx9-month-
oldxchildxtoxseexthexpediatricianxandxhasxconcernsxthatxthexchildxmayxhavexaxdevelopment
alxdelayxbecausexthexchildxcannotxrollxoverxyet.xforxthexnursexshouldxaskxthexmotherxabout
xwhichxriskxfactorsxassociatedxwithxaxdevelopmentalxdelay?xSelectxallxthatxapply.
Age
Race
, Income
Chronicxillness
Lowxbirthxweight
Environmentalxexposurextoxtoxinsx-xans--C,D,xE,xFx
Rationale:xDevelopmentalxdelaysxcanxoccurxatxanyxage;xhowever,xitxisxmostxcommonlyxse
enxinxinfancyxthroughxadolescence.xDevelopmentalxdelaysxcanxoccurxregardlessxofxrace.x
Childrenxlivingxinxpoverty,xthosexwithxchronicxillnesses,xlowxbirthxweight,xorxexposurextoxen
vironmentalxexposurextoxtoxinsxarexatxaxhigherxriskxforxdevelopmentalxdelays.
Thexnursexinxaxpediatricxunitxisxplanningxthexstaffxassignmentsxforxchildrenxwithxdevelopm
entalxdelays.xWhenxplanningxthexassignment,xthexnursexdecidesxtoxassignxthosexchildrenx
whoxhavexsocialxorxemotionalxdelaysxamongstxdifferentxnurses.xWhichxchildrenxshouldxbex
assignedxtoxdifferentxnurses?xSelectxallxthatxapply.
Axchildxwithxautism
Anxinfantxwithxfetalxalcoholxsyndrome
Axchildxwithxattentionxdeficitxdisorder
Axchildxwithxgeneralizedxanxietyxdisorder
Axchildxwithxexpressivexlanguagexdisorderx-xans--A,xD
Rationale:xAxdevelopmentalxdelayxisxdefinedxasxnotxmeetingxthexexpectedxdevelopmental
xlevel.xSocialxandxemotionalxdevelopmentalxdelaysxincludexthosexaffectingxpersonality, xe
motion,xorxbehaviors.xTwoxexamplesxarexautismxandxgeneralizedxanxietyxdisorder.xAttenti
onxdeficitxdisorderxandxfetalxalcoholxsyndromexarexclassifiedxasxcognitivexdevelopmentalx
delays,xandxexpressivexlanguagexdisorderxisxaxcommunicationxdevelopmentalxdelay.
Thexclientxhasxbeenxprescribedxamoxiciilinx250xmgxthreextimesxdailyxforxsinusitis.xThexme
dicationxisxsuppliedxinxax500xmgxtablet.xHowxmanyxtablet(s)xwouldxthexnursexpreparexever
yx8xhoursxtoxadministerxthexcorrectxdose?xFillxinxthexblank.xRecordxthexanswerxusingxonexd
ecimalxplace.x_____________xtablet(s)x-xans--0.5
Thexnursexisxcaringxforxaxclientxadmittedxtoxthexhospitalxforxshortnessxofxbreathxandxedem
axinxbothxlowerxextremities.xThexclientxisxprescribedxfurosemidex40xmgxbyxthexintravenous
xroutexoncexdaily.xWhatxinformationxinxthexchartxwouldxwarrantxthexnursextoxverifyxcontinui
ngxthexprescriptionxwithxthexhealthxcarexproviderx(HCP)?xReferxtoxchart.
Expiratoryxrales
Atorvastatinxprescription
Peripheralxvascularxdisease
Potassiumxlevelxofx3.5xmEq/Lx(3.5xmmol/L)x-xans--Dx
Rationale:xFurosemidexisxaxpotassium-
losingxdiuretic.xThexserumxpotassiumxlevelxofx3.5xmEq/Lx(3.5xmmol/L)xisxonxthexlowerxlimit
xofxnormal,xandxthexnursexshouldxanticipatexthatxthexpotassiumxlevelxwouldxdropxwithxthexa
dministrationxofxfurosemide.xTherefore,xthexnursexshouldxverifyxcontinuingxthexprescriptio
