H-Quest q&a
Because of census overload, the charge nurse of an acute care medical unit must
select a client who can be transferred back to a residential facility. The client with which
symptomology is the most stable? - (correct answer)A stage 3 sacral pressure ulcer,
with colonized methicillin-resistant Staphylococcus aureus (MRSA)
-The client with colonized MRSA (A) is the most stable client, because colonization does
not cause symptomatic disease.
The nurse is developing a health risk assessment protocol for use in a well-baby clinic
in a low-income neighborhood. Which information is most important for the nurse to
include in the assessment? - (correct answer)Immunization history
- Rationale:
The Centers for Disease Control and Prevention indicate that vaccines are among the
most widely used, effective, and safe medical products in use today. Assessing the
infant immunization histories in clients from disadvantaged socioeconomic groups (B) is
the most effective method for determining these infants' susceptibilities to vaccine-
preventable diseases.
Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP.
Team 1's assignment includes two clients who are both 1 day postangioplasty and two
clients with unstable angina. Team 2's assignment includes all stable clients, but two
clients are bedridden and incontinent. Which staffing plan represents the best use of
available staff? - (correct answer)Team 1: RN team leader, PN; team 2, PN team leader,
UAP
-Team 1 includes high-risk clients who require a higher level of assessment and
decision making, which should be provided by an RN and PN (A). Team 2 has stable
clients at lower risk than those on team 1. Although two clients on team 2 require
frequent care, the care is routine and predictable in nature and can be managed by the
PN and UAP.
For what complication should a nurse assess a newborn after a precipitate birth?
1. Brachial Palsy
,2. Dislocated hip
3. Fractured clavicle
4. Intracranial hemorrhage - (correct answer)--Intracranial hemorrhage
A rapid birth does not give the fetal head adequate time for molding; therefore pressure
against the head is increased and blood vessels may burst.
-Brachial palsy and fractured clavicle are the results of
excessive pulling on the head and shoulders during a delivery involving shoulder
dystocia delivery.
-A dislocated hip is more likely to occur in a footling breech birth.
A registered nurse (RN) in charge of a mental health unit has two additional staff
members: a licensed practical nurse (LPN) and a nursing assistant (NA). The unit has
20 clients, with one client on constant observation for acute suicidality. What should the
nurse in charge do when making the daily assignments?
1. Administer medications and assign the LPN to maintain observation of the suicidal
client and the nursing assistant to provide client care.
2. Maintain constant observation of the suicidal client and assign the LPN to administer
medications and the nursing assistant to provide client care.
3. Perform client care and administrative duties and assign the nursing assistant to
administer medications and the LPN to maintain observation of the suicidal client.
4. Provide client care and administrative duties and assign the LPN to administer
medications and the nursing assistant to maintain constant observatio - (correct
answer)--Provide client care and administrative duties and assign the ***LPN to
, administer medications*** and the ***nursing assistant to maintain constant
observation*** of the suicidal client.
--[Assigning the LPN to administer medications utilizes the LPN's skills; providing
constant observation of a client is within the role of NAs and frees the RN to perform
client care and administrative duties.]
-Administering medications will keep the RN from performing administrative duties;
having the LPN perform direct client observation will underutilize the abilities of the LPN.
Providing suicide observation will prevent the RN from performing required
administrative duties. Having an NA administer medications is illegal in many states.
NAs are not educated about the actions and side effects of medications.
The husband of a client in labor asks about an indentation on his wife's abdomen. The
nurse explains that it is a retraction ring (Bandl's ring). What is the next nursing action? -
(correct answer)Explaining to him what it means and notify the practitioner
[Bandl's ring is a pathological retraction ring, a sign of impending uterine rupture. There
is a ridge around the uterus at the junction of the upper and lower uterine segments.
The upper segment is distended and thin and the lower segment is thick. Although the
ring may occur during the second stage of labor, it is not a sign that the second stage of
labor is beginning. A retraction ring impedes the progress of labor; it is associated with
premature rupture of the membranes, dystocia, and prolonged labor. A retraction ring is
pathological, not expected.]
A client with myasthenia gravis who is taking a cholinesterase inhibitor is admitted to the
emergency department in crisis. To distinguish between myasthenic crisis and
cholinergic crisis, the nurse expects the health care provider to prescribe:
1. Atropine sulfate.
2. Protamine sulfate.
Because of census overload, the charge nurse of an acute care medical unit must
select a client who can be transferred back to a residential facility. The client with which
symptomology is the most stable? - (correct answer)A stage 3 sacral pressure ulcer,
with colonized methicillin-resistant Staphylococcus aureus (MRSA)
-The client with colonized MRSA (A) is the most stable client, because colonization does
not cause symptomatic disease.
The nurse is developing a health risk assessment protocol for use in a well-baby clinic
in a low-income neighborhood. Which information is most important for the nurse to
include in the assessment? - (correct answer)Immunization history
- Rationale:
The Centers for Disease Control and Prevention indicate that vaccines are among the
most widely used, effective, and safe medical products in use today. Assessing the
infant immunization histories in clients from disadvantaged socioeconomic groups (B) is
the most effective method for determining these infants' susceptibilities to vaccine-
preventable diseases.
Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP.
Team 1's assignment includes two clients who are both 1 day postangioplasty and two
clients with unstable angina. Team 2's assignment includes all stable clients, but two
clients are bedridden and incontinent. Which staffing plan represents the best use of
available staff? - (correct answer)Team 1: RN team leader, PN; team 2, PN team leader,
UAP
-Team 1 includes high-risk clients who require a higher level of assessment and
decision making, which should be provided by an RN and PN (A). Team 2 has stable
clients at lower risk than those on team 1. Although two clients on team 2 require
frequent care, the care is routine and predictable in nature and can be managed by the
PN and UAP.
For what complication should a nurse assess a newborn after a precipitate birth?
1. Brachial Palsy
,2. Dislocated hip
3. Fractured clavicle
4. Intracranial hemorrhage - (correct answer)--Intracranial hemorrhage
A rapid birth does not give the fetal head adequate time for molding; therefore pressure
against the head is increased and blood vessels may burst.
-Brachial palsy and fractured clavicle are the results of
excessive pulling on the head and shoulders during a delivery involving shoulder
dystocia delivery.
-A dislocated hip is more likely to occur in a footling breech birth.
A registered nurse (RN) in charge of a mental health unit has two additional staff
members: a licensed practical nurse (LPN) and a nursing assistant (NA). The unit has
20 clients, with one client on constant observation for acute suicidality. What should the
nurse in charge do when making the daily assignments?
1. Administer medications and assign the LPN to maintain observation of the suicidal
client and the nursing assistant to provide client care.
2. Maintain constant observation of the suicidal client and assign the LPN to administer
medications and the nursing assistant to provide client care.
3. Perform client care and administrative duties and assign the nursing assistant to
administer medications and the LPN to maintain observation of the suicidal client.
4. Provide client care and administrative duties and assign the LPN to administer
medications and the nursing assistant to maintain constant observatio - (correct
answer)--Provide client care and administrative duties and assign the ***LPN to
, administer medications*** and the ***nursing assistant to maintain constant
observation*** of the suicidal client.
--[Assigning the LPN to administer medications utilizes the LPN's skills; providing
constant observation of a client is within the role of NAs and frees the RN to perform
client care and administrative duties.]
-Administering medications will keep the RN from performing administrative duties;
having the LPN perform direct client observation will underutilize the abilities of the LPN.
Providing suicide observation will prevent the RN from performing required
administrative duties. Having an NA administer medications is illegal in many states.
NAs are not educated about the actions and side effects of medications.
The husband of a client in labor asks about an indentation on his wife's abdomen. The
nurse explains that it is a retraction ring (Bandl's ring). What is the next nursing action? -
(correct answer)Explaining to him what it means and notify the practitioner
[Bandl's ring is a pathological retraction ring, a sign of impending uterine rupture. There
is a ridge around the uterus at the junction of the upper and lower uterine segments.
The upper segment is distended and thin and the lower segment is thick. Although the
ring may occur during the second stage of labor, it is not a sign that the second stage of
labor is beginning. A retraction ring impedes the progress of labor; it is associated with
premature rupture of the membranes, dystocia, and prolonged labor. A retraction ring is
pathological, not expected.]
A client with myasthenia gravis who is taking a cholinesterase inhibitor is admitted to the
emergency department in crisis. To distinguish between myasthenic crisis and
cholinergic crisis, the nurse expects the health care provider to prescribe:
1. Atropine sulfate.
2. Protamine sulfate.
