Unit 4 Critical Thinking questions and
answers with solutions
Which client would benefit from the application of warm moist heat? - ANSWER a client with
low back pain
Direct application of warm moist heat would benefit a client with low back pain because the
heat relaxes muscle spasms. Heat should not be applied to a client who has appendicitis
because it can lead to rupture of the appendix and peritonitis. Ice is applied to recently sprained
joints to help decrease edema. Applying heat to the area of a suspected malignancy can
increase blood flow to the tumor and promote nourishment of the cancer cells.
A nurse is administering vitamin K to a neonate following birth. The medication comes in a
concentration of 2 mg/ml, and the ordered dose is 0.5 mg to be given subcutaneously. How
many milliliters would the nurse administer? Record your answer using two decimal places. -
ANSWER 0.25
Use the following formula to calculate drug dosages:Dose on hand/Quantity on hand = Dose
desired/XPlug in the values and the equation is as follows:2 mg/ml = 0.5 mg/XX = 0.25 ml.
A child is to receive IV fluids at a rate of 95 mL/h. The tubing for the infusion delivers 10
drops/mL. At which rate should the nurse infuse the solution? - ANSWER 16 drops/min
To determine the number of drops per minute, multiply 95 ml/hour by 10 drops/mL (drop
factor). This equals 950 mL/h. Dividing 950 mL/h by 60 min/h yields 15.8 drops/min. Therefore,
16 drops/min should be infused.
A 5-year-old child is brought to the emergency department after injuries sustained in a motor
vehicle accident. The child is diagnosed with a cervical spinal cord injury. Which assessment
,data would the nurse consider as most significant when assessing for signs of cervical spinal
cord swelling? - ANSWER changes in respiration
Impaired diaphragm function is common with cervical cord injuries in children and is potentially
life threatening. It interferes with the ability to breathe, causing changes in respiration.
The healthcare provider prescribes meperidine hydrochloride 1.5 mg/kg intramuscularly to a
school-age client. The pharmacy supplies meperidine hydrochloride injection as 50 mg/mL. The
client weighs 25 kg. How many milliliters will the nurse administer? Record your answer using
two decimal places. - ANSWER 0.75
1.5 mg/kg × 25 kg = 37.5 mg per dose
37.5 mg / 50 mg x 1ml = 0.75 ml for injection
A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for
which indicator of early shock? - ANSWER heart rate above 100 beats/minute
In early shock, the body attempts to meet its perfusion needs through tachycardia,
vasoconstriction, and fluid conservation.The skin becomes cool and clammy.Urine output in
early shock may be normal or slightly decreased.The client may experience increased
restlessness and anxiety from hypoxia, but loss of consciousness is a late sign of shock.
A client reports pain in the right heel and is requesting medication. The nurse assesses the client
and administers an analgesic. The client experiences no pain relief and states that the heel pain
is worse. What is an appropriate intervention by the nurse? - ANSWER Call the physician to
report the finding.
The best response would be to notify the physician. The nurse cannot repeat the dose of
analgesic without an order. Massaging the ankle and applying moist heat would be
inappropriate for a number of reasons. The client could be developing a deep vein thrombosis,
,which may dislodge an embolus. Unrelieved pain indicates that an adverse event is developing,
and the physician should be made aware of the situation.
A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source
of energy that was not turned off while working on it. What is the priority nursing intervention
in the acute phase of care? - ANSWER A cardiac monitor should be used for at least 24 hours to
anticipate the potential for cardiac dysrhythmias.
A client with electrical burns based on energy and potential damage to the heart needs cardiac
monitoring. Dextrose is not useful for fluid volume expansion and infection would occur much
later. Urine output needs hourly monitoring based on myoglobin release.
During the nurse's assessment, the newborn wakes and is in a quiet-alert state. The nurse
counts the apical pulse to be 157 beats per minute. Which is the most appropriate nursing
action? - ANSWER Document this finding as on the high end of the normal range and plan to
reassess.
Heart rates can be as fast as 180 bpm, but the normal range for a newborn heart rate is 110-160
bpm. Thus, the newborn's heart rate of 157 bpm is on the high end of the normal range, but still
within the normal range. It would be appropriate to reassess the client's heart rate because
newborn heart rates can fluctuate depending on the state of consciousness/wakefulness,
hunger, temperature, and especially if the newborn is moving or startled. It would be
inappropriate to call the pediatrician or to notify the charge nurse at this time because the value
is currently within the normal range.
When developing the collaborative plan of care with the health care provider (HCP) for a
multigravid client at 10 weeks' gestation with a history of cardiac disease who was being treated
with digitalis therapy before this pregnancy, the nurse should instruct the client about which
modifications regarding the client's drug therapy regimen? - ANSWER need for an increased
dosage
, Clients on cardiac medications may need dosage increases as their blood volume increases.
Drug level monitoring may be needed after dose changes or if the client presents with toxicity,
but weekly monitoring is unnecessary. The medication would be switched only if digitalis
toxicity occurs. A diuretic is added only if congestive heart failure is not controlled by sodium
and activity restrictions.
A full-term client is admitted for induction of labor. When admitted, her cervix is effaced 25%
but has not dilated. The initial goal is cervical ripening prior to labor induction. Which drug will
prepare her cervix for induction? - ANSWER dinoprostone
Cervical ripening, or creating a cervix that is soft, anterior, and dilated to 2 to 3 cm, must occur
before the cervix can efface and dilate with oxytocin. Drugs to accomplish this goal include
dinoprostone, misoprostol, and prostaglandin E2. Nalbuphine is a narcotic analgesic used in
early labor and has no influence on the cervix. Betamethasone is a corticosteroid given to
mature fetal lungs.
When assessing a client with asthma, which findings would most likely indicate the presence of
a respiratory infection? - ANSWER cough productive of yellow sputum
A cough productive of yellow sputum is the most likely indicator of a respiratory infection. The
other signs and symptoms—wheezing, chest tightness, and increased respiratory rate—are all
findings associated with an asthma attack and do not necessarily mean an infection is present.
A client's blood glucose level is 45 mg/dl (2.5 mmol/L). The nurse should be alert for which signs
and symptoms? - ANSWER coma, anxiety, confusion, headache, and cool, moist skin
Signs and symptoms of hypoglycemia [indicated by a blood glucose level of 45 mg/dl (2.5
mmol/L)] include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin,
tremors, coma, and seizures. Kussmaul's respirations, dry skin, hypotension, and bradycardia
are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are
symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic
signs and symptoms of diabetes mellitus.
answers with solutions
Which client would benefit from the application of warm moist heat? - ANSWER a client with
low back pain
Direct application of warm moist heat would benefit a client with low back pain because the
heat relaxes muscle spasms. Heat should not be applied to a client who has appendicitis
because it can lead to rupture of the appendix and peritonitis. Ice is applied to recently sprained
joints to help decrease edema. Applying heat to the area of a suspected malignancy can
increase blood flow to the tumor and promote nourishment of the cancer cells.
A nurse is administering vitamin K to a neonate following birth. The medication comes in a
concentration of 2 mg/ml, and the ordered dose is 0.5 mg to be given subcutaneously. How
many milliliters would the nurse administer? Record your answer using two decimal places. -
ANSWER 0.25
Use the following formula to calculate drug dosages:Dose on hand/Quantity on hand = Dose
desired/XPlug in the values and the equation is as follows:2 mg/ml = 0.5 mg/XX = 0.25 ml.
A child is to receive IV fluids at a rate of 95 mL/h. The tubing for the infusion delivers 10
drops/mL. At which rate should the nurse infuse the solution? - ANSWER 16 drops/min
To determine the number of drops per minute, multiply 95 ml/hour by 10 drops/mL (drop
factor). This equals 950 mL/h. Dividing 950 mL/h by 60 min/h yields 15.8 drops/min. Therefore,
16 drops/min should be infused.
A 5-year-old child is brought to the emergency department after injuries sustained in a motor
vehicle accident. The child is diagnosed with a cervical spinal cord injury. Which assessment
,data would the nurse consider as most significant when assessing for signs of cervical spinal
cord swelling? - ANSWER changes in respiration
Impaired diaphragm function is common with cervical cord injuries in children and is potentially
life threatening. It interferes with the ability to breathe, causing changes in respiration.
The healthcare provider prescribes meperidine hydrochloride 1.5 mg/kg intramuscularly to a
school-age client. The pharmacy supplies meperidine hydrochloride injection as 50 mg/mL. The
client weighs 25 kg. How many milliliters will the nurse administer? Record your answer using
two decimal places. - ANSWER 0.75
1.5 mg/kg × 25 kg = 37.5 mg per dose
37.5 mg / 50 mg x 1ml = 0.75 ml for injection
A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for
which indicator of early shock? - ANSWER heart rate above 100 beats/minute
In early shock, the body attempts to meet its perfusion needs through tachycardia,
vasoconstriction, and fluid conservation.The skin becomes cool and clammy.Urine output in
early shock may be normal or slightly decreased.The client may experience increased
restlessness and anxiety from hypoxia, but loss of consciousness is a late sign of shock.
A client reports pain in the right heel and is requesting medication. The nurse assesses the client
and administers an analgesic. The client experiences no pain relief and states that the heel pain
is worse. What is an appropriate intervention by the nurse? - ANSWER Call the physician to
report the finding.
The best response would be to notify the physician. The nurse cannot repeat the dose of
analgesic without an order. Massaging the ankle and applying moist heat would be
inappropriate for a number of reasons. The client could be developing a deep vein thrombosis,
,which may dislodge an embolus. Unrelieved pain indicates that an adverse event is developing,
and the physician should be made aware of the situation.
A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source
of energy that was not turned off while working on it. What is the priority nursing intervention
in the acute phase of care? - ANSWER A cardiac monitor should be used for at least 24 hours to
anticipate the potential for cardiac dysrhythmias.
A client with electrical burns based on energy and potential damage to the heart needs cardiac
monitoring. Dextrose is not useful for fluid volume expansion and infection would occur much
later. Urine output needs hourly monitoring based on myoglobin release.
During the nurse's assessment, the newborn wakes and is in a quiet-alert state. The nurse
counts the apical pulse to be 157 beats per minute. Which is the most appropriate nursing
action? - ANSWER Document this finding as on the high end of the normal range and plan to
reassess.
Heart rates can be as fast as 180 bpm, but the normal range for a newborn heart rate is 110-160
bpm. Thus, the newborn's heart rate of 157 bpm is on the high end of the normal range, but still
within the normal range. It would be appropriate to reassess the client's heart rate because
newborn heart rates can fluctuate depending on the state of consciousness/wakefulness,
hunger, temperature, and especially if the newborn is moving or startled. It would be
inappropriate to call the pediatrician or to notify the charge nurse at this time because the value
is currently within the normal range.
When developing the collaborative plan of care with the health care provider (HCP) for a
multigravid client at 10 weeks' gestation with a history of cardiac disease who was being treated
with digitalis therapy before this pregnancy, the nurse should instruct the client about which
modifications regarding the client's drug therapy regimen? - ANSWER need for an increased
dosage
, Clients on cardiac medications may need dosage increases as their blood volume increases.
Drug level monitoring may be needed after dose changes or if the client presents with toxicity,
but weekly monitoring is unnecessary. The medication would be switched only if digitalis
toxicity occurs. A diuretic is added only if congestive heart failure is not controlled by sodium
and activity restrictions.
A full-term client is admitted for induction of labor. When admitted, her cervix is effaced 25%
but has not dilated. The initial goal is cervical ripening prior to labor induction. Which drug will
prepare her cervix for induction? - ANSWER dinoprostone
Cervical ripening, or creating a cervix that is soft, anterior, and dilated to 2 to 3 cm, must occur
before the cervix can efface and dilate with oxytocin. Drugs to accomplish this goal include
dinoprostone, misoprostol, and prostaglandin E2. Nalbuphine is a narcotic analgesic used in
early labor and has no influence on the cervix. Betamethasone is a corticosteroid given to
mature fetal lungs.
When assessing a client with asthma, which findings would most likely indicate the presence of
a respiratory infection? - ANSWER cough productive of yellow sputum
A cough productive of yellow sputum is the most likely indicator of a respiratory infection. The
other signs and symptoms—wheezing, chest tightness, and increased respiratory rate—are all
findings associated with an asthma attack and do not necessarily mean an infection is present.
A client's blood glucose level is 45 mg/dl (2.5 mmol/L). The nurse should be alert for which signs
and symptoms? - ANSWER coma, anxiety, confusion, headache, and cool, moist skin
Signs and symptoms of hypoglycemia [indicated by a blood glucose level of 45 mg/dl (2.5
mmol/L)] include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin,
tremors, coma, and seizures. Kussmaul's respirations, dry skin, hypotension, and bradycardia
are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are
symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic
signs and symptoms of diabetes mellitus.
