NUR 304 Exam 1 Practice Questions and Answers

NUR 304 Exam 1 Practice Questions and Answers A nurse is caring for a group of clients. One client is scheduled for the operating room (OR) in one hour. The second client needs information on nursing homes, and the third client needs to provide a urine specimen. The nurse has not documented on any clients. What task would the nurse delegate to an licensed practical nurse (LPN/LVN)? A.) Preparing the client for the OR B.) Documenting client care C.) Providing nursing home information D.) Retrieving the urine specimen D.) Retrieving the urine specimen Rationale: The nurse should delegate the retrieval of the urine specimen to the LPN. This task is in the LPN's scope of practice, and constitutes appropriate use of staff. When staffing the surgical nursing unit, which of the following clients could the nurse delegate to an unlicensed assistive person (UAP)? A.) A third-day-postoperative client who needs to be walked and have a blood glucose check at bedtime B.) A new surgical client who has just complained of oozing from the mastectomy site C.) A new amputee who is stable, but needs dressings reinforced D.) A fourth-day coronary artery bypass client who still has stable angina after surgery A.) A third-day-postoperative client who needs to be walked and have a blood glucose check at bedtime Rationale: Delegation to UAPs can include any activity that is within their role. Ambulating the client and blood glucose monitoring are within this role. What is an appropriate task for the registered nurse (RN) to delegate to the unlicensed assistant (UA)? A.) Intake and output B.) Irrigating a nasogastric (NG) tube C.) Changing a burn dressing D.) Monitoring pain status A.) Intake and output Rationale: Intake and output are tasks that fall within the scope of practice for the UA. The registered nurse (RN) is working with an unlicensed assistant (UA) for the shift. Which activity is best retained by the RN rather than delegated to the UA? A.) Weighing a client B.) Discharging a client C.) Emptying the urinary catheter D.) Bathing a client B.) Discharging a client Rationale: Discharging a client (and the associated teaching that is involved) is within the scope of the RN only. A staff nurse is orienting a new nurse to the unit. The orientee is overwhelmed by the many tasks required. How should the staff nurse respond? A.) "Make a to-do list, and prioritize to keep yourself on track." B.) "Start with the tasks that require less time and skill." C.) "Try to get most of the work done yourself." D.) "Start medication administration, then go from there." A.) "Make a to-do list, and prioritize to keep yourself on track." Rationale: The staff nurse should respond by instructing the orientee to make a to-do list and prioritize to stay on track. Many sources recommend to-do lists to help organize tasks, and prioritizing the list allows the nurse to focus on tasks that require immediate attention first. A nurse plans to delegate some responsibilities of client care to a licensed practical/vocational nurse (LPN/LVN). Which task should the nurse delegate to the LPN/LVN? A.) Assessment of a newly admitted client B.) Admission of a postoperative client C.) Dressing changes for a client with wounds D.) Assist a client with ambulation and AM care C.) Dressing changes for a client with wounds Rationale: The best choice is to assign the LPN to change the client's dressing. The staffing on the unit consists of one registered nurse (RN), two licensed practical nurses (LPNs), and an unlicensed assistant (UA). Which task is the most appropriate to be completed by the LPN? A.) Assessing a client following chest tube removal B.) Dressing changes on a client who sustained a major burn C.) Dressing changes on a client who underwent an appendectomy D.) Emptying the urinary catheters on the unit C.) Dressing changes on a client who underwent an appendectomy Rationale: This is a stable client, and dressing changes on a stable client are within the scope of practice of the LPN. While working on a nursing unit that has been short-staffed for three months, a nurse has fallen behind schedule in performing care to some assigned clients. The charge nurse recommends delegating some tasks to another nurse or CNA. The nurse responds, "I'll catch up; I can handle it." The charge nurse then counsels the nurse about which delegation barrier? A.) Inexperience B.) Disorganization C.) Inadequate support D.) Self-absorbing attitude C.) Inadequate support Rationale: Nurses are often hesitant to ask for help because they may be expected to meet the needs of all clients at all times. In this case, however, the chronic short-staffing on the unit is a barrier because fewer staff mean less support from others in the work of the unit. A nurse is assessing a surgical client. An unlicensed assistant (UA) enters the room and informs the nurse that a client in the next room is cold, clammy, and diaphoretic. What should the nurse do first? A.) Call the charge nurse for help. B.) Continue to assess the surgical client. C.) Assess the client who is clammy and diaphoretic. D.) Call the client's health care provider for new orders. C.) Assess the client who is clammy and diaphoretic. Rationale: There is an urgent situation in the next room, and the nurse should assess that client to determine the extent of the client's change in status. A staff nurse on the clinical excellence committee must prepare an in-service on delegation for nursing staff. In preparing the presentation, the nurse includes which explanation of how delegation impacts the safety and quality of client care? A.) Prevents nursing staff from becoming nonproductive and ineffective B.) Gets assigned nursing tasks done in most efficient way, utilizing appropriate resources C.) Gives nursing tasks to staff who can best understand the goal to be met D.) A way to make nursing staff feel as though they are part of the team B.) Gets assigned nursing tasks done in most efficient way, utilizing appropriate resources Rationale: The main purpose of delegation is to get the job done in the most efficient way using appropriate resources. A nurse is prepared to administer 0900 medications. Which medication should the nurse administer first? A.) Montelukast (Singulair) 10 mg orally for a client with asthma. B.) Potassium 40 mEq orally for a client with a potassium level of 2.8 mEq/L. C.) Two liters of oxygen for a client with an oxygen saturation of 94%. D.) Metoprolol (Toprol) 50 mg for a client with a BP of 108/66. B.) Potassium 40 mEq orally for a client with a potassium level of 2.8 mEq/L. Rationale: The client with a potassium level of 2.8 mEq/L has a critically low level and could develop a cardiac dysrhythmia. This client should receive potassium immediately. Which task would not be appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN) or unlicensed assistive personnel (UAP)? A.) Instructing the LPN/LVN to reinforce teaching of the RN's assigned clients prior to discharge B.) Assigning UAPs to complete vital signs and document and report changes to the RN C.) Asking the UAP to assess and evaluate the client response to IV pain medication D.) Instructing the LPN/LVN to remove a dressing from a postoperative client's abdominal wound C.) Asking the UAP to assess and evaluate the client response to IV pain medication Rationale: The decision to delegate should be consistent with the nursing process (appropriate assessment, planning, implementation, and evaluation). The person responsible for client assessment, diagnosis, care planning, and evaluation is the registered nurse. The nurse has admitted to the intermediate care unit a client who sustained a spinal cord injury at T1 in a motor vehicle accident. Which nursing care activity can the nurse delegate to the unlicensed assistive person (UAP) working with this client? Select all that apply. A.) Measure oxygen saturation level every hour. B.) Listen to breath sounds. C.) Provide mouth care. D.) Teach use of incentive spirometer. E.) Assess for Homan's sign while bathing client. A.) Measure oxygen saturation level every hour. C.) Provide mouth care. Rationale: ~ The UAP can perform tasks or nursing care activities, such as measuring oxygen saturation level, under supervision of the nurse. ~ The RN retains responsibility for assessment of breath sounds. ~ The UAP can perform tasks or nursing care activities, such as mouth care, under the supervision of the RN. ~ The RN retains responsibility for teaching. ~ The RN retains responsibility for assessment of Homan's sign. A charge nurse is making assignments for the unit. Which assignment is best for the licensed practical nurse (LPN)? A.) Client post-myocardial infarction who is also three days postoperative and receiving IV fluids B.) Client post-chest tube removal who is on oxygen at three liters/minute by nasal cannula C.) A client who is post-tonsillectomy who is complaining of a feeling of wetness in the throat D.) A client who is post-craniotomy who is going home in the morning D.) A client who is post-craniotomy who is going home in the morning Rationale: The post-craniotomy client who is approaching discharge is the most stable of clients. LPNs should take clients who are more likely to achieve expected outcomes without complications. A nurse is delegating care of clients to the certified nursing assistant (CNA) and licensed practical/vocational nurse (LPN/LVN). Which tasks should the nurse give the CNA and LPN/LVN? A.) CNA: Measure vital signs; LPN/LVN: Give oral medications on assigned clients B.) CNA: Change a non-infected dressing; LPN/LVN: Administer IV piggyback medications C.) CNA: Ambulate a client who had a CVA; LPN/LVN: Assess two clients D.) CNA: Measure vital signs; LPN/LVN: Complete a head-to-toe assessment on a newly admitted client A.) CNA: Measure vital signs; LPN/LVN: Give oral medications on assigned clients Rationale: The scope of practice and most job descriptions for CNAs include vital signs. It is within the scope of practice for the LPN/LVN to administer oral medications. After receiving intershift report, the registered nurse (RN) is aware that it will be a busy shift. Which task is a priority nursing action? A.) Administer potassium to a client with a potassium level of 3.7 mEq/L. B.) Check oxygen saturation on a client whose arterial blood gases (ABGs) are pH 7.38, PCO2 38 mmHg, and HCO3- 22 mEq/L. C.) Assess a wound on a client with a diabetic foot ulcer and a blood glucose level of 168 mg/dL. D.) Administer ordered magnesium sulfate to a client with a magnesium level of 0.8 mEq/L. D.) Administer ordered magnesium sulfate to a client with a magnesium level of 0.8 mEq/L. Rationale: The client with a magnesium level of 0.8 mEq/L is at risk for seizures and tetany if it falls further, so administering magnesium is a priority to keep this client safe and prevent seizure activity. Which task is best delegated by the registered nurse (RN) to the unlicensed assistant (UA)? A.) Recording weights of a client with burn injury B.) Draining the irrigation bags for a colostomy C.) Assisting a client to eat and bathe D.) Monitoring the cardiac status of a client post-myocardial infarction C.) Assisting a client to eat and bathe Rationale: The nursing assistant can complete and be assigned tasks that do not require teaching or assessment. In this case, the tasks that can best be assigned are feeding and bathing. A nurse delegates to an unlicensed assistant (UA) the task of blood glucose (BG) monitoring, which must be done every two hours. What critical component of delegation by the nurse is necessary to ensure the measurements are completed every two hours? A.) The nurse must provide feedback and evaluate performance. B.) The nurse must limit the nursing assistant's authority. C.) The nurse must watch the assistant to make sure the BG monitoring is done. D.) The nurse and the nursing assistant should rotate the BG monitoring. A.) The nurse must provide feedback and evaluate performance. Rationale: The nurse must provide feedback and evaluate performance to ensure the BG checks are completed every two hours. A charge nurse is supervising the work of a new registered nurse (RN). The new nurse is asking for help with delegating tasks to licensed practical/vocational nurses (LPN/LVNs). How should the charge nurse respond? A.) "Delegate based on the task and the skill of the LPN/LVN." B.) "When delegating, provide constant feedback." C.) "Only delegate tasks that you are not able to complete yourself." D.) "Give the LPN/LVN full responsibility to complete the task." A.) "Delegate based on the task and the skill of the LPN/LVN." Rationale: The charge nurse should tell the nurse to delegate tasks based on the task and the LPN/LVN's skill. The nurse on a cardiac medical unit has an unlicensed assistive person (UAP) assigned to the nursing team. The nurse would delegate which client care activities to the UAP? A.) Assist the client to choose low-fat and low-sodium food selections from the dietary menu. B.) Measure client's pulse, blood pressure, and oxygen saturation after ambulation. C.) Explain the need to alternate activity periods with rest. D.) Help the client use nitroglycerin left at the bedside if chest pain occurs. B.) Measure client's pulse, blood pressure, and oxygen saturation after ambulation. Rationale: The nurse should delegate the activity that is procedural in nature, which is within the scope of training of the UAP. A nurse is preparing for a busy morning. The first assigned client has hemodialysis in two hours. The second client has discharge orders. The third client has congestive heart failure (CHF), and needs furosemide (Lasix) IV push. The fourth client is a 36-year-old with type 2 diabetes mellitus and a blood glucose of 156 mg/dL. What should the nurse do first? A.) Assess the client who is going to dialysis in two hours. B.) Administer furosemide (Lasix) IVP to the client with CHF. C.) Provide discharge teaching to the client who is ready to go home. D.) Administer ordered regular insulin 2 units subcutaneously to the client with diabetes. B.) Administer furosemide (Lasix) IVP to the client with CHF. Rationale: The nurse should use the ABCs of care to help guide this decision. The client who needs furosemide (Lasix) to treat CHF, has a cardiac illness that can also affect respiratory status. The other clients can wait until this client is medicated. A female staff nurse on the unit asks the charge nurse to complete the wound care and dressing change on an assigned client because she finds wound care distasteful. The nurse manager would counsel the nurse about which subject? A.) Reverse delegation B.) Overdelegation C.) Underdelegation D.) Incomplete delegation A.) Reverse delegation Rationale: Reverse delegation occurs when a person with a lower rank delegates to someone with authority. In this instance, the nurse with a limited client assignment is delegating upward to a nurse who has responsibility for the entire nursing unit for that shift. In which setting would the Laissez-Faire style of leadership work best? a. A busy intensive care unit b. A organization involved in long term nursing research c. A nursing home staffed mostly by ancillary health care workers d. An ambulance service staffed by paramedics b. A organization involved in long term nursing research A High Task - Low Relationship style of leadership is similar to what other style of leadership? a. Laissez-Faire b. Democratic c. Low Task - High Relationship d. Authoritarian d. Authoritarian Which skill would a good leader least likely have? a. Good listener b. Problem solver c. Quick decision maker d. Maintain convictions in the face of adversity c. Quick decision maker The nurse should evaluate results of which laboratory tests while caring for a client who has cirrhosis of the liver? Select all that apply. A.) Prothrombin time B.) Urinalysis C.) Serum lipase D.) Serum troponin E.) Serum albumin A.) Prothrombin time E.) Serum albumin Rationale: Many clotting factors are producedin hte liver, including fibrinogen (factorI), prothrombin (factor II), factor V, serum prothrombin conversion accelerator (factor VII), factor IX, and factor X. The client's ability to form these factors may be impaired with cirrhosis, putting the client at risk for bleeding. The prothrombin time will evaluate blood clotting ability. Urinalysis is a general screening measure or can be used to diagnose problems with the urinary tract. Serum lipase is a useful indicator of disorders of the pancreas. Serum torponin is a common laboratory test used to diagnose myocardial infarction. One function of the liver is to synthesize protein, which may be impaired with cirrhosis. The nurse caring for a client with hemolytic jaundice anticipates which findings on laboratory test results? A.) Elevated serum indirect bilirubin B.) Decreases serum protein C.) Elevated urine bilirubin D.) Decreased urine pH A.) Elevated serum indirect bilirubin Rationale: Hemolytic jaundice is caused by excessive breakdown of red blood cells and the amount of bilirubin produced exceeds the ability of the liver to conjugate it, so there is an increase in indirect bilirubin. Serum protein is not measured to detect hemolytic jaundice. Unconjugated bilirubin is insoluble in water and is not found in the urine. Urine pH is not deceased by hemolytic jaundice. Which assessments made by the nurse could indicate the development of portal hypertension in a client with cirrhosis? Select all that apply. A.) Hemorrhoids B.) Bleeding gums C.) Muscle wasting D.) Splenomegaly E.) Ascites A.) Hemorrhoids D.) Splenomegaly E.) Ascites Rationale: Obstruction to portal blood flow causes a rise in portal venous pressure resulting in splenomegaly, ascites, and dilation of collateral venous channels predominantly in the paraumbilical and hemorhoidal veins, the cardia of the stomach, and extending into the esophagus. Bleeding gums would indicate insufficient vitamin K production in the liver. Muscle wasting commonly accompanies the poor nutritional intake commonly seen in clients with cirrhosis. The nurse is caring for a client who has ascites, and the health care provider prescribes spironolactone. The client asks why this drug is being used. What is the best response by the nurse? A.) "This drug will help increase the level of protein in your blood." B.) "The drug will cause an increase in the amount of the hormone aldosterone your body produces." C.) "This medication is a diuretic but does not make the kidneys excrete potassium." D.) "This will help you excrete larger amounts of ammonia." C.) "This medication is a diuretic but does not make the kidneys excrete potassium." Rationale: Spironolactone is used in clients with ascites who show no improvement with bedrest and fluid restriction. It inhibits sodium reabosprtion in the distal tubule and promotes potassium retention by inhibiting aldosterone. Spironolactone does not increase protein levels in the blood. Spironolactone does not aid in excreting ammonia, although lactulose (Cephulac) will do this. When caring for a client who has cirrhosis, the nurse notices flapping tremors of the wrist and fingers. How should the nurse chart this finding? A.) "Trousseau's sign noted." B.) "Caput medusa noted." C.) "Fetor hepaticus noted." D.) "Asterixis noted." D.) "Asterixis noted." Rationale: Asterixis, also called liver flap, is the flapping tremor of the hands when the arms are extended. Trousseau's sign reflects hypocalcemia. Caput medusa refers to spider-like abdominal veins that are also commonly found in clients with cirrhosis who have portal hypertension as a complication. Fector hepaticus is a specific odor noted in liver failure. A client scheduled for discharge after coronary artery bypass grafting (CABG) reports a new onset of anorexia and nausea. The client's new medications include digoxin, metoprolol, and furosemide. The nurse plans to report this finding to the health care provider after checking the result of which laboratory test drawn earlier in the morning? A.) Potassium level B.) Sodium level C.) Creatinine kinsease level D.) Digoxin level D.) Digoxin level Rationale: Nausea and anorexia are signs of digitalis toxicity, making the digoxin level high priority for assessment. The potassium, sodium, and creatinine kinase levels would not explain the client's symptoms and therefore are not priorities to assess before telephoning the health care provider. A client is getting ready to go home after a myocardial infarction (MI). The client is asking questions about his medications, and wants to know why metoprolol was prescribed. The nurse's best response would be which of the following? A.) "Your heart was beating too slowly, and metoprolol increases your heart rate." B.) "Metoprolol helps to increase the blood supply to the heart by dilating your coronary arteries." C.) "Metoprolol helps make your heart beat stronger to supply more blood to your body." D.) "Metoprolol slows your heart rate and decreases the amount of work it has to do so it can heal." D.) "Metoprolol slows your heart rate and decreases the amount of work it has to do so it can heal." Rationale: Metoprolol (Lopressor) is a beta adrenergic blocker that slows the heart rate and decreases myocardial contractility. The nurse is caring for a client with atrial fibrillation. The nurse is administering digoxin, and is assessing the apical pulse. The nurse expects to hear which of the following types of rhythms? A.) A very rapid, regular rhythm B.) A regular rhythm with intermittent irregular beats C.) A rhythm that is irregularly irregular D.) A regular rhythm with intermittent pauses C.) A rhythm that is irregularly irregular Rationale: Atrial fibrillation is characterized by irregularly irregular QRS complexes and rhythm. There is no underlying regular rhythm with atrial fibrillation. A client on a telemetry monitor has a heart rate of 54 bpm. The nurse knows that this rate would probably not increase oxygen demand for the myocardium, but the rate is indicative of which of the following? A.) Tachycardia B.) Ventricular hypertrophy C.) Hypertension D.) Bradycardia D.) Bradycardia Rationale: Bradycardia decreases the myocardium's demand for oxygen by decreasing the workload of the heart. Heart rates less than 60 bpm are considered bradycardia. However, if the heart rate is too low, blood supply is decreased and oxygen supply may be hindered. The client with a diagnosis of anterior myocardial infarction (MI) begins to show dysrhythmias on the monitor. Which of the following most likely predisposes to dysrhythmia development with a myocardial infarction? A.) Respiratory alkalosis B.) Tissue ischemia C.) Hypokalemia D.) Digitalis toxicity B.) Tissue ischemia Rationale: The ischemia that causes the MI can also cause the heart muscle to become irritable and irritated cells fire early, causing dysrhythmias. Although hypokalemia and digoxin toxicity are true, nothing in the stem indicates that these are specific to this client. Acidosis is usually the shift with MI, if one occurs. The nurse has begun a continuous infusion of nitroglycerin intravenously. Which of the following indicates to the nurse that the client is experiencing an adverse reaction? A.) Pulmonary capillary wedge pressure (PCWP) falling from 13 to 11 mm Hg B.) Central venous pressure (CVP) falling from 10 to 7 mm Hg C.) Heart rate (HR) falling from 96 to 78 D.) Blood pressure (BP) falling from 130/80 to 90/64 D.) Blood pressure (BP) falling from 130/80 to 90/64 Rationale: Nitroglycerin is an antianginal of the nitrate type that causes vasodilation of coronary and other arteries. It would be expected to cause a decrease in PCWP and CVP. The heart rate could also decrease with overall improvement in cardiac output. A decrease in BP from 130/80 to 90/64 is excessive, and warrants further assessment by the nurse to determine whether perfusion to major organs is adequate. The nurse notes that the international normalized ratio (INR) of a client with aortic valve replacement taking sodium warfarin is 2.6. What action should the nurse take at this time? A.) Encourage the client to eat foods high in vitamin K. B.) Administer the daily dose of Coumadin as ordered. C.) Monitor the client closely for signs of a deep vein thrombosis. D.) Withhold the next scheduled dose of Coumadin, and notify the prescriber. B.) Administer the daily dose of Coumadin as ordered. Rationale: The usual therapeutic INR level during medication therapy with sodium warfarin (Coumadin) is 2-3. The next dose should be given as scheduled. The nurse is caring for a client who is being discharged after valve replacement surgery. The client has a new St. Jude Medical valve, and the nurse is reviewing the instructions for the client's follow-up care. The nurse determines that the client understands an important aspect of responsibility in the care of this valve when the client makes which of the following statements? A.) "I will take Coumadin for two months, and get my blood drawn every week until I stop taking it." B.) "I will remind the doctor to give me a prescription for anticoagulant medication every time I go to the dentist." C.) "I will need to take anticoagulant medication for the rest of my life." D.) "I won't take any anticoagulant medication or blood thinners because they could cause a problem with my new valve." C.) "I will need to take anticoagulant medication for the rest of my life." Rationale: St. Jude Medical is a mechanical valve. Lifelong anticoagulation therapy is required with this mechanical valve because there is a risk of thrombus formation. If a valve is replaced with a tissue valve, anticoagulation might be required during the immediate postoperative period, but not necessarily lifelong anticoagulation. It is recommended to take antibiotics prior to dental care. The nurse is caring for a client with new-onset atrial fibrillation. The nurse anticipates that which of the following is a possible treatment for this dysrhythmia when it first develops? A.) External pacemaker application B.) Insertion of automatic internal cardiac defibrillator (AICD) C.) Synchronized cardioversion D.) Defibrillation C.) Synchronized cardioversion Rationale: Synchronized cardioversion is most effective with new-onset atrial fibrillation. Pacemakers are indicated for heart block, AICDs are used for ventricular dysrhythmias, and defibrillation is indicated for ventricular fibrillation and pulseless ventricular tachycardia. The physician has prescribed propranolol for a client with frequent premature ventricular contractions (PVCs). The nurse collects material to conduct an education session with the client. Which of the following should the nurse plan to include in the teaching session? A.) A description of other effective medications B.) Information about side effects and adverse reactions C.) Material about the cellular effect of the medication D.) Data regarding various dysrhythmias B.) Information about side effects and adverse reactions Rationale: The medication has side effects that could be disturbing to the client. These include hypotension, insomnia, lethargy, bronchospasm, mood changes, and decreased libido. The client should be alert to these so that he can notify the health care provider. Which consideration by the nurse is of the highest priority when preparing to administer a medication to a client with cirrhosis? A.) Frequency of the medication B.) Purpose of the medication C.) Necessity of the medication D.) Metabolism of the medication D.) Metabolism of the medication Rationale: In cirrhosis, the liver cannot metabolize or biotransform medications as well because of scarring of liver tissue. Certain medications are metabolized primarily by the liver, while other medications are metabolized by other organs. Consideration should be made for each medicine ordered to avoid overburdening the liver. A client on the unit with hepatitis B suddenly develops anorexia, vomiting, abdominal pain, progressive jaundice, lethargy, and disorientation. The nurse interprets that these indicate which of the following? A.) Laënnec's cirrhosis B.) Fulminant hepatitis C.) Portal hypertension D.) Cancer of the liver B.) Fulminant hepatitis Rationale: A condition developing 6 to 8 weeks after initial symptoms in a client with hepatitis is fulminant hepatitis where there is necrosis and shrinking of the liver with possible liver damage. The symptoms are classic and the condition often leads to coma, possibly death. A client is admitted with dehydration secondary to prolonged nausea and vomiting. Which serum laboratory test results would the nurse expect to note as a result of the dehydration? Select all that apply. A.) Sodium 138 mEq/dL B.) Potassium 4.2 mEq/dL C.) Blood urea nitrogen (BUN) 30mg/dL D.) Hematocrit 49% E.) Total protein 6.8 mg/dL C.) Blood urea nitrogen (BUN) 30mg/dL D.) Hematocrit 49% Rationale: ~ The sodium is normal and would be more likely to be elevated from hemoconcentration with dehydration. ~ The potassium level is normal, and would most likely be lower because of losses from the vomiting. ~ Dehydration results in loss of fluids, causing a hemoconcentration of BUN, which is elevated. ~ The hematocrit would be elevated secondary to hemoconcentration from dehydration. ~ The total protein level is normal, and would not likely be influenced by dehydration. Diffuse fibrosis and conversion of normal liver tissue into abnormal nodules with fibrous bands describes the progression of which hepatic disorders? A.) Liver failure B.) Cirrhosis C.) Hepatitis A D.) Liver cancer B.) Cirrhosis Rationale: The process of cirrhosis involves fibrotic changes in the liver in which fibrous bands form nodules, which gives the liver a cobblestone appearance. Liver failure is a secondary condition. The process in hepatitis is more necrosis, hyperplasia, and inflammation. Liver cancer is the development of tumor cells. A 65-year-old female with a history of hepatic encephalopathy is hospitalized for pneumonia and dehydration. When she complains about the small portions of meat ordered by the dietitian, what is the the best response by the nurse? A.) "Ask your doctor about it in the morning." B.) "I will call and order larger portions for you." C.) "The amount of meat on your tray is dictated by certain blood test results." D.) "Your protein is being limited, but you can have more food from another group." D.) "Your protein is being limited, but you can have more food from another group." Rationale: The client is at increased risk for a return of encephalopathy because of the diagnosis of pneumonia and dehydration. She has volume depletion and the potential for electrolyte imbalance, both of which can contribute to the development of encephalopathy. Protein needs to be controlled to prevent this. The client has just had a liver biopsy. Which nursing action would be the priority after the biopsy? A.) Monitor pulse and blood pressure every 30 minutes until stable and then hourly for up to 24 hours. B.) Ambulate every 4 hours for the first day as long as client can tolerate this. C.) Measure urine specific gravity every 8 hours for the next 48 hours. D.) Maintain NPO status for 24 hours post-biopsy. A.) Monitor pulse and blood pressure every 30 minutes until stable and then hourly for up to 24 hours. Rationale: Complications of liver biopsy include hemorrhage or accidental penetration of biliary canniculi. The nurse should assess for signs of hemorrhage (increased pulse, decreased blood pressure) every 30 minutes for the first few hours and then hourly for 24 hours. A newly admitted client with cirrhosis of the liver has a distended abdomen and the umbilicus is protruding. The nurse interprets that what is the pathological basis for this sign? A.) Increased fluid intake resulting from excessive use of alcohol causing overhydration. B.) Increased size of the liver results in abdominal distension. C.) Hypoalbuminemia causes fluid to leave the vascular system and enter the peritoneal cavity. D.) Shunting of the blood to the collateral circulation in the esophagus results in decreased blood volume and accumulation of fluid. C.) Hypoalbuminemia causes fluid to leave the vascular system and enter the peritoneal cavity. Rationale: Low albumin in the blood causes a decrease in plasma colloidal osmotic pressure, causing fluid to escape into the extravascular compartment. The client who has liver disease asks the nurse why he bruises so easily. Which information should the nurse include in the response? A.) "Your liver is unable to make the proteins that are needed to make clotting factors." B.) "Your liver can no longer metabolize drugs and render them inactive." C.) "Your liver is breaking down blood cells too rapidly." D.) "Your liver can't store Vitamin C any longer." A.) "Your liver is unable to make the proteins that are needed to make clotting factors." Rationale: The liver synthesizes clotting factors I, II, VII, IX, and X as well as prothrombin and fibrinogen. These substances are needed for adequate clotting, so their reduction leads to increased risk of bleeding. In caring for a client with liver failure, the nurse explains that the pathophysiology of the disease causes which of the following? A.) Decreased serum creatinine B.) Increased red blood cells (RBCs) C.) Increased calcium D.) Increased ammonia D.) Increased ammonia Rationale: Increased ammonia occurs because the liver is unable to convert ammonia to urea. Calcium is probably decreased because of bedrest. Serum creatinine is probably increased because of impaired renal function; RBCs are probably decreased because of decreased production in the bone marrow. The nurse would anticipate that a client with cirrhosis of the liver would have increased levels of which laboratory values? Select all that apply. A.) Albumin B.) Bilirubin C.) Ammonia D.) Prothrombin time E.) Calcium B.) Bilirubin C.) Ammonia D.) Prothrombin time Rationale: ~ In cirrhosis, the damaged liver is unable to properly metabolize amino acids and synthesize albumin, resulting in decreased serum concentrations. ~ The cirrhotic liver is unable to completely break down bilirubin, and serum levels are elevated. ~ Ammonia is normally converted to urea in the liver; serum levels are increased with liver damage. ~ Prothrombin times are increased when the liver is unable to synthesize clotting factors. ~ Calcium levels should be unaffected by cirrhosis. A client with a diagnosis of cirrhosis of the liver and a history of alcohol abuse is admitted to the unit. The nurse knows that portal hypertension is a possible complication of this condition for which reason? A.) Hyponatremia and hypoproteinemia B.) Ecchymosis, edema, and jaundice C.) Fibrotic tissue from cell destruction D.) Development of esophageal varices C.) Fibrotic tissue from cell destruction Rationale: Portal hypertension develops as a result of development of fibrous bands, which develop following necrosis and regeneration of lung tissue. The other conditions are due to other changes in the liver as well as bleeding. Esophageal bleeding occurs as a result of portal hypertension, not just the opposite. The nurse notes that the physical assessment findings of spider angiomas, palmar erythema, peripheral edema, ascites, and change in mental status are consistent with which client disorder? A.) Cholelithiasis B.) Cholecystitis C.) Cirrhosis D.) Pancreatitis C.) Cirrhosis Rationale: Portal hypertension and liver cell failure contribute to the late manifestations of cirrhosis. Cholelithiasis and cholecystitis will be accompanied by pain, food intolerances and/or vomiting. Pancreatitis presents with pain radiating to the back, mild cardiovascular changes, and hypocalcemia. A client has been admitted to the hospital with chest pain. The pain has not been relieved after one dose of nitroglycerine (NTG) sublingually. Upon monitoring the vital signs (VS), the nurse notices that the blood pressure has dropped to 126/84 from 130/90. Which action should the nurse take next? A.) Notify the physician. B.) Obtain an electroencephalogram (EEG). C.) Give another dose of nitroglycerine. D.) Add a dose of nitroglycerine paste. C.) Give another dose of nitroglycerine. A client has an order to begin an IV nitroglycerin (Nitrostat) drip. What consideration should the nurse make in preparing to administer this medication? A.) Cover the solution with a plastic bag. B.) Maintain the solution in a glass bottle. C.) Replace the solution every 2 hours due to instability. D.) Prepare the solution under a laminar flow hood. B.) Maintain the solution in a glass bottle. A client has been exposed to hepatitis A. Which client factor would be an indication to the nurse for withholding administration of immune serum globulin to the client? A.) The client has received a hepatitis B vaccine. B.) The client has recently fallen and suffered a hip fracture. C.) The client has a history of a coagulation disorder. D.) The client is scheduled for foreign travel. C.) The client has a history of a coagulation disorder. Rationale: Immune serum globulin should not be administered to clients with a history of coagulation disorders. The nurse assesses a client taking cholestyramine (Questran) for signs of possible deficiency of which vitamins? A.) Niacin and thiamine B.) Folic acid and vitamin C C.) Vitamins A and D D.) Thiamine and cyanocobalamin C.) Vitamins A and D The nurse has given medication instructions to the client receiving nicardipine (Cardene) for angina. What statement by the client would indicate to the nurse that the teaching needs to be reinforced? A.) "I will keep track of angina episodes, and report them if they increase." B.) "Edema or weight gain are expected side effects of the medication." C.) "I will report a pulse rate of fewer than 50 beats per minute." D.) "I will take any missed dose as soon as remembered, unless it is almost time for the next dose." B.) "Edema or weight gain are expected side effects of the medication." After receiving digoxin 0.125 po daily for 5 days, the client exhibits visual disturbances and cardiac dysrhythmias. After administering digoxin immune fab (Digibind), the nurse should take which action? A.) Monitor serum digoxin at least 12 hrs later. B.) Monitor for hyperkalemia C.) Explain that the current symptoms will not be of further concern. D.) Monitor for allergic reaction D.) Monitor for allergic reaction A client is to begin weight-based intravenous heparin therapy for treatment of a deep vein thrombosis. The client's weight is 220 pounds. The client is to receive an infusion of 6 units per kilogram per hour. The intravenous heparin on hand contains 100 units per milliliter. The client will receive _________ mL of heparin per hour. Record your answer as a whole number. 6 mL of heparin per hour Rationale: The key to answering the question on weight-based heparin is to identify the infusion rate, which is 6 units per kilogram per hour. Thus, to accurately obtain the information, the weight must be converted from pounds to kilograms. There are 2.2 pounds per kilogram. To convert this amount into milliliters, it is necessary to identify how many units are in each milliliter of available solution. Select all that apply. Select the key behaviors of successful leaders and managers. a. Chooses one person in the work group to rely on b. Acknowledges good work and success c. Provides individuals with more difficult challenges d. Resolves conflicts before they get out of control e. Keeps good records of all the mistakes individuals in the group make f. Maintains a highly competitive environment b. Acknowledges good work and success c. Provides individuals with more difficult challenges d. Resolves conflicts before they get out of control Identify the quality that a good follower would least likely display. a. Criticizes the leader b. Think outside the box c. Is always compliant and obedient d. Questions the leader c. Is always compliant and obedient How can leaders better understand their effectiveness by using information from their followers? a. How do the followers view themselves in the organizational structure? b. Followers believe they have little power over decisions that are made? c. How do the followers view the mistakes the leader makes? d. How submissive are the followers to the leader? a. How do the followers view themselves in the organizational structure? True or False Management and leadership are the same thing. False Trait Theory • Trait Theory o The trait theory identifies qualities that are common to effective leaders. o Trait theory by itself is limited because it focuses only on the traits of the individual and does not take into account how the person acts in specific situations. o Leadership Traits ~ High level of intelligence and skill ~ Self-motivation and initiative ~ Ability to communicate well ~ Self-confidence and assertiveness ~ Creativity ~ Persistence ~ Stress tolerance ~ Willingness to take risks ~Ability to accept criticism Leadership-Style Theory • Leadership-Style Theory o A continuum of leadership style that ranges from a mostly passive approach to a highly controlling one. ~ Laissez-faire ~ Democratic - The democratic leadership style is based on four beliefs: 1. Every member of the group needs to participate in all decision-making. 2. Within the limits established by the group, freedom of expression is allowed to maximize creativity. 3. Individuals in the group accept responsibility for themselves and for the welfare of the whole group. 4. Each member must respect all the other members of the group as unique and valuable contributors. ~ Authoritarian You are a charge nurse on the medical-surgical unit. You are expecting 4 admissions. Which patient will you assign to the room directly across from the nurses' station? A.) The patient admitted with diverticulitis. B.) The patient admitted with unrelenting migraine headaches. C.) The patient admitted after a fall who has a history of dementia and wandering. D.) The patient who had a right total knee replacement done this morning. C.) The patient admitted after a fall who has a history of dementia and wandering. Which of the following is an example of collective power? a. Informing legislators about issues that affect health and nursing. b. Organizing a large group of individuals who have similar beliefs and concerns. c. Working through professional organizations to increase individual accountability. d. Demonstrating that they are professionals dedicated to a career. b. Organizing a large group of individuals who have similar beliefs and concerns. Sources of Power Define: ~ Referent Power ~ Expert Power ~ Reward Power ~ Coercive Power ~ Legitimate Power ~ Collective Power • The following list includes some of the more accessible and acceptable sources of power that nurses should consider using in their practice: o Referent (Close Personal Relationships) ~ The referent source of power depends on establishing and maintaining a close personal relationship with someone. In any close personal relationship, one individual often will do something he or she would really rather not do because of the relationship. This ability to change the actions of another is an exercise of power. o Expert (Knowledge) ~ The expert source of power derives from the amount of knowledge, skill, or expertise that an individual or group has. This power source is exercised by the individual or group when knowledge, skills, or expertise is either used or withheld in order to influence the behavior of others. o Reward ~ The reward source of power depends on the ability of one person to grant another some type of reward for specific behaviors or changes in behavior. o Coercive ~ The coercive source of power is the flip side of the reward source. The ability to reprimand, withhold rewards, and threaten punishment is the key element underlying the coercive source of power. o Legitimate (Legal Act) ~ The legitimate source of power depends on a legislative or legal act that gives the individual or organization a right to make decisions that they might not otherwise have the authority to make. o Collective (Use of Media) ~ The collective source of power is often used in a broader context than individual client care and is the underlying source for many other sources of power. When a large group of individuals who have similar beliefs, desires, or needs become organized, a collective source of power exists. A nurse in an outpatient clinic is returning phone calls that have been made to the clinic. Which client call should have the highest priority? A.) The client with diabetes who states "I am starting to have breakdown on one of my heels." B.) The client who received an upper extremity cast yesterday reports, "I can't feel my fingers in my right hand today." C.) A client reports, "I fell and hurt my ankle yesterday and today it is very swollen." D.) A client reports, "My knee is still hurting from the total knee repair I had two weeks ago." B.) The client who received an upper extremity cast yesterday reports, "I can't feel my fingers in my right hand today." The nurse just finished receiving the morning change-of-shift report. Which client should the nurse assess first? A.) The client diagnosed with pneumonia who continues to have bilateral crackles. B.) The client on strict bed rest who is now complaining of calf pain. C.) The client who complains of back pain after being in the chair for several hours. D.) The client who is very angry because he needs to have more blood drawn due to a lab error. B.) The client on strict bed rest who is now complaining of calf pain. Care Delivery Models Describe: ~ Functional Nursing ~ Team Nursing ~ Primary Care Nursing ~ Modular Nursing • Functional o Nurses are Called ~ Charge Nurse ~ Medical Nurse ~ Treatment Nurse o Description ~ Nurses are assigned to specific tasks rather than specific clients o Where Model is Used ~ Hospitals ~ Nursing Homes ~ Nurse Consultants ~ Operating Rooms • Team o Nurses are Called ~ Team Leader ~ Team Member o Description ~ Nursing staff members are divided into small groups responsible for the total care of a given number of clients. o Where Model is Used ~ Hospitals ~ Nursing Homes ~ Home Care ~ Hospice • Primary Care o Nurses are Called ~ Primary Nurse ~ Associate Nurse o Description ~ Nurses are designated either as the primary nurse responsible for clients' care or as the associate nurse who assists in carrying out the care o Where Model is Used ~ Hospitals ~ Specialty Units ~ Dialysis ~ Home Care • Modular o Nurses are Called ~ Care Pair o Description ~ Nurses are paired with less-trained caregivers. Generally involves cross-training of personnel. o Where Model is Used ~ Hospitals ~ Home Health Care ~ Transport Teams When providing discharge teaching to a client with chronic cirrhosis, the client's partner asks why there is so much emphasis on bleeding precautions. What is the most appropriate response? A.) "The liver affected by cirrhosis is unable to produce sufficient clotting factors." B.) "The low protein diet will result in reduced clotting factors." C.) "The increased production of bile decreases clotting factors." D.) "The required medications reduce clotting factors." A.) "The liver affected by cirrhosis is unable to produce sufficient clotting factors." Rationale: When bile production is reduced, the body has reduced ability to absorb fat-soluble vitamins. Without adequate Vitamin K absorption, clotting factors II, VII, IX, and X are not produced in sufficient amounts. The client with cirrhosis of the liver asks the nurse why he has edema. The nurse would use which statement to explain how edema results from pathophysiologic changes in cirrhosis? A.) "The edema occurs because your liver produces fewer proteins that help draw fluid into the blood stream." B.) "The high osmotic pressure of proteins in your blood pushes fluid into body tissues." C.) "Because of the liver disease, the kidneys are able to filter less fluid, so the body cannot excrete it as urine very easily." D.) "Your body is metabolizing sex hormones more quickly, leading to fluid retention." A.) "The edema occurs because your liver produces fewer proteins that help draw fluid into the blood stream." The nurse interprets that which of the following clients is most likely to acquire hepatitis? A.) A child with a bacterial infection B.) A client with dysfunction of the biliary system C.) A client with metastasis of liver cancer D.) An adult with varicella zoster D.) An adult with varicella zoster Rationale: Although hepatitis is associated with cholestasis, the most likely candidate would be someone with a viral infection. Other causes include alcohol, toxins, and severe hepatocellular damage. In caring for a client recovering from hepatitis A, who is no longer infectious and has no hepatic encephalopathy, which meal would the nurse consider to be most appropriate? A.) Pancakes, poached eggs, orange juice, coffee (breakfast) B.) Fried chicken, potatoes and gravy, green beans (noon) C.) Enchiladas, tortillas, chips, salsa (evening) D.) Salami sandwich, French fries, ketchup, coca cola (evening) A.) Pancakes, poached eggs, orange juice, coffee (breakfast) Rationale: If there are no complications, it is better to give high-calorie and high-protein food items early in the morning before developing nausea. Decreased excretion of bilirubin would probably be attributed to which of the following? A.) A blood transfusion reaction B.)Hemolytic anemia C.) An obstructed common bile duct D.) An obstructed pancreatic duct C.) An obstructed common bile duct Rationale: Obstruction of the common bile duct interferes with movement of the bile so that it cannot be excreted. When completing discharge teaching for a client who has cirrhosis and ascites, the nurse should instruct the client to avoid which food used by the client as a snack? A.) Whole wheat bread B.) Cookies C.) Potato chips D.) Hard candy C.) Potato chips Rationale: A low-sodium diet is recommended for clients who have cirrhosis and ascites. Potato chips are high in sodium. Which of the following findings would strongly indicate the possibility of cirrhosis? A.) Dry skin B.) Hepatomegaly C.) Peripheral edema D.) Pruritus B.) Hepatomegaly The client is exposed to hepatitis A. When teaching this client about infection control, the nurse explains that the client is most infectious to others at which of these times? A.) 7 days after exposure B.) 10 days before the onset of symptoms C.) 2 months after exposure D.) 14 days after symptoms begin B.) 10 days before the onset of symptoms In reviewing the possible causes of hepatitis A in a 22-year-old male, which of the following would be the most likely factor? A.) Contact with blood in his profession as a policeman B.) Receiving a blood transfusion during surgery C.) Eating shrimp at the local pub D.) Admitting to being sexually active C.) Eating shrimp at the local pub Rationale: Hepatitis A is transmitted by fecal-oral route. The virus is excreted in oropharyngeal secretions (nose and throat) and transmitted by direct contact of person-to-person, or by fecal contamination of food or water. A worker at the pub could have hepatitis A and transfer it to the food that is being prepared. Hepatic fat accumulation in a 55-year-old man is usually a result of which type of cirrhosis? A.) Biliary B.) Metabolic C.) Postnecrotic D.) Laënnec's D.) Laënnec's A client presents to the emergency department with a stab wound to the right upper abdominal quadrant. The client's vital signs are BP 85/60, pulse 125, and respiratory rate of 28 breaths/minute. The nurse should immediately suspect damage to what organ? A.) Stomach B.) Liver C.) Large intestine D.) Kidney B.) Liver Rationale: The primary organ in the right upper quadrant of the abdominal cavity is the liver. Because of the early shock symptoms, which are presented, it would be expected that this organ has possibly been lacerated, causing extensive uncontrolled internal bleeding. Which statement is true regarding viral hepatitis infection? A.) Hepatitis B is transmitted by the fecal-oral route. B.) Hepatitis A is a sexually transmitted disease. C.) The posticteric phase follows jaundice and lasts several weeks. D.) Hepatitis D has a slow onset. C.) The posticteric phase follows jaundice and lasts several weeks. A client taking digoxin along with amphotericin B (Fungizone) could experience digitalis toxicity due to which of the following? A.) Hypokalemia B.) Antifungal attaching to receptors before digoxin C.) Increased plasma concentration of amphotericin B D.) Increased gastrointestinal absorption of digoxin and amphotericin B A.) Hypokalemia The nurse would assess a client receiving a nonselective beta blocker for development of which of the following complications related to drug therapy? A.) Hyperlipidemia B.) Decreased liver enzymes C.) Hypoglycemia D.) Increased BUN A.) Hyperlipidemia A client who has multiple sclerosis and receives cyclophosphamide (Cytoxan) and digoxin (Lanoxin) reports nausea. The nurse would place highest priority on which of the following actions? A.) Evaluate the cyclophosphamide level. B.) Administer an oral anti-emetic daily. C.) Provide six small, frequent meals. D.) Evaluate the digoxin level. D.) Evaluate the digoxin level. Rationale: Cyclophosphamide (Cytoxan) combined with digoxin (Lanoxin) can result in digoxin toxicity, so the health care team must continually assess for signs and symptoms of toxicity. Nausea is an early sign of digoxin toxicity. The nurse has received preoperative medications from the pharmacy for an adult male is scheduled for a coronary artery bypass graft. Which nursing action is a priority in administering these drugs? A.) Checking the gag reflex B.) Obtaining consent from the client C.) Checking the allergy history D.) Asking the family to leave the room C.) Checking the allergy history Rationale: Checking the allergy history is important so that potentially fatal reactions do not occur. A client with advanced liver disease is being treated with antibiotics for a respiratory infection. The nurse should assess the client for which of the following? A.) High risk for allergy to drugs B.) Teratogenic effects of antibiotics C.) Symptoms of drug toxicity D.) Drug dependence C.) Symptoms of drug toxicity