Nursing Health Care

Nursing Health Care 1. Parents of a toddler tell the nurse that their child eats little at mealtime, sits at the table with the family only briefly, and wants snacks all the time. What recommendation should the nurse provide? A) Give the toddler nutritious snacks. Feedback: CORRECT B) Offer rewards for eating at mealtimes. Feedback: INCORRECT C) Avoid snacks so the child is hungry at mealtimes. Feedback: INCORRECT D) Explain to the child in a firm manner what is expected. Feedback: INCORRECT Feedback: CORRECT At approximately 18 months of age, most toddlers manifest lower nutritional need and decreased appetite, a phenomenon known as physiologic anorexia which is often manifested as a picky, fussy eater with strong taste preferences, and erratic eating patterns. Toddlers are learning to differentiate self and social boundaries and may be disruptive while sitting at the table, so offering nutritious finger foods (A) is a good way to ensure proper nutrition during this stage. Although rewards (B) act as reinforcers, children may eat for nonnutritive reasons, which may affect subsequent eating habits. (C) does not ensure that the toddler will eat at mealtime. Explanations about expectations (D) are ineffective at this age. Category: Pediatrics Points Earned: 1.0/1.0 Correct Answer(s): A 2. The nurse is informed that a client is returning to the unit from the post-anesthesia care unit following abdominal surgery. Which task is best to delegate to the unlicensed assistive personnel (UAP)? A) Assess breathing pattern after transport is completed. Feedback: INCORRECT B) Notify the family that the client is returning from surgery. Feedback: INCORRECT C) Report to the charge nurse the appearance of the dressing. Feedback: INCORRECT D) Assist the transport team with transferring the client to the bed. Feedback: CORRECT Feedback: CORRECT The UAP can be assigned to assist with transferring the client from the gurney to the bed (D) since repositioning following abdominal surgery is not a high-risk intervention and does not require nursing judgment. (A) requires judgment and should be performed by a licensed person. (B) should be done by the nurse who may provide additional information if requested. The nurse should directly observe the dressing (C) and should not rely on the UAP's assessment of the dressing's appearance. Category: Management Points Earned: 1.0/1.0 Correct Answer(s): D 3. A nurse who adheres to the belief that life is sacred should be able to establish a therapeutic relationship most effectively with which client? A) A terminally ill and depressed client with cancer. Feedback: CORRECT B) A client who is planning to have an elective abortion. Feedback: INCORRECT C) A suicidal client who has made a highly-lethal attempt. Feedback: INCORRECT D) A client who refuses a blood transfusion due to religious beliefs. Feedback: INCORRECT Feedback: INCORRECT A nurse who believes in the sanctity of life may find it difficult to relate to individuals who do not place the same high level of value on life. Clients with cancer, who have not made a conscious decision to end their lives, are most likely to be easily understood by this nurse (A). The clients in (B, C, and D) have exhibited behaviors contrary to the nurse's beliefs, and it may be more difficult for this nurse to empathize with their situation. Category: Psychiatric Mental Health Points Earned: 0.0/1.0 Correct Answer(s): A 4. A staff member tells the charge nurse that a float nurse assigned to work on the unit has made several medication errors in the past, but is currently working with the education department to improve this skill. What action is best for the charge nurse to take? A) Dismiss the staff nurse's report about the float nurse because it may be just gossip. Feedback: INCORRECT B) Call the nursing supervisor and request a different employee be sent to the unit. Feedback: INCORRECT C) Assign the float nurse to function as a UAP for the day. Feedback: INCORRECT D) Arrange for someone to be available to assess and assist the float nurse. Feedback: CORRECT Feedback: CORRECT The float nurse is receiving education, but careful assessment of her/his skills and assistance, as needed, is still warranted, so (D) is the best choice. Though the staff member's report may indeed be gossip, failure to pay attention to the information could constitute negligence on the part of the charge nurse (A). (B) is not the best way to manage the unit. (C) is not the best use of a licensed person, and would also eliminate the float nurse's opportunity to improve medication administration skills. Category: Management Points Earned: 1.0/1.0 Correct Answer(s): D 5. An older adult client begins wearing binaural hearing aids due to presbycusis. Which instruction should the nurse provide to assist the client in adapting to the new hearing aids? A) Begin wearing the aids in quiet environments to experiment with adjustments. Feedback: CORRECT B) Wear the hearing aids for an hour a day at first, gradually increasing the time. Feedback: INCORRECT C) Keep the volume on low until the conditions with noises are audible. Feedback: INCORRECT D) Use one hearing aid until comfortable, then add the second aid. Feedback: INCORRECT Feedback: INCORRECT Initially, the use of hearing aids should be restricted to quiet situations in the home (A). As adjustments occur, the client should gradually be exposed to conditions with background noise and the outdoors. Time restriction (B) is not necessary. (C and D) do not help the client adjust as well as gradually introducing various sound conditions. Category: Medical-Surgical Points Earned: 0.0/1.0 Correct Answer(s): A 6. The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan? A) Hand washing prior to preparation of the injection. Feedback: INCORRECT B) Method used to aspirate medication from a vial. Feedback: CORRECT C) Selection and rotation of injection sites. Feedback: INCORRECT D) Proper disposal of injection equipment. Feedback: INCORRECT Feedback: CORRECT To maintain sterility of the procedure, the most important factor to include in the teaching plan is how to manipulate the syringe parts so that the medication maintains sterility during the preparation and administration (B). (A, C, and D) are teaching topics, but are not components of maintaining sterile technique while administering an injection. Category: Fundamentals Points Earned: 1.0/1.0 Correct Answer(s): B 7. A client is transferred to the postoperative unit after 2 hours in the postanesthesia care unit (PACU). What is the priority nursing action? A) Determine the client's pain. Feedback: INCORRECT B) Take the client's vital signs. Feedback: CORRECT C) Calculate the IV infusion rate. Feedback: INCORRECT D) Check the postop prescriptions. Feedback: INCORRECT Feedback: CORRECT After the client is transferred from the PACU stretcher to the hospital bed and the PACU nurse reports the client's condition, the client's vital signs should be obtained first (B), so a change in the client's status can be determined. Vital sign changes are a primary indicator of cardiopulmonary complications and bleeding in the first hours postoperatively. Then, (A, C, and D) should be implemented. Category: Medical- Surgical Points Earned: 1.0/1.0 Correct Answer(s): B 8. A client who delivered a 9 pound 2 ounce infant 3 hours ago is experiencing uterine atony. Which action should the nurse implement first? A) Massage the fundus. Feedback: CORRECT B) Catheterize the bladder. Feedback: INCORRECT C) Establish venous access. Feedback: INCORRECT D) Prep for surgical intervention. Feedback: INCORRECT Feedback: CORRECT The initial management for uterine atony is fundal massage (A) to prevent postpartum hemorrhage. (B and D) are actions that can be implemented if fundal massage is unsuccessful. A client who is 3-hours post-delivery usually has IV fluids infusing, so the venous access (C) may only need to be assessed. Category: Maternity Points Earned: 1.0/1.0 Correct Answer(s): A 9. A client has a precipitous delivery attended only by the nurse. What nursing intervention has the highest priority? A) Ensure an adequate airway in the newborn. Feedback: CORRECT B) Massage the uterine fundus until it is firm. Feedback: INCORRECT C) Clamp and cut the umbilical cord. Feedback: INCORRECT D) Assess for signs of placental detachment. Feedback: INCORRECT Feedback: CORRECT Ensuring an adequate airway in the newborn (A) is the priority. (B, C and D) can be delayed until this is accomplished. Category: Maternity Points Earned: 1.0/1.0 Correct Answer(s): A 10. A healthcare provider tells the nurse that a certain medication will be prescribed for a client. After the prescription is written, the nurse notes that the provider has prescribed another medication that sounds similar to the medication that the provider and nurse originally discussed. What action should the nurse implement? A) Write the correct prescription as a verbal order received from the healthcare provider. Feedback: INCORRECT B) Correct the misspelled medication in the written prescription and initial the change. Feedback: INCORRECT C) Consult with the pharmacist to determine the best medication for the client. Feedback: INCORRECT D) Contact the healthcare provider to clarify the prescription intended for the client. Feedback: CORRECT Feedback: CORRECT Since the nurse received contradictory information, the provider should be contacted (D) to clarify the intended prescription. (A) may result in a medication error. The nurse does not have the authority to alter prescriptions (B). The pharmacist (C) cannot determine the best medication for a client. Category: Fundamentals Points Earned: 1.0/1.0 Correct Answer(s): D 11. A client with a markedly distended bladder is diagnosed with hydronephrosis and left hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650 ml. This finding supports which pathophysiological cause of the client's urinary tract obstruction? A) Obstruction at the urinary bladder neck. Feedback: CORRECT B) Ureteral calculi obstruction. Feedback: INCORRECT C) Ureteropelvic junction stricture. Feedback: INCORRECT D) Partial post-renal obstruction due to ureteral stricture. Feedback: INCORRECT Feedback: CORRECT Hydroureter (dilation of the renal pelvis), vesicoureteral reflux (backward movement of urine from the lower to upper urinary tracts), and hydronephrosis (dilation or enlargement of the renal pelvis and calyces) result from post-renal obstruction which can consequently result in chronic pyelonephritis and renal atrophy. Ascending urinary reflux occurs when normal ureteral peristaltic pressure is met with an increase in urinary pressure occurring during bladder filling if the urinary bladder neck is obstructed (A). A large residual urine does not occur with (B, C, and D) because the urine can not get to the bladder. Category: Medical-Surgical Points Earned: 1.0/1.0 Correct Answer(s): A 12. Which client requires the most immediate intervention by the nurse? A) A client with low back pain who is experiencing tolerance to the effects of an analgesic. Feedback: INCORRECT B) An adolescent with a history of drug addiction who is requesting a sedative. Feedback: INCORRECT C) A client with a chronic renal disease who is demonstrating a therapeutic response to a diuretic. Feedback: INCORRECT D) A young adult who is reporting an anaphylactic response to an antibiotic. Feedback: CORRECT Feedback: CORRECT An anaphylactic response (D) is a severe allergic reaction that may result in airway constriction and shock, so the nurse should first respond to this potentially life- threatening situation. Drug tolerance (A) occurs when there is a decreased physiological response after repeated administration of a drug, so the client may be experiencing pain, but this is of less priority than (D). Possible drug-seeking behaviors (B) and diuresis, the therapeutic response to a diuretic (C), require intervention by the nurse but are of less priority than (D). Category: Pharmacology Points Earned: 1.0/1.0 Correct Answer(s): D 13. The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? A) Use an electronic sphygmomanometer to take the BP every 30 minutes. Feedback: INCORRECT B) Retake the blood pressure in the same arm, deflating the cuff slowly. Feedback: CORRECT C) Ask another nurse to recheck the blood pressure to compare results. Feedback: INCORRECT D) Obtain another blood pressure cuff and retake the blood pressure. Feedback: INCORRECT Feedback: INCORRECT The nurse should first retake the blood pressure in the right arm, deflating the cuff more slowly (B), because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. There is no indication that the BP needs to be taken frequently (A). If the blood pressure remains low, further assessment is needed, which may include (C). If deflating the cuff slowly does not resolve the discrepancy, the nurse may then need to implement (D). Category: Fundamentals Points Earned: 0.0/1.0 Correct Answer(s): B