Module 10 Exam Saunders
A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor
screen. What does the nurse immediately do?
a. Call a code
b. Assess the client
c. Check the cardiac leads and wires
d. Obtain a rhythm strip from the monitor device - ANS-Assess the client
Rationale: If a monitor alarm sounds, the nurse should immediately assess the
clinical status of the client to see whether the problem is an actual dysrhythmia or a
malfunction of the monitoring system. Asystole should not be mistaken for an
unattached electrocardiogram wire. If the client is alert and the client's status is
stable, the problem is likely an unattached cardiac lead or wire. Calling a code and
obtaining a rhythm strip from the monitor device are unnecessary if the client's
condition is stable.
\A child with a diagnosis of pertussis (whooping cough) is being admitted to the
pediatric unit. As soon as the child arrives at the unit, what should the nurse do first?
a. Weigh the child
b. Take the child's temperature
c. Attach the child to a pulse oximeter
d. Administer the prescribed antibiotic - ANS-Attach the child to a pulse oximeter
Rationale: To adequately determine whether the child is getting enough oxygen, the
nurse attaches the child to a pulse oximeter. The pulse oximeter will then provide
ongoing information on the child's oxygen level. The child is also immediately
attached to a cardiorespiratory monitor to provide early identification of periods of
apnea and bradycardia. Next, the nurse performs an assessment, including the
child's temperature and weight, and asks the parents about the child. An antibiotic
may be prescribed, but the child's airway status must be assessed first.
\A client arrives at the emergency department with reports of a headache, hives,
itching, and difficulty swallowing. The client states that he/she took ibuprofen 1 hour
earlier and believes that he/she is experiencing an allergic reaction to this
medication. After ensuring that the client has a patent airway, which intervention
does the nurse prepare the client for first?
a. Administration of normal saline solution
b. Administration of an intravenous (IV) glucocorticoid
c. Administration of pain medication to relieve the client's headache
,d. Administration of a subcutaneous injection of epinephrine - ANS-Administration of
a subcutaneous injection of epinephrine
Rationale: Once airway has been established, the client would first be given
subcutaneous epinephrine. IV corticosteroids and IV fluids may also be prescribed.
Pain medication may or may not be prescribed.
\A client arrives in the emergency department for treatment of a surface injury
sustained when sand blew into the eye. Which action does the nurse take first?
Assessing the client's vision
Placing ice on the eye
Removing the sand particles
Irrigating the eye with sterile saline solution - ANS-Assessing the client's vision
Rationale: When a client has sustained a surface injury of the eye as a result of the
introduction of a foreign body, the nurse must first assess visual acuity. The eye is
then assessed for corneal abrasions; this is followed by irrigation with sterile normal
saline solution to gently remove the particles. Ice would be placed on the eye if the
client had sustained an eye contusion.
\A client has an arteriovenous fistula in place for hemodialysis. What should the
nurse do to assess the patency of the fistula?
a. Irrigate the fistula with 3 mL of normal saline solution
b. Infuse 50 mL of normal saline once per 24 hours
c. Palpate for a vibrating sensation at the fistula site
d. Flush the fistula with 1 mL of heparin solution once per shift - ANS-Palpate for a
vibrating sensation at the fistula site
Rationale: An arteriovenous fistula is created in a surgical procedure in which an
anastomosis is created between an artery and a vein in the arm in an end-to-side,
side-to-side, side-to-end, or end-to-end fashion. In a patent fistula (or graft), a "thrill,"
or vibrating sensation, should be palpable and a bruit should be audible with a
stethoscope. An arteriovenous fistula is the client's lifeline, and the nurse does not
irrigate or infuse solutions into it. It is used only for hemodialysis.
\A client has just had a plaster leg cast applied, and the nurse has given the client
instructions on cast care. Which statement by the client indicates the need for further
instruction?
a. "I may feel cool while the cast is drying."
b. "I shouldn't use anything to scratch underneath the cast."
c. "If I smell any odor from the cast, I should call the doctor."
d. "I can dry the cast faster if I use a hairdryer on the hot setting." - ANS-"I can dry
the cast faster if I use a hairdryer on the hot setting."
,Rationale: Using a blow dryer on the hot setting to dry the cast is not advised
because it may burn the client's skin under the cast and crack the cast. While the
cast is still damp, the client may feel cold and may experience a decrease in body
temperature. The client should never insert any item under the cast because of the
risk skin compromise. An odor coming from the cast could indicate the presence of
infection, warranting health care provider notification.
\A client has undergone creation of an Indiana pouch for urine diversion after
cystectomy, and the nurse provides instructions about reservoir catheterization.
What does the nurse tell the client?
a. To plan to drain the reservoir every 2 to 3 hours initially
b. That if mucus drains from the reservoir the primary health care provider should be
contacted
c. That sometimes force is needed to insert the catheter into the reservoir
d. To obtain 26F catheters from the medical supply store for the irrigations - ANS-To
plan to drain the reservoir every 2 to 3 hours initially
Rationale: An Indiana pouch is a continent internal ileal reservoir, and the nurse
instructs the client in the technique of catheterization. Initially the client drains the
reservoir every 2 to 3 hours. Each week thereafter, the interval is increased by 1
hour until finally catheterization is completed every 4 to 6 hours during the day. The
catheter is never forced into the reservoir. If resistance is met, the client is instructed
to pause and apply only gentle pressure while slightly rotating the catheter. A 16F to
20F catheter is used; 26F is too large and could damage the reservoir. Mucus is
expected, and the client is instructed to irrigate the reservoir with 50 to 60 mL of
normal saline solution to prevent excessive mucus buildup
\A client in the third trimester of pregnancy is experiencing painless vaginal bleeding,
and placenta previa is suspected. For which intervention does the nurse prepare the
client?
a. An ultrasound examination
b. Internal fetal monitoring
c. Administration of oxytocin
d. A manual (digital) pelvic examination - ANS-An ultrasound examination
Rationale: A manual pelvic examination or any action that would stimulate uterine
activity is contraindicated when vaginal bleeding is apparent in the third trimester
until a diagnosis is made and placental previa is ruled out. Digital examination of the
cervix can lead to maternal and fetal hemorrhage. A diagnosis of placental previa is
made with the use of ultrasound. Electronic fetal monitoring (external) is crucial in
evaluating the status of the fetus that is at risk for severe hypoxia, but internal fetal
monitoring is contraindicated. Oxytocin would stimulate uterine contractions and is
therefore contraindicated.
, \A client is found to have AIDS. What is the nurse's highest priority in providing care
to this client?
a. Providing emotional support to the client
b. Discussing the cause of AIDS with the client
c. Instituting measures to prevent infection in the client
d. Identifying risk factors related to contracting AIDS with the client - ANS-Instituting
measures to prevent infection in the client
Rationale: The client with AIDS has inadequate immune bodies and is at risk for
infection. The highest priority nursing intervention is protecting the client from
infection. The nurse would also provide emotional support to the client. Discussing
the cause of AIDS and the ways in which AIDS is contracted are not priority
interventions.
\A client is found to have viral hepatitis, and the nurse provides home care
instructions to the client. What should the nurse tell the client to do?
a. Maintain strict bed rest
b. Limit the intake of alcohol
c. Take acetaminophen for discomfort
d. Eat small frequent meals that are low in fat and protein and high in carbohydrates
- ANS-Eat small frequent meals that are low in fat and protein and high in
carbohydrates
Rationale: Fatigue is a normal response to hepatic cellular damage. During the acute
stage, rest is an essential intervention to reduce metabolic demand on the liver and
increase its blood supply, but strict bed rest is unnecessary. The client should avoid
taking medications, including acetaminophen (which is hepatotoxic), unless they are
prescribed by the primary health care provider. The client must avoid all alcohol
consumption. The client should consume small frequent meals that are low in fat and
protein and high in carbohydrates to reduce the workload of the liver.
\A client is transported to the recovery area of the ambulatory care unit after cataract
surgery. In which position does the nurse place the client?
Supine
Semi-Fowler
On the side that has undergone surgery
Prone on the side that has undergone surgery - ANS-Semi-Fowler
Rationale: After cataract extraction surgery, the client should be placed in the
semi-Fowler position or on the unaffected side to prevent edema at the surgical site.
Supine, on the affected side, and prone are all incorrect because they will result in
increased edema at the site.
A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor
screen. What does the nurse immediately do?
a. Call a code
b. Assess the client
c. Check the cardiac leads and wires
d. Obtain a rhythm strip from the monitor device - ANS-Assess the client
Rationale: If a monitor alarm sounds, the nurse should immediately assess the
clinical status of the client to see whether the problem is an actual dysrhythmia or a
malfunction of the monitoring system. Asystole should not be mistaken for an
unattached electrocardiogram wire. If the client is alert and the client's status is
stable, the problem is likely an unattached cardiac lead or wire. Calling a code and
obtaining a rhythm strip from the monitor device are unnecessary if the client's
condition is stable.
\A child with a diagnosis of pertussis (whooping cough) is being admitted to the
pediatric unit. As soon as the child arrives at the unit, what should the nurse do first?
a. Weigh the child
b. Take the child's temperature
c. Attach the child to a pulse oximeter
d. Administer the prescribed antibiotic - ANS-Attach the child to a pulse oximeter
Rationale: To adequately determine whether the child is getting enough oxygen, the
nurse attaches the child to a pulse oximeter. The pulse oximeter will then provide
ongoing information on the child's oxygen level. The child is also immediately
attached to a cardiorespiratory monitor to provide early identification of periods of
apnea and bradycardia. Next, the nurse performs an assessment, including the
child's temperature and weight, and asks the parents about the child. An antibiotic
may be prescribed, but the child's airway status must be assessed first.
\A client arrives at the emergency department with reports of a headache, hives,
itching, and difficulty swallowing. The client states that he/she took ibuprofen 1 hour
earlier and believes that he/she is experiencing an allergic reaction to this
medication. After ensuring that the client has a patent airway, which intervention
does the nurse prepare the client for first?
a. Administration of normal saline solution
b. Administration of an intravenous (IV) glucocorticoid
c. Administration of pain medication to relieve the client's headache
,d. Administration of a subcutaneous injection of epinephrine - ANS-Administration of
a subcutaneous injection of epinephrine
Rationale: Once airway has been established, the client would first be given
subcutaneous epinephrine. IV corticosteroids and IV fluids may also be prescribed.
Pain medication may or may not be prescribed.
\A client arrives in the emergency department for treatment of a surface injury
sustained when sand blew into the eye. Which action does the nurse take first?
Assessing the client's vision
Placing ice on the eye
Removing the sand particles
Irrigating the eye with sterile saline solution - ANS-Assessing the client's vision
Rationale: When a client has sustained a surface injury of the eye as a result of the
introduction of a foreign body, the nurse must first assess visual acuity. The eye is
then assessed for corneal abrasions; this is followed by irrigation with sterile normal
saline solution to gently remove the particles. Ice would be placed on the eye if the
client had sustained an eye contusion.
\A client has an arteriovenous fistula in place for hemodialysis. What should the
nurse do to assess the patency of the fistula?
a. Irrigate the fistula with 3 mL of normal saline solution
b. Infuse 50 mL of normal saline once per 24 hours
c. Palpate for a vibrating sensation at the fistula site
d. Flush the fistula with 1 mL of heparin solution once per shift - ANS-Palpate for a
vibrating sensation at the fistula site
Rationale: An arteriovenous fistula is created in a surgical procedure in which an
anastomosis is created between an artery and a vein in the arm in an end-to-side,
side-to-side, side-to-end, or end-to-end fashion. In a patent fistula (or graft), a "thrill,"
or vibrating sensation, should be palpable and a bruit should be audible with a
stethoscope. An arteriovenous fistula is the client's lifeline, and the nurse does not
irrigate or infuse solutions into it. It is used only for hemodialysis.
\A client has just had a plaster leg cast applied, and the nurse has given the client
instructions on cast care. Which statement by the client indicates the need for further
instruction?
a. "I may feel cool while the cast is drying."
b. "I shouldn't use anything to scratch underneath the cast."
c. "If I smell any odor from the cast, I should call the doctor."
d. "I can dry the cast faster if I use a hairdryer on the hot setting." - ANS-"I can dry
the cast faster if I use a hairdryer on the hot setting."
,Rationale: Using a blow dryer on the hot setting to dry the cast is not advised
because it may burn the client's skin under the cast and crack the cast. While the
cast is still damp, the client may feel cold and may experience a decrease in body
temperature. The client should never insert any item under the cast because of the
risk skin compromise. An odor coming from the cast could indicate the presence of
infection, warranting health care provider notification.
\A client has undergone creation of an Indiana pouch for urine diversion after
cystectomy, and the nurse provides instructions about reservoir catheterization.
What does the nurse tell the client?
a. To plan to drain the reservoir every 2 to 3 hours initially
b. That if mucus drains from the reservoir the primary health care provider should be
contacted
c. That sometimes force is needed to insert the catheter into the reservoir
d. To obtain 26F catheters from the medical supply store for the irrigations - ANS-To
plan to drain the reservoir every 2 to 3 hours initially
Rationale: An Indiana pouch is a continent internal ileal reservoir, and the nurse
instructs the client in the technique of catheterization. Initially the client drains the
reservoir every 2 to 3 hours. Each week thereafter, the interval is increased by 1
hour until finally catheterization is completed every 4 to 6 hours during the day. The
catheter is never forced into the reservoir. If resistance is met, the client is instructed
to pause and apply only gentle pressure while slightly rotating the catheter. A 16F to
20F catheter is used; 26F is too large and could damage the reservoir. Mucus is
expected, and the client is instructed to irrigate the reservoir with 50 to 60 mL of
normal saline solution to prevent excessive mucus buildup
\A client in the third trimester of pregnancy is experiencing painless vaginal bleeding,
and placenta previa is suspected. For which intervention does the nurse prepare the
client?
a. An ultrasound examination
b. Internal fetal monitoring
c. Administration of oxytocin
d. A manual (digital) pelvic examination - ANS-An ultrasound examination
Rationale: A manual pelvic examination or any action that would stimulate uterine
activity is contraindicated when vaginal bleeding is apparent in the third trimester
until a diagnosis is made and placental previa is ruled out. Digital examination of the
cervix can lead to maternal and fetal hemorrhage. A diagnosis of placental previa is
made with the use of ultrasound. Electronic fetal monitoring (external) is crucial in
evaluating the status of the fetus that is at risk for severe hypoxia, but internal fetal
monitoring is contraindicated. Oxytocin would stimulate uterine contractions and is
therefore contraindicated.
, \A client is found to have AIDS. What is the nurse's highest priority in providing care
to this client?
a. Providing emotional support to the client
b. Discussing the cause of AIDS with the client
c. Instituting measures to prevent infection in the client
d. Identifying risk factors related to contracting AIDS with the client - ANS-Instituting
measures to prevent infection in the client
Rationale: The client with AIDS has inadequate immune bodies and is at risk for
infection. The highest priority nursing intervention is protecting the client from
infection. The nurse would also provide emotional support to the client. Discussing
the cause of AIDS and the ways in which AIDS is contracted are not priority
interventions.
\A client is found to have viral hepatitis, and the nurse provides home care
instructions to the client. What should the nurse tell the client to do?
a. Maintain strict bed rest
b. Limit the intake of alcohol
c. Take acetaminophen for discomfort
d. Eat small frequent meals that are low in fat and protein and high in carbohydrates
- ANS-Eat small frequent meals that are low in fat and protein and high in
carbohydrates
Rationale: Fatigue is a normal response to hepatic cellular damage. During the acute
stage, rest is an essential intervention to reduce metabolic demand on the liver and
increase its blood supply, but strict bed rest is unnecessary. The client should avoid
taking medications, including acetaminophen (which is hepatotoxic), unless they are
prescribed by the primary health care provider. The client must avoid all alcohol
consumption. The client should consume small frequent meals that are low in fat and
protein and high in carbohydrates to reduce the workload of the liver.
\A client is transported to the recovery area of the ambulatory care unit after cataract
surgery. In which position does the nurse place the client?
Supine
Semi-Fowler
On the side that has undergone surgery
Prone on the side that has undergone surgery - ANS-Semi-Fowler
Rationale: After cataract extraction surgery, the client should be placed in the
semi-Fowler position or on the unaffected side to prevent edema at the surgical site.
Supine, on the affected side, and prone are all incorrect because they will result in
increased edema at the site.
