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A nurse is assigned to care for a client with chronic renal failure who is undergoing
hemodialysis through an internal arteriovenous (AV) fistula in the right arm. Which
intervention should the nurse implement in caring for the client? Select all that apply.
A. Assessing the radial pulse in the right extremity
B. Using the left arm to take blood pressure readings
C. Drawing predialysis blood specimens from the left arm
D. Assessing the area over the AV fistula for a bruit and thrill each shift
E. Placing a pressure dressing over the site after each dialysis treatment
F. Administering intravenous (IV) fluids through the venous site of the AV fistula as needed -
ANSWER A. Assessing the radial pulse in the right extremity
B. Using the left arm to take blood pressure readings
C. Drawing predialysis blood specimens from the left arm
D. Assessing the area over the AV fistula for a bruit and thrill each shift
Rational: Several precautions must be observed to ensure the function of an internal AV
fistula. The nurse assesses the fistula, and the distal portion of the extremity, for adequate
circulation; checks for a bruit and a thrill by means of auscultation or palpation over the
access site; monitors the radial pulse in the extremity; and avoids taking blood pressure
readings or drawing blood from the arm with the AV fistula. Venipuncture is avoided in the
extremity bearing the AV fistula. Blood is never drawn from the AV fistula, and the AV fistula
is not used for the administration of IV fluids. The AV fistula site is not covered with a
pressure dressing after dialysis.
A nurse is evaluating outcomes for a client with Guillain-Barre Syndrome. Which outcome
does the nurse recognize as optimal respiratory outcomes for the client? Select all that apply
A. Normal deep tendon flexes
B. Improved skeletal muscle tone
1
,C. Absence of paresthesias in the lower extremities
D. Clear sounds in the low lung fields bilaterally
E. pO2 88mgHg and pCO2 of 40mmHg - ANSWER D. Clear sounds in the low lung fields
bilaterally
E. pO2 88mgHg and pCO2 of 40mmHg
Rational: Satisfactory respiratory outcomes include clear breath sounds on auscultation,
clear mentation, spontaneous breathing, normal vital capacity, and normal arterial blood
gases. The ABG results listed here — a Po2 of 85% and a Pco2 of 40 mm Hg — are normal.
The presence of normal deep tendon reflexes, improved skeletal muscle tone, and absence
of paresthesias in the lower extremities reflect improvement in the symptoms associated
with Guillain-Barré but are not specific to a respiratory outcome.
A nurse on the telemetry unit is caring for a client who has had a myocardial infarction and is
now attached to a cardiac monitor. The nurse, monitoring the client's cardiac rhythm, notes
the rhythm depicted in the image. Which nursing action should the nurse take first?
A. Calling the rapid response team
B. Preparing the client for cardioversion
C. Asking the client to bear down and cough
D. Preparing to administer diltiazem - ANSWER A. Calling the rapid response team
Rational: This pattern indicates ventricular fibrillation (VF). Clients who have sustained a
myocardial infarction are at great risk for VF. With the onset of VF the client feels faint, then
immediately loses consciousness and becomes pulseless and apneic. There is no blood
pressure, and heart sounds are absent. The goals of treatment are to terminate VF promptly
and convert it to an organized rhythm. Because defibrillation is the immediate treatment,
the nurse must call the rapid response team and initiate cardiopulmonary resuscitation. The
client would not be able to bear down or cough. Cardioversion is a synchronized
countershock that may be performed in emergencies for unstable ventricular or
supraventricular tachydysrhythmias or electively for stable tachydysrhythmias that are
resistant to medical therapies such as the administration of diltiazem.
2
,A nurse developing a plan of care for a client with a spinal cord injury includes measures to
prevent autonomic dysreflexia (hyperreflexia). Which intervention does the nurse
incorporate into the plan to prevent this complication?
A. Keeping a fan running in the client's room
B. Keeping the linens wrinkle-free under the client
C. Limiting bladder catheterization to once every 12 hours
D. Avoiding the administration of enemas and rectal suppositories - ANSWER B.
Keeping the linens wrinkle-free under the client
Rational: The most frequent causes of autonomic dysreflexia are a distended bladder and
impacted feces in the rectum. Straight catheterization should be performed every 4 to 6
hours, and the Foley catheter should be checked frequently to prevent kinks in the tubing.
Constipation and fecal impaction are other causes, so maintaining bowel regularity is
important. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli.
The nurse renders care in such a way as to minimize risk in these areas.
A nurse provides home care instructions to a client who has been fitted with a halo device to
treat a cervical fracture. Which statement by the client indicates the need for further
instruction?
A. "I need to get more fluids and fiber into my diet."
B. "I should cut my food into small pieces before I eat."
C. "I need to put powder under the vest twice a day to prevent sweating."
D. "I have to check the pin sites every day and watch for signs of infection." -
ANSWER C. "I need to put powder under the vest twice a day to prevent sweating."
Rational: The client should cleanse the skin under the lambs-wool liner each day to prevent
rashes or sores. Powder or lotions should be used only sparingly or not at all because they
may cake, resulting in skin irritation. The client should increase intake of fluid and fiber to
help prevent constipation. Food should be cut into small pieces to facilitate chewing and
swallowing. The client should also use a straw for drinking. The pin sites should be checked
daily for signs of infection.
3
, A nurse is caring for client with increased intracranial pressure (ICP). In which position
should the nurse maintain the client?
A. Supine, with the head extended
B. Side-lying, with the neck flexed
C. Supine, with the head turned to the side
D. Head midline and elevated 30 to 45 degrees - ANSWER D. Head midline and
elevated 30 to 45 degrees
Rational: The client with increased ICP should be positioned with the head in a neutral
midline position. It is the responsibility of the nurse to ensure that all those delivering care
to the client maintain the proper positioning. The client should avoid flexing or extending
the neck or turning the neck side to side. The head of the bed should be raised to 30 to 45
degrees. Use of proper positioning promotes venous drainage from the cranium to keep ICP
down.
A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should
take which action first?
A. Assess the clear fluid for protein
B. Check the clear fluid for the presence of glucose
C. Place cotton balls or dry gauze loosely in the ears
D. Use an otoscope to assess the tympanic membrane for rupture - ANSWER B. Check
the clear fluid for the presence of glucose
Rational: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar
skull fracture. CSF can be distinguished from other body fluids because it will separate into
bloody and yellow concentric rings on dressing material, a phenomenon referred to as the
halo sign. It also tests positive for glucose. CSF does not contain protein. The presence of CSF
indicates a disruption in the integrity of the cranium. Therefore inserting cotton balls, gauze,
or an otoscope into the ear puts the client at risk for infection.
A nurse is caring for a client who has just undergone cardioversion. Which intervention is the
nurse's priority after this procedure?
4
A nurse is assigned to care for a client with chronic renal failure who is undergoing
hemodialysis through an internal arteriovenous (AV) fistula in the right arm. Which
intervention should the nurse implement in caring for the client? Select all that apply.
A. Assessing the radial pulse in the right extremity
B. Using the left arm to take blood pressure readings
C. Drawing predialysis blood specimens from the left arm
D. Assessing the area over the AV fistula for a bruit and thrill each shift
E. Placing a pressure dressing over the site after each dialysis treatment
F. Administering intravenous (IV) fluids through the venous site of the AV fistula as needed -
ANSWER A. Assessing the radial pulse in the right extremity
B. Using the left arm to take blood pressure readings
C. Drawing predialysis blood specimens from the left arm
D. Assessing the area over the AV fistula for a bruit and thrill each shift
Rational: Several precautions must be observed to ensure the function of an internal AV
fistula. The nurse assesses the fistula, and the distal portion of the extremity, for adequate
circulation; checks for a bruit and a thrill by means of auscultation or palpation over the
access site; monitors the radial pulse in the extremity; and avoids taking blood pressure
readings or drawing blood from the arm with the AV fistula. Venipuncture is avoided in the
extremity bearing the AV fistula. Blood is never drawn from the AV fistula, and the AV fistula
is not used for the administration of IV fluids. The AV fistula site is not covered with a
pressure dressing after dialysis.
A nurse is evaluating outcomes for a client with Guillain-Barre Syndrome. Which outcome
does the nurse recognize as optimal respiratory outcomes for the client? Select all that apply
A. Normal deep tendon flexes
B. Improved skeletal muscle tone
1
,C. Absence of paresthesias in the lower extremities
D. Clear sounds in the low lung fields bilaterally
E. pO2 88mgHg and pCO2 of 40mmHg - ANSWER D. Clear sounds in the low lung fields
bilaterally
E. pO2 88mgHg and pCO2 of 40mmHg
Rational: Satisfactory respiratory outcomes include clear breath sounds on auscultation,
clear mentation, spontaneous breathing, normal vital capacity, and normal arterial blood
gases. The ABG results listed here — a Po2 of 85% and a Pco2 of 40 mm Hg — are normal.
The presence of normal deep tendon reflexes, improved skeletal muscle tone, and absence
of paresthesias in the lower extremities reflect improvement in the symptoms associated
with Guillain-Barré but are not specific to a respiratory outcome.
A nurse on the telemetry unit is caring for a client who has had a myocardial infarction and is
now attached to a cardiac monitor. The nurse, monitoring the client's cardiac rhythm, notes
the rhythm depicted in the image. Which nursing action should the nurse take first?
A. Calling the rapid response team
B. Preparing the client for cardioversion
C. Asking the client to bear down and cough
D. Preparing to administer diltiazem - ANSWER A. Calling the rapid response team
Rational: This pattern indicates ventricular fibrillation (VF). Clients who have sustained a
myocardial infarction are at great risk for VF. With the onset of VF the client feels faint, then
immediately loses consciousness and becomes pulseless and apneic. There is no blood
pressure, and heart sounds are absent. The goals of treatment are to terminate VF promptly
and convert it to an organized rhythm. Because defibrillation is the immediate treatment,
the nurse must call the rapid response team and initiate cardiopulmonary resuscitation. The
client would not be able to bear down or cough. Cardioversion is a synchronized
countershock that may be performed in emergencies for unstable ventricular or
supraventricular tachydysrhythmias or electively for stable tachydysrhythmias that are
resistant to medical therapies such as the administration of diltiazem.
2
,A nurse developing a plan of care for a client with a spinal cord injury includes measures to
prevent autonomic dysreflexia (hyperreflexia). Which intervention does the nurse
incorporate into the plan to prevent this complication?
A. Keeping a fan running in the client's room
B. Keeping the linens wrinkle-free under the client
C. Limiting bladder catheterization to once every 12 hours
D. Avoiding the administration of enemas and rectal suppositories - ANSWER B.
Keeping the linens wrinkle-free under the client
Rational: The most frequent causes of autonomic dysreflexia are a distended bladder and
impacted feces in the rectum. Straight catheterization should be performed every 4 to 6
hours, and the Foley catheter should be checked frequently to prevent kinks in the tubing.
Constipation and fecal impaction are other causes, so maintaining bowel regularity is
important. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli.
The nurse renders care in such a way as to minimize risk in these areas.
A nurse provides home care instructions to a client who has been fitted with a halo device to
treat a cervical fracture. Which statement by the client indicates the need for further
instruction?
A. "I need to get more fluids and fiber into my diet."
B. "I should cut my food into small pieces before I eat."
C. "I need to put powder under the vest twice a day to prevent sweating."
D. "I have to check the pin sites every day and watch for signs of infection." -
ANSWER C. "I need to put powder under the vest twice a day to prevent sweating."
Rational: The client should cleanse the skin under the lambs-wool liner each day to prevent
rashes or sores. Powder or lotions should be used only sparingly or not at all because they
may cake, resulting in skin irritation. The client should increase intake of fluid and fiber to
help prevent constipation. Food should be cut into small pieces to facilitate chewing and
swallowing. The client should also use a straw for drinking. The pin sites should be checked
daily for signs of infection.
3
, A nurse is caring for client with increased intracranial pressure (ICP). In which position
should the nurse maintain the client?
A. Supine, with the head extended
B. Side-lying, with the neck flexed
C. Supine, with the head turned to the side
D. Head midline and elevated 30 to 45 degrees - ANSWER D. Head midline and
elevated 30 to 45 degrees
Rational: The client with increased ICP should be positioned with the head in a neutral
midline position. It is the responsibility of the nurse to ensure that all those delivering care
to the client maintain the proper positioning. The client should avoid flexing or extending
the neck or turning the neck side to side. The head of the bed should be raised to 30 to 45
degrees. Use of proper positioning promotes venous drainage from the cranium to keep ICP
down.
A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should
take which action first?
A. Assess the clear fluid for protein
B. Check the clear fluid for the presence of glucose
C. Place cotton balls or dry gauze loosely in the ears
D. Use an otoscope to assess the tympanic membrane for rupture - ANSWER B. Check
the clear fluid for the presence of glucose
Rational: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar
skull fracture. CSF can be distinguished from other body fluids because it will separate into
bloody and yellow concentric rings on dressing material, a phenomenon referred to as the
halo sign. It also tests positive for glucose. CSF does not contain protein. The presence of CSF
indicates a disruption in the integrity of the cranium. Therefore inserting cotton balls, gauze,
or an otoscope into the ear puts the client at risk for infection.
A nurse is caring for a client who has just undergone cardioversion. Which intervention is the
nurse's priority after this procedure?
4
