NUR 111 Quiz Summary Questions and Answers

The nurse is preparing to perform an abdominal assessment on a client. Which position would best accommodate this assessment? A) SIMS B) Supine C) High Fowler's D) Prone B) Supine What is the best practice for the nurse to use to promote infection control in the hospital? A) Practice hand hygiene by washing with soap and water and/or alcohol-based rubs. B) Avoid touching any object in the hospital, including door knobs. C) Avoid contact with soiled linen by asking the family to perform all client care. D) Take prescribed antibiotics to remain infection-free while working. A) Practice hand hygiene by washing with soap and water and/or alcohol-based rubs During an assessment, the nurse uses the method of inspection. What is needed to perform this skill? A) Electronic thermometer B) Senses of hearing and sight C) High quality stethoscope D) Documentation skill checklist B) Senses of hearing and sight When auscultating an apical pulse, what is the site to be used? A) Left fifth intercostal space midclavicular line B) Right third intercostal space C) Right fifth intercostal space midclavicular line D) Left third intercostal space A) Left 5th intercostal space midclavicular line The nurse has weighed a new client during the admission assessment. How does this action best contribute to safe medication administration? A) Provides baseline for changes in fluid balance B) Confirms appropriate use of subcutaneous or intramuscular injectionsC) Allows the care team to prescribe the correct medication dose D) Identifies nutritional deficiencies that may affect drug dosage C) Allows the care team to prescribe the correct medication dose Rationale: Dosage of medication is often calculated based on the client's weight, so getting the client's weight wrong could cause a medication error The nurse should consider teratogenic effects when caring for what clients? Select all that apply. A) 50-year-old post-menopausal female being treated for acute renal failure B) 37-year-old female taking fertility drugs C) 81-year-old with chronic heart failure D) 41-year-old male who is post-bone marrow transplant E) 29-year-old receiving prenatal care during first trimester of pregnancy B) 37-year-old female taking fertility drugs Rationale: Teratogenic effects are harmful to the fetus E) 29-year-old receiving prenatal care during first trimester of pregnancy Rationale: Teratogenic effects are harmful to the fetus A client was prescribed a 10-day course of antibiotics to treat a sinus infection. With symptom relief after 3 days of medications, the client stopped taking the antibiotic. What is a priority nursing diagnosis for this client? A) Chronic confusion B) Risk for injury C) Knowledge deficit D) Non-compliance D) Non-compliance Rationale: The priority is the client's non-adherence to the treatment/ drug regime When documenting subjective client data, the nurse should: A) verify the information with the client's family prior to documentation. B) use the client's own words placed in quotation marks. C) record the information using generic wording. D) document everything that was said by the client in an unstructured manner B) use the client's own words placed in quotation marks Which is a correctly written client outcome?A) The client understands what foods are low in sodium. B) The client correctly self-administers the morning dose of insulin. C) The client will ambulate 10 ft (3 m) with a walker by October 12. D) The client will eliminate a soft, formed stool. C) The client will ambulate 10 ft (3 m) with a walker by October 12 When a client achieves their expected outcome in the care plan, which action should the nurse do first? A) Continue the care plan. B) Create a new care plan. C) Modify the care plan. D) Terminate the care plan. D) Terminate the care plan The nurse is caring for an older adult client who is prescribed a benzodiazepine. When planning the client's assessment, the nurse should be aware of what possible adverse effect? A) Acute renal failure B) Dysuria (painful urination) C) Epistaxis (nosebleeds) D) Unpredictable reactions D) Unpredictable reactions Rationale: Use benzodiazepines with caution in elderly or debilitated clients because of the possibility of unpredictable reactions and in clients with renal or hepatic dysfunction, which may alter the metabolism and excretion of these drugs, resulting in direct toxicity. Dosage adjustments usually are needed for such clients. Acute renal failure, dysuria, and epistaxis are not commonly related to therapy with these medications in the elderly. The nurse is caring for a client who does not have a respiratory disorder but has been prescribed acetylcysteine. What is an additional indication for acetylcysteine? A) Antidote for acetaminophen poisoning B) Conversion of cardiac rhythm irregularities C) Treatment of bronchospasm D) Treatment of stomach ulcers A) Antidote for acetaminophen poisoning Rationale: Acetylcysteine is used orally to protect liver cells from being damaged during episodes of acetaminophen toxicity because it normalizes hepatic glutathione levels and bindswith a reactive hepatotoxic metabolite of acetaminophen. Acetylcysteine is not used for the conversion of cardiac dysrhythmias, for treatment of peptic ulcer disease, or for decreasing bronchospasm. Karch Ch 54 Acetylcysteine is used orally to protect liver cells from being damaged during episodes of acetaminophen toxicity because it normalizes hepatic glutathione levels and binds with a reactive hepatotoxic metabolite of acetaminophen. Acetylcysteine affects the mucoproteins in the respiratory secretions by splitting apart disulfide bonds that are responsible for holding the mucus material together. The result is a decrease in the tenacity and viscosity of the secretions. Karch pg 955 A client has taken a benzodiazepine for one year following a divorce. During an annual physical, the client states, "I decided it was time to move on, so I stopped this drug three days ago." The nurse then assesses the client for what symptoms of withdrawal? A) Trembling. muscle cramps, and sweating B) Sedation and drowsiness C) Decreased libido (sex drive) and urinary hesitancy D) Dry mucous membranes and constipation A) Trembling, muscle cramps, and sweating Rationale: Taper dose gradually after long-term therapy, especially in epileptic patients. Acute withdrawal could precipitate seizures in these patients. It may also cause withdrawal syndrome. Karch, pg 346 A client with a persistent, dry, non-productive cough has been diagnosed with chronic pharyngitis (sore throat). The client should benefit the most from what medication category? A) Mucolytics B) Oral decongestants C) Antitussives D) Nasal sprays C) Antitussives Rationale: Antitussives are drugs that suppress the cough reflex. Many disorders involving the respiratory tract, including the common cold, sinusitis, pharyngitis, and pneumonia are accompanied by an uncomfortable, nonproductive cough. Persistent coughing can be exhausting and can cause muscle strain and further irritation of the respiratory tract. Nasal sprays, oral decongestants, and mucolytics are not generally prescribed for chronic pharyngitis. Karch 8e pg 940