Q&a Prioritization 1

Results for Q&A-Priority Questions are numbered by the order in which they appeared in the test. Represents the correct answer. Question 1 The nurse is caring for a client several days following a Answers Correct A cerebral vascular accident. Coumadin (warfarin) has been Student's A prescribed. Today's prothrombin level is 40 seconds (normal range 10-14 seconds). Which of the following findings requires priority follow-up? A) Gum bleeding B) Lung sounds C) Homan's sign D) Generalized weakness Review Information: The correct answer is A: Gum bleeding The prothrombin time is elevated, indicating a high risk for bleeding. Neurological assessments remain important for post-CVA clients. Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company. Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

Question 2 The nurse is caring for a client who is receiving total Answers Correct C parenteral nutrition (TPN) (hyperalimentation and lipids). Student's C What is the priority nursing action on every 8 hour shift? A) Monitor blood pressure, temperature and weight B) Change the tubing under sterile conditions C) Check urine glucose, acetone and specific gravity D) Adjust the infusion rate to provide for total volume Review Information: The correct answer is C: Check urine glucose, acetone and specific gravity Because of the high dextrose and protein content in parenteral nutrition, the nurse should assess the urine at least every 8 hours. Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.

(2nd ed). Clinton Park, New York: Delmar. Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

Question 3 The nurse assesses several post partum women in the Answers Correct C clinic. Which of the following women is at highest risk for Student's D puerperal infection? 12 hours post partum, temperature of 100.4 degrees A) Fahrenheit since delivery 2 days post partum, temperature of 101.2 degrees B) Fahrenheit this morning 3 days post partum, temperature of 100.8 degrees C) Fahrenheit the past 2 days 4 days post partum, temperature of 100 degrees D) Fahrenheit since delivery Review Information: The correct answer is C: 3 days post partum, temperature of 100.8 degrees Fahrenheit the past 2 days A temperature of 100.4 degrees Fahrenheit or higher on 2 successive days, not counting the first 24 hours after birth, indicates a post partum infection. Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri. Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Question 4 A client is placed on sulfamethoxazole-trimethoprim Answers Correct A (Bactrim) for a recurrent urinary tract infection. Which of Student's A the following is appropriate reinforcement of information by the nurse? A) "Drink at least 8 glasses of water a day." B) "Be sure to take the medication with food." C) "It is safe to take with oral contraceptives." D) "Stop the medication after 5 days." Review Information: The correct answer is A: "Drink at least 8 glasses of water a day." Bactrim is a highly insoluble drug and requires a large volume of fluid intake. It is not necessary to take it with food. Options C and D are incorrect instructions for those taking Bactrim. Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper

Saddle River, New Jersey: Pearson Prentice Hall. Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

Question 5 The nurse performs an assessment during a fluid exchange Answers Correct D for the client who is 48 hours post-insertion of an Student's D abdominal Tenckhoff catheter for peritoneal dialysis. The nurse knows that the appearance of which of the following needs to be reported to the provider immediately? A) slight pink-tinged drainage B) abdominal discomfort C) muscle weakness D) cloudy drainage Review Information: The correct answer is D: cloudy drainage Cloudy drainage is a sign of infection that can lead to peritonitis (inflammation of the peritoneum). The other options are expected side effects of peritoneal dialysis. Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar. Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

Question 6 Before administering a feeding through a gastrostomy Answers Correct D tube, what is the priority nursing assessment? Student's D A) Measure the vital signs B) Palpate the abdomen C) Assess for breath sounds D) Verify tube patency Review Information: The correct answer is D: Verify tube patency Tube patency should be checked prior to all feedings. The feeding should not be attempted if the tube is not patent. Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar. Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Question 7 A client is 2 days post operative. The vital signs are: BP - Answers Correct B 120/70, HR -- 110 BPM, RR - 26, and Temperature - 100.4 Student's A degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition? A) Heart rate B) Respiratory rate C) Blood pressure D) Temperature Review Information: The correct answer is B: Respiratory rate Tachypnea is one of the first clues that the client is not oxygenating appropriately. The compensatory mechanism for decreased oxygenation is increased respiratory rate. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby. Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

Question 8 The registered nurse (RN) is making decisions regarding Answers Correct C client room assignments on a pediatric unit. Which Student's C possible roommate would be most appropriate for a 3 yearold child with minimal change nephrotic syndrome? A) 2 year-old with respiratory infection B) 3 year-old fracture whose sibling has chickenpox C) 4 year-old with bilateral inguinal hernia repair D) 6 year-old with a sickle cell anemia crisis Review Information: The correct answer is C: 4 year-old with bilateral inguinal hernia repair The nurse must know that children with nephrotic syndrome are at high risk for development of infections as a result of the standard use of immunosuppressant therapy, as well as from the accumulation of fluid (edema). Therefore, these children must be protected from sources of possible infection. D is incorrect because the sickle cell crisis is potentially due to an infectious process. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby. Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

Question 9

The nurse is caring for a client with a chest tube. On the Answers Correct D second postoperative day, the chest tube accidentally Student's D disconnects from the drainage tube. The first action the nurse should take is A) reconnect the tube B) raise the collection chamber above the client's chest C) call the health care provider D) clamp the chest tube Review Information: The correct answer is D: clamp the chest tube Immediate steps should be taken to prevent air from entering the chest cavity. Lung collapse may occur if air enters the chest cavity. Clamping the tube close to the client’s chest is the first action to take, followed by health care provider notification. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins. Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 10 A client arrives in the emergency department after a Answers Correct B radiologic accident at a local factory. The first action of the Student's B nurse would be to A) begin decontamination procedures for the client B) ensure physiologic stability of the client wrap the client in blankets to minimize staff C) contamination D) double bag the client’s contaminated clothing Review Information: The correct answer is B: ensure physiologic stability of the client The nurse must initially assist in stabilizing the patient prior to performing the other tasks related to radiologic contamination. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby. Veenema, T. & Karam, A. (2003). Radiation: Clinical responses to radiologic incidents and emergencies. American Journal of Nursing, 103 (5), 32-40.

Question 11

The nurse is caring for a pregnant woman with pregnancy Answers Correct C induced hypertension (PIH) receiving magnesium sulfate Student's C intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should the nurse do first? A) Administer calcium gluconate B) Call the provider immediately C) Discontinue the magnesium sulfate D) Perform additional assessments Review Information: The correct answer is C: Discontinue the magnesium sulfate The assessments strongly suggest magnesium sulfate toxicity. The nurse must discontinue the IV immediately and take measures to ensure the safety of the client. Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company. Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Question 12 A client is waiting to have an intravenous pyelogram Answers Correct B (IVP). The most important information to be obtained by Student's B the nurse prior to the procedure is A) time of the client's last meal B) client's allergy history C) assessment of the peripheral pulses D) results of the blood coagulation studies Review Information: The correct answer is B: client''s allergy history Intravenous Pyelogram is a dye study that uses an iodine-based contract. Therefore, the study is contraindicated in clients with allergy to iodine. Cavanaugh, B.M. (2003). Nurse’s manual of laboratory and diagnostic tests, 4th ed. Philadelphia: F.A. Davis. Schnell, Z.B., Van Leeuwen, A.M., Kranpitz, T.R. (2003). Comprehensive handbook of laboratory and diagnostic tests with nursing implications. Philadelphia: F.A. Davis.

Question 13 A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the nursing priority would be to A) maintain fluid and electrolyte balance B) manage post-operative pain C) ambulate the client within 1 hour of surgery D) control bladder spasms

Answers Correct B Student's A

Review Information: The correct answer is B: manage post-operative pain Due to the location of the incision, pain management is the priority. Bladder spasms are more related to prostate surgery. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question 14 The nurse is caring for a client on complete bed rest. Answers Correct D Which action by the nurse is most important in preventing Student's A the formation of deep vein thrombosis? A) Elevate the foot of the bed B) Apply knee high support stockings C) Encourage passive exercises D) Prevent pressure at back of knees Review Information: The correct answer is D: Prevent pressure at back of knees Preventing popliteal pressure will prevent venous stasis and possibly deep vein thrombosis. Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question 15 The nurse reviews an order to administer Rh (D) immune Answers Correct B globulin to an Rh negative woman following the birth of an Student's B Rh positive baby. Which assessment is a priority before the nurse gives the injection? A) Newborn's blood type B) Coombs' test results C) Previous RhoGAM history D) Gravida and parity Review Information: The correct answer is B: Coombs'' test results Rh (D) immune globulin (RhoGAM) is given only if antibody formation has not occurred. A negative Coombs'' test confirms this. Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company. Tierney, L.M., McPhee, S.J., and Papadakis, M.A. (2004). Current medical Diagnosis and Treatment. (43rd edition). USA:McGraw-Hill.

Question 16 A client with a fracture of the radius had a plaster cast Answers Correct C applied 2 days ago. The client complains of constant pain Student's C and swelling of the fingers. The first action of the nurse should be A) elevate the arm no higher than heart level B) remove the cast C) assess capillary refill of the exposed hand and fingers D) apply a warm soak to the hand Review Information: The correct answer is C: assess capillary refill of the exposed hand and fingers A deterioration in neurovascular status indicates the development of compartment syndrome (elevated tissue pressure within a confined area) which requires immediate pressure-reducing interventions. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Question 17 A client has been on antibiotics for 72 hours for cystitis. Answers Correct C Which report from the client requires priority attention by Student's C the nurse? A) foul smelling urine B) burning on urination C) elevated temperature D) nausea and anorexia Review Information: The correct answer is C: elevated temperature Elevated temperature after 72 hours on an antibiotic indicates the antibiotic has not been effective in eradicating the offending organism. The provider should be informed immediately so that an appropriate medication can be prescribed, and complications such as pyelonephritis are prevented. Options A and B are expected with cystitis. Option D may be related to the antibiotics as a side effect and should also be reported to the provider. Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar. Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

Question 18

The nurse is caring for a school-aged child with a diagnosis Answers Correct A of secondary hyperparathyroidism following treatment for Student's A chronic renal disease. Which of the following lab data should receive priority attention? A) Calcium and phosphorus levels B) Blood sugar C) Urine specific gravity D) Blood urea nitrogen Review Information: The correct answer is A: Calcium and phosphorus levels Calcium and phosphorous levels will be elevated until the client is stabilized. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby. Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

Question 19 The nurse must know that the most accurate oxygen Answers Correct A delivery system available is Student's A A) the Venturi mask B) nasal cannula C) partial non-rebreather mask D) simple face mask Review Information: The correct answer is A: the Venturi mask The most accurate way to deliver oxygen to the client is through a Venturi system such as the Venti Mask. The Venti Mask is a high flow device that entrains room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client’s respiratory rate and respiratory pattern do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can be delivered by this system is 55%. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question 20 When caring for a client with urinary incontinence, which content should be reinforced by the nurse? A) hold the urine to increase bladder capacity B) avoid eating foods high in sodium C) restrict fluid to prevent elimination accidents D) avoid taking antihistamines

Answers Correct D Student's C

Review Information: The correct answer is D: avoid taking antihistamines Antihistamines can aggravate urinary incontinence and should be avoided by these clients. Holding the urine, avoiding sodium, and restricting fluids have not been shown to reduce urinary incontinence. Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar. Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

Question 21 What must the nurse emphasize when teaching a client Answers Correct B with depression about a new prescription for nortriptyline Student's B (Pamelor)? A) Symptom relief occurs in a few days B) Alcohol use is to be avoided C) Medication must be stored in the refrigerator D) Episodes of diarrhea can be expected Review Information: The correct answer is B: Alcohol use is to be avoided Alcohol potentiates the action of tricyclic antidepressants. Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company. Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

Question 22 If a very active two year-old client pulls his tunneled Answers Correct C central venous catheter out, what initial nursing action is Student's C appropriate? A) Obtain emergency equipment B) Assess heart rate, rhythm and all pulses C) Apply pressure to the vessel insertion site D) Use cold packs at the exit incision site Review Information: The correct answer is C: Apply pressure to the vessel insertion site If a central venous catheter is accidentally removed, pressure should be applied to the vein entry site. Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri. Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Question 23 The nurse is caring for a client with a vascular access for Answers Correct D hemodialysis. Which of these findings necessitates Student's D immediate action by the nurse? A) pruritic rash B) dry, hacking cough C) chronic fatigue D) elevated temperature Review Information: The correct answer is D: elevated temperature It is a priority to report this finding since clients on hemodialysis are prone to infection, and the first sign is an elevated temperature. The other findings should be reported to the provider as well. Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar. Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

Question 24 A client calls the evening health clinic to state “I know I Answers Correct B have a severely low sugar since the Lantus insulin was Student's B given 3 hours ago and it peaks in 2 hours.” What should be the nurse’s initial response to the client? A) What else do you know about this type of insulin? B) What are you feeling at this moment? C) Have you eaten anything today? D) Are you taking any other insulin or medication? Review Information: The correct answer is B: What are you feeling at this moment? When a client has changed from stable to unstable, the nurse’s initial response should be to do further assessment of the client. White, L., and Duncan, G,. (2002). Medical-Surgical Nursing An Integrated Approach (2nd ed.). Australia: Delmar. Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

Question 25

A client has a serum glucose of 385 mg/dl. Which of these Answers Correct C orders would the nurse question first? Student's C A) Repeat glycohemoglobin in 24 hours Document Accu-checks, intake and output every 4 B) hours C) Humulin N 20 units IV push D) IV fluids of 0.9% normal saline at 125 ml per hour Review Information: The correct answer is C: Humulin N 20 units IV push Regular insulin is the only insulin that can be given by the intravenous route. This is the initial order to question. Option A should also be questioned, although it is not a priority since the client would not be harmed by this action. This lab test gives the average glucose on the hemoglobin molecule for the past 2 to 3 months. There would be no need to repeat it at this time. A fasting glucose in the morning would be a more appropriate assessment. The other orders are within expected actions in this situation. White, L., and Duncan, G,. (2002). Medical-Surgical Nursing An Integrated Approach (2nd ed.). Australia: Delmar. Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.