Q&a Priority

Question Number 1 of 25 The nurse assesses several post partum women in the clinic. Which of the following women is at highest risk for puerperal infection? The correct response is "C". A) 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery B) 2 days post partum, temperature of 101.2 degrees Farenheit this morning C) 3 days post partum, temperature of 100.8 degrees Fahrenheit the past 2 days D) 4 days post partum, temperature of 100 degrees Fahrenheit since delivery Your response was "B". 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, constitutes a post partum infection. Question Number 2 of 25 A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a recurrent urinary tract infection. Which of the following is appropriate reinforcement of information by the nurse? The correct response is "A". 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." Your response was "A". 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. Taking with food is not necessary. Options 3 and 4 are incorrect instructions with use of bactrim Question Number 3 of 25 A client is 2 days post operative. The vital signs are: BP - 120/70, HR - 110, RR - 26, and Temperature - 100.4 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? The correct response is "B". A) Heart rate B) Respiratory rate C) Blood pressure D) Temperature Your response was "C". 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. Question Number 4 of 25 A client calls the evening health clinic to state “I know I have a severely low sugar since the Lantus insulin was given 3 hours ago and it peaks in 2 hours.” What should be the nurse’s initial response to the client? The correct response is "B". 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? Your response was "B". The correct answer is B: What are you feeling at this moment? When a client has changed from stable to unstable the initial response is to do further assessment of the client.

Question Number 5 of 25 The nurse is caring for a client several days following a cerebral vascular accident. Coumadin (warfarin) has been prescribed. Today's prothrombin level is 40 (normal range 10-14). Which of the following is a priority assessment? The correct response is "A". A) Neurological signs B) Lung sounds C) Homan's sign D) Gum bleeding Your response was "B". The correct answer is A: Neurological signs Question Number 6 of 25 If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate? The correct response is "C". 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 Your response was "C". 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 assessments are a priority in this post-CVA client Question Number 8 of 25 Before administering a feeding through a gastrostomy tube, what is the priority nursing assessment? The correct response is "D". A) Measure the vital signs B) Palpate the abdomen C) Assess for breath sounds D) Verify tube patency Your response was "D". 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 Question Number 9 of 25 During a fluid exchange for the client who is 48 hours post insertion of the abdominal Tenckhoff catheter for peritoneal dialysis, the nurse knows that the appearance of which of the following needs to be reported to the health care provider immediately? The correct response is "D". A) Slight pink - tinged drainage B) Abdominal discomfort C) Muscle weakness D) Cloudy drainage Your response was "C". The correct answer is D: Cloudy drainage Cloudy drainage is a sign of infection that can lead to peritonitis (inflammation of the peritoneum). Other options are expected side effects of peritoneal dialysis. Question Number 10 of 25 A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first? The correct response is "C". A) repeat glycohemoglobin in 24 hours B) document accuchecks, intake and output every 4 hours C) humulin N 20 units IV push D) IV fluids of 0.9% normal saline at 125 ml per hour Your response was "C". 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. Another order to question is option 1 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 more appropriate to obtain. The other orders are within expected actions in this situation. Question Number 11 of 25 The nurse is caring for a client who is receiving total parenteral nutrition (hyperalimentation and lipids). What is the priority nursing action on every 8 hour shift? The correct response is "C". 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 Your response was "B". 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 Question Number 12 of 25 The nurse is caring for a client on complete bed rest. Which action by the nurse is most important in preventing the formation of deep vein thrombosis? The correct response is "D". A) Elevate the foot of the bed B) Apply knee high support stockings C) Encourage passive exercises D) Prevent pressure at back of knees Your response was "C". 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 Question Number 13 of 25 What must the nurse emphasize when teaching a client with depression about a new prescription for nortriptyline (Pamelor)? The correct response is "B". 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 Your response was "B". The correct answer is B: Alcohol use is to be avoided Alcohol potentiates the action of tricyclic antidepressants Question Number 14 of 25 A client returns from the operating room after a right orchiectomy. For the immediate post operative period the nursing priority would be to The correct response is "B". A) Maintain fluid and electrolyte balance B) Manage post operative pain C) Ambulate the client within 1 hour of surgery D) Control bladder spasms Your response was "A".

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 Question Number 15 of 25 A client is waiting to have an intravenous pyelogram (IVP). The most important factor to be obtained by the nurse prior to the procedure is The correct response is "B". A) time to the client's last meal B) the client's allergy history C) assessment of the peripheral pulses D) results of the blood coagulation studies Your response was "B". The correct answer is B: the 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. Question Number 16 of 25 A client with a fracture of the radius had a plaster cast applied 2 days ago. The client complains of constant pain and swelling of the fingers. The first action of the nurse should be The correct response is "C". 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 Your response was "C". 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 Question Number 17 of 25 When caring for a client with urinary incontinence, which content should be reinforced by the nurse? The correct response is "D". 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 Your response was "D". The correct answer is D: Avoid taking antihistamines Antihistamines can aggravate urinary incontinence and should be avoided in clients with urinary incontinence. Holding the urine, avoiding sodium, and restricting fluids have not been shown to reduce urinary incontinence. Question Number 18 of 25 A client arrives in the emergency department after a radiologic accident at a local factory. The next action of the nurse would be to The correct response is "B". A) begin decontamination procedures for the client B) ensure physiologic stability of the client C) wrap the client in blankets to minimize staff contamination D) double bag the client’s contaminated clothing Your response was "D".

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. Question Number 19 of 25 A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires priority attention by the nurse? The correct response is "C". A) Foul smelling urine B) Burning on urination C) Elevated temperature D) Nausea and anorexia Your response was "A". The correct answer is C: Elevated temperature Elevated temperature after 72 hours on an antibiotic indicates the antibiotic is not effective in eradicating the offending organism. The provider should be informed immediately so that a more effective medication can be prescribed, and complications such as pyelonephritis are prevented. Options 1 and 2 are expected with cystitis. Option 4 may be related to the antibiotics as a side effect and should also be reported to the provider Question Number 20 of 25 The nurse is caring for a school aged child with a diagnosis of secondary hyperparathyroidism following treatment for chronic renal disease. Which of the following lab data should receive priority attention? The correct response is "A". A) Calcium and phosphorus levels B) Blood sugar C) Urine specific gravity D) Blood urea nitrogen Your response was "B". The correct answer is A: Calcium and phosphorus levels Calcium and phosphorous levels will be elevated until the client is stabilized. Question Number 21 of 25 The nurse is caring for a pregnant woman with pregnancy induced hypertension receiving magnesium sulfate 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? The correct response is "C". A) Administer calcium gluconate B) Call the health care provider immediately C) Discontinue the magnesium sulfate D) Perform additional assessments Your response was "C". 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. Question Number 22 of 25 The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates immediate action by the nurse? The correct response is "D". A) Pruritic rash B) Dry, hacking cough

C) Chronic fatigue D) Elevated temperature Your response was "A". 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. Other findings should be reported to the care provider as well Question Number 23 of 25 The nurse must know that the most accurate oxygen delivery system available is The correct response is "A". A) The venturi mask B) Nasal cannula C) Partial non-rebreather mask D) Simple face mask Your response was "A". 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%. Question Number 24 of 25 The nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally disconnects from the drainage tube. The first action the nurse should take is The correct response is "D". 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 Your response was "A". 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. Health care provider notification follows this action Question Number 25 of 25 The nurse is responsible for decisions regarding client room assignments. Which possible roommate would be most appropriate for a 3 year-old child with minimal change nephrotic syndrome? The correct response is "C". 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 Your response was "C". 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. The sickle cell crisis has potential to have occurred from an infectious process