Q&a Reduction Of Risk-1

Results for Lesson 7: Reduction of Risk Potential Questions are numbered by the order in which they appeared in the test. Represents the correct answer. Question 1 A 60 year-old male client had a hernia repair in an Answers Correct C outpatient surgery clinic. He is awake and alert, but has not Student's C been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? A) Have him drink several glasses of water Perform Credé's method on the bladder from the B) bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again Review Information: The correct answer is C: Assist him to stand by the side of the bed to void When a male is not able to use a urinal unassisted, the client should stand by the side of the bed to void. This is the most desirable position for normal voiding for male clients. Also, given his age, he most likely has some degree of prostate enlargement which may interfere with voiding. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby. Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 2 A nurse checks a client who is on a volume-cycled Answers Correct D ventilator. Which finding indicates that the client may need Student's D suctioning? A) Drowsiness B) Complaint of nausea C) Pulse rate of 82 D) Restlessness Review Information: The correct answer is D: Restlessness Restlessness, increased heart and respiratory rates, and noisy expiration suggest

hypoxia and are indications for suctioning. Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning. Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 3 A nurse is to collect a sputum specimen for acid-fast Answers Correct D bacillus (AFB) from a client. Which action should the Student's B nurse take first? A) Ask client to cough sputum into container B) Have the client take several deep breaths C) Provide a appropriate specimen container D) Assist with oral hygiene Review Information: The correct answer is D: Assist with oral hygiene Obtain a specimen early in the morning after mouth care. The other responses follow this first action: the client should take several deep breaths then cough into the appropriate sterile container to obtain the AFB specimen of the sputum. Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning. Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 4 A client is diagnosed with a spontaneous pneumothorax Answers Correct B necessitating the insertion of a chest tube. What is the best Student's B explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest." B) "The tube will remove excess air from your chest." "The tube controls the amount of air that enters your C) chest." D) "The tube will seal the hole in your lung." Review Information: The correct answer is B: "The tube will remove excess air from your chest." The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space. Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question 5 The nurse is preparing a client who will undergo a Answers Correct B myelogram. Which of the following statements by the Student's B client indicates a contraindication for this test? "I can't lie in one position for more than thirty A) minutes." B) "I am allergic to shrimp." C) "I suffer from claustrophobia." D) "I developed a severe headache after a spinal tap." Review Information: The correct answer is B: "I am allergic to shrimp." A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could even include seizures. 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 6 The nurse is performing a physical assessment on a client Answers Correct C who just had an endotracheal tube (ET) inserted. Which Student's C finding would call for immediate action by the nurse? A) Breath sounds can be heard bilaterally B) Mist is visible in the T-Piece C) Pulse oximetry of 88 BPM D) Client is unable to speak Review Information: The correct answer is C: Pulse oximetry of 88 BPM Pulse oximetry should not be lower than 90. Placement of the ET will need to be checked, along with the ventilator settings. 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 7

A 4 year-old has been hospitalized for 24 hours with Answers Correct A skeletal traction for treatment of a fracture of the right Student's A femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? A) Notify the health care provider B) Readjust the traction C) Administer the ordered prn medication D) Reassess the foot in fifteen minutes Review Information: The correct answer is A: Notify the health care provider The findings are indicative of circulatory impairment. The health care provider (or practitioner) must be notified immediately. 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. Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Question 8 The nurse is reviewing laboratory results on a client with Answers Correct D acute renal failure. Which one of the following should be Student's D reported immediately? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7.30 D) Serum potassium 6 mEq/L Review Information: The correct answer is D: Serum potassium 6 mEq/L Although all of these findings are abnormal, the elevated potassium level is a life threatening finding and must be reported immediately. Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Question 9

The nurse is caring for a client who requires a mechanical Answers Correct B ventilator for breathing. The high pressure alarm goes off Student's B on the ventilator. What is the first action the nurse should perform? Disconnect the client from the ventilator and use a A) manual resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator Review Information: The correct answer is B: Perform a quick assessment of the client''s condition A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist. 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 10 To prevent unnecessary hypoxia during suctioning of a Answers Correct A tracheostomy, the nurse must Student's A A) apply suction for no more than 10 seconds B) maintain sterile technique C) lubricate 3 to 4 inches of the catheter tip D) withdraw catheter in a circular motion Review Information: The correct answer is A: apply suction for no more than 10 seconds Applying suction for more than 10 seconds may result in hypoxia. Although options B, C, and D are important in during suctioning a tracheostomy, hypoxia results from actions that decrease the oxygen supply. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby. Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 11

A client has a history of chronic obstructive pulmonary Answers Correct C disease (COPD). As the nurse enters the client's room, his Student's C oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? A) Obtain a 12-lead EKG B) Place client in high Fowler's position C) Lower the oxygen rate D) Take baseline vital signs Review Information: The correct answer is C: Lower the oxygen rate A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development of or worsening of respiratory acidosis. Unless corrected, it can lead to the client''s death. 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 12 A client is receiving external beam radiation to the Answers Correct B mediastinum for treatment of bronchial cancer. Addressing Student's B which of the following should take priority in planning care? A) Esophagitis B) Leukopenia C) Fatigue D) Skin irritation Review Information: The correct answer is B: Leukopenia Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer. 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 13

The nurse is caring for a child immediately after surgical Answers Correct B correction of a ventricular septal defect. Which of the Student's B following nursing assessments should be a priority? A) Blanch nail beds for color and refill B) Assess for post-operative arrhythmias C) Auscultate for pulmonary congestion D) Monitor equality of peripheral pulses Review Information: The correct answer is B: Assess for post-operative arrhythmias The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening. 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. Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Question 14 A client has returned from a cardiac catheterization. Which Answers Correct C one of the following findings would indicate the client is Student's C experiencing a complication from the procedure? A) Increased blood pressure B) Increased heart rate C) Loss of pulse in the extremity D) Decreased urine output Review Information: The correct answer is C: Loss of pulse in the extremity Loss of the pulse in the extremity would indicate impaired circulation. 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 15 The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse’s immediate attention? A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms Review Information: The correct answer is C: Dyspnea

Answers Correct C Student's C

Client’s having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication. Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle River, NJ: Prentice-Hall. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question 16 The nurse is assessing a client 2 hours postoperatively after Answers Correct C a femoral popliteal bypass. The upper leg dressing Student's C becomes saturated with blood. The nurse's first action should be to A) wrap the leg with elastic bandages B) apply pressure at the bleeding site C) reinforce the dressing and elevate the leg D) remove the dressings and re-dress the incision Review Information: The correct answer is C: reinforce the dressing and elevate the leg The interventions that must be taken are: reinforce the dressing, elevate the extremity to decrease blood flow into the extremity and thus decrease bleeding, and call the provider immediately. This is an emergency post surgical situation. 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 The provider order reads "Aspirate nasogastric (NG) Answers Correct A feeding tube every 4 hours and check pH of aspirate." The Student's A pH of the aspirate is 10. Which action should the nurse take? A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube Review Information: The correct answer is A: Hold the tube feeding and notify the provider A pH of less than 4 indicates that the tube is appropriately placed in the stomach, a highly acidic environment. A pH higher than 4 (alkaline pH) indicates intestinal placement.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar. Cavanaugh, B. M. (2003). Nurse’s manual of laboratory and diagnostic tests, 4th ed. Philadelphia: Davis.

Question 18 A client has a chest tube inserted following a left lower Answers Correct D lobectomy required by a stab wound to the chest. While Student's D repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Prepare for blood transfusion D) Continue to monitor the rate of drainage Review Information: The correct answer is D: Continue to monitor the rate of drainage It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest. Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Question 19 The most effective nursing intervention to prevent Answers Correct B atelectasis from developing in a post-operative client is to Student's B A) maintain adequate hydration B) assist client to turn, deep breathe, and cough C) ambulate client within 12 hours D) splint incision Review Information: The correct answer is B: assist client to turn, deep breathe, and cough Deep air excursion by turning, deep breathing, and coughing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Question 20 When caring for a client with a post-right thoracotomy Answers Correct B who has undergone an upper lobectomy, the nurse focuses Student's B on pain management to promote A) relaxation and sleep B) deep breathing and coughing C) incisional healing D) range of motion exercises Review Information: The correct answer is B: deep breathing and coughing The priority is preventing postoperative respiratory complications. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. Client compliance with recommended deep breathing and coughing exercises will only be achieved with the appropriate pain management. 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.