Question 1

A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for further instruction?

Accepted Answer

11ecbb05_cb77_f67e_b433_19a1177f4469_MD0009_00 To provide full support when climbing stairs, clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the direction of the stairs (Option B). They should also keep 2 points of support on the floor at all times (eg, both feet, cane and foot) and face forward when going up or down the stairs, especially if there is no handrail (Option A). The nurse should instruct the client on the following: When ascending stairs: Step up with the stronger leg first (in this client, the right leg) Move the cane next while bearing weight on the stronger leg Finally, move the weaker leg (in this client, the left leg) When descending stairs: Lead with the cane Bring the weaker leg down next Finally, step down with the stronger leg The nurse may use the mnemonic "up with the good and down with the bad." The cane always moves before the weaker leg. (Option D) Clients are usually hospitalized for 3-4 days following a total knee replacement and can bear full weight by the time of discharge. Early ambulation and weight-bearing helps to hasten recovery and prevent complications (eg, thromboembolism). Educational objective: Clients who have had total knee replacement surgery can typically bear full weight by the time of discharge. To reduce the risk of falls, the client should hold the cane on the stronger side and face forward when going up and down the stairs. To ascend the stairs, the client should first step up with the stronger leg, next bear weight on that leg and move the cane, and finally step up with the weaker leg.

Question 2

A client with a dislocated shoulder is prescribed a shoulder sling. The nurse applies the sling and evaluates the fit before discharge from the emergency room. Which assessment finding indicates an incorrect fit?

Accepted Answer

11ecbb05_cb79_07ef_b433_81ac3a5aff94_MD0009_00 A sling is used to support the shoulder after a fracture, dislocation, injury, or surgery. Commercially made slings are used almost exclusively. They have a sleeve that fits around the injured extremity and extends above the elbow and adjustable straps to provide a snug and comfortable fit around the waist and neck. To prevent injury and provide proper support of the affected extremity, the nurse should evaluate the proper fit of the sling by assessing for the following factors: Elbow is flexed at 90 degrees to support the forearm, prevent swelling, and relieve shoulder pressure (Option A) Hand is held slightly above the level of the elbow, through adjustment of the neck strap, to prevent venous pooling and edema (Option B) Bottom of the sling ends in the middle of the palm with the fingers visible, to be able to assess circulation, sensation, and movement (Option C) Sling supports the wrist joint with the thumb facing upward or inward toward the body, to maintain proper alignment (Option D) Skin irritation, which can occur under the sling and around the neck if the strap is too tight Educational objective: To ensure proper shoulder sling fit, the nurse should assess for the following: Elbow is flexed at 90 degrees Hand is held slightly above the level of the elbow Bottom of the sling ends in the middle of the palm with the fingers visible Sling supports the wrist joint

Question 3

A client started a 24-hour urine collection test at 6:00 AM.  The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time.  What action should the nurse take?

Accepted Answer

Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine (eg, creatinine, protein, uric acid, hormones). These tests require the collection of all urine produced in a specified time period (a crucial step) to ensure accurate test results. The proper container (with or without preservative) for any specific test is obtained from the laboratory. The collection container must be kept cool (eg, on ice, refrigerated) to prevent bacterial decomposition of the urine. Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning voiding and to end it at the same hour the next morning after the morning voiding (Option B). (Option A) Adding 250 mL to the total output when the test is completed is not an appropriate action as the actual urine output from the 24-hour period is needed for accurate results. (Option C) To start the collection period, the nurse asks the client to void and discards this specimen (it is not added to the collection container). The 24-hour period starts at the time of the client's first voiding. (Option D) Relabeling the same container and changing the start time from 6:00 AM to 10:00 AM is not an appropriate action. The container would include part of the urine produced in a 28-hour period, and the test results would be inaccurate. Educational objective: It is common practice to start a 24-hour urine collection test at the time of the client's first voiding in the morning. If any urine is discarded by accident during the test period, the procedure must be restarted. All produced urine should be placed in the same container and kept cool (on ice).

Question 4

An elderly client is brought to the emergency department with lethargy, chills, and sharp chest pain with deep breathing. Pulse oximeter shows 93% on room air and respirations are 24/min. What is the nurse's initial action?

Accepted Answer

Assessment is the first step in the nursing process that is used to gather information. Lung auscultation is the nurse's initial action with this client. Before intervening, the nurse should assess respiratory status and vital signs to obtain the baseline data that will be compared to subsequent changes. (Option A) Morphine is administered to provide comfort and pain relief. This is an appropriate intervention to facilitate breathing and oxygenation, but it is not the best initial action. Assessment of respiratory status and vital signs should be performed before intervening. (Option C) Initiation of an IV infusion of saline is done to provide hydration and IV access. This is an appropriate intervention, but it is not the best initial action. (Option D) Although the saturation is decreased (93%) and the respiratory rate is increased (24/min), both are adequate to support oxygenation at this time. Nasal oxygen at 3 L/min should be initiated to improve oxygenation. Even though this is an appropriate intervention, it is not the best initial action. Educational objective: The nurse should first assess the client's condition before intervening. This is important as the ability to plan effective nursing care, set priorities, identify appropriate interventions, and make sound clinical decisions is based on the information obtained from the assessment.

Question 5

The nurse is preparing a client for a magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment data? Select all that apply.

Accepted Answer

Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive diagnostic test used to visualize the biliary, hepatic, and pancreatic ducts via MRI. MRCP uses oral or IV gadolinium (noniodine contrast material) and is a safer, less-invasive alternative to endoscopic retrograde cholangiopancreatography to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction. The nurse must assess for contraindications before the procedure, including the presence of certain metal and/or electrical implants (eg, aneurysm clip, pacemaker, cochlear implant) or any previous allergy or reaction to gadolinium (Option D). A client with a history of rash following prior IV contrast administration should be assessed to determine the type of contrast that caused the reaction. Although allergies to iodine-based contrast material are more common, the nurse must rule out a gadolinium allergy (Option B). Pregnancy also is a contraindication for MRCP as gadolinium crosses the placenta and may adversely affect the fetus. Delayed/irregular menses may be a normal variation in some clients; however, delayed menses may indicate pregnancy and should be reported for further investigation prior to MRCP (Option C). (Option A) Many clients should be NPO for 4 hours prior to the procedure to allow better visualization of the anatomical features. (Option E) Smoking does not affect MRI visualization and is not a contraindication. Educational objective: Magnetic resonance cholangiopancreatography uses MRI to visualize the biliary and hepatic ductal system. Contraindications, including pregnancy, the presence of certain metal implants, and an allergy to gadolinium (ie, noniodine contrast agent), should be assessed before the procedure.

Question 6

A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate? Select all that apply.

Accepted Answer

11ecbb05_cb73_89a9_b433_757a6f3d0127_MD0009_00 When administering bolus enteral feedings, the nurse should elevate the head of the bed to 30-45 degrees (semi-Fowler position) and keep it elevated for 30-60 minutes afterwards to decrease aspiration risk (Option C). Many institutions require the nurse to hold feeding if the client must remain supine (eg, diagnostic tests). Feeding tubes should be flushed before and after feedings to keep the tube patent (Option B). Gastric residual volumes (GRVs) are traditionally checked every 4 hours with continuous feeding or before each bolus feeding. Per facility policy, enteral feedings may be held for high GRV (eg, >500 mL) to reduce aspiration risk. Low GRV indicates that the client is tolerating feedings well (Option D). Some facilities no longer routinely check GRVs because recent evidence shows that the procedure may not truly indicate aspiration risk and actually impairs calorie delivery. Regardless of GRV checks, the nurse should closely monitor clients for symptoms of intolerance (eg, abdominal distension, nausea/vomiting), which may indicate that feedings should be held or reduced in volume. (Option A) Aspirated GRV should be returned to the stomach. If acidic gastric juices are repeatedly discarded, there is risk for hypokalemia and metabolic alkalosis. (Option E) Gastric pH should be acidic (pH ≤5). A pH ≥6 requires x-ray confirmation of tube placement. Newly inserted nasogastric tubes also require x-ray confirmation before feedings are initiated. Educational objective: When administering bolus enteral feedings, the nurse should place the client in semi-Fowler position, check gastric residual volumes (GRVs) as prescribed, verify acidic pH ≤5, return aspirated GRV to the stomach, and flush the tube before and after feedings.

Question 7

Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube? Select all that apply.

Accepted Answer

A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded. The general steps for chest tube removal include: Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal (Option A). Provide the health care provider (HCP) with sterile suture removal equipment (Option E). Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space (Option B). Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space (Option D). Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame. (Option C) The client should be placed in semi-Fowler's position or on the unaffected side to promote comfort and facilitate access for tube removal. Educational objective: Before chest tube removal, the client is given an analgesic and then asked to perform Valsalva during the procedure. The nurse should also bring sterile suture removal equipment and a sterile airtight occlusive dressing. Post-procedure chest x-ray is necessary within 2-24 hours.

Question 8

The nurse notes muffled heart tones in a client with a pericardial effusion.  How would the nurse assess for a pulsus paradoxus?

Accepted Answer

Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. Cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration. cardiac tamponade The procedure for measurement of pulsus paradoxus is as follows: Place client in semirecumbent position Have client breathe normally Determine the SBP using a manual BP cuff Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade. (Option A) Variation in QRS amplitude is termed electrical alternans. It could be present in cardiac tamponade, but it is not how pulsus paradoxus is determined. Electrical alternans is due to the swinging motion of the heart in a fluid-filled pericardial sac. (Option B) An apical/radial pulse deficit may be present during certain dysrhythmias, but this is not the procedure for measuring pulsus paradoxus. (Option D) This is the formula for calculating mean arterial pressure. Educational objective: The nurse should assess the client for pulsus paradoxus when cardiac tamponade is suspected. The amount of paradox is the difference between the pressure heard at the first Korotkoff sound during expiration and the Korotkoff sounds heard throughout inspiration and expiration. A difference of <10 mm Hg is normal, but if it is >10 mm Hg, this may indicate cardiac tamponade.

Question 9

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply.

Accepted Answer

A tourniquet is applied 3-5 inches above the desired puncture site for no longer than 1 minute when looking for a vein. If longer time is needed, release the tourniquet for at least 3 minutes before reapplying. Prolonged obstruction of blood flow by the tourniquet can change some test results. Pulsating bright red blood indicates that an artery was accessed. If this happens, the needle should be removed immediately and pressure should be applied for at least 5 minutes, followed by a pressure dressing to prevent a hematoma. (Option B) Skin preparation involves cleaning using an antiseptic solution and friction and allowing the skin to air dry. Remaining solution may hemolyze and/or dilute the blood sample. Traditionally, alcohol (alone or with povidone iodine) is applied in a circular motion, from insertion site outward (clean to dirty). Current research suggests that the most effective method is applying chlorhexidine (2%) in a back and forth motion, followed by adequate drying time. (Option D) The veins on the ventral aspect of the wrist are located near nerves, resulting in painful venipuncture and a higher risk of nerve injury. There is also an increased risk of arterial access on the ventral aspect of the wrist, and so this site should be avoided. (Option E) The filled tube should be gently inverted 5-10 times to mix anticoagulant solution with the blood. Vigorously shaking the tube can cause hemolysis and false results. Educational objective: When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of wrist, position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes.

Question 10

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply.

Accepted Answer

When performing phlebotomy, clean the site, "fix" or hold the vein taut, and then insert the needle bevel up at a 15-degree angle (no steeper than 30 degree). Some recommend bevel down for children. This will help prevent going through the vein completely. The Infusion Nurses Society (INS) identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw. The affected side of a client who has had a mastectomy (especially with lymph node removal) should not be used. It places the client at risk for infection and lymphedema. (Option C) An arm without IV infusion is preferred. If it is necessary to use the arm with the IV infusion, the specimen should be collected from a vein several centimeters below (distal to) the point of IV infusion, with the tourniquet placed in between. (Option E) The finger specimen should be obtained from the third or fourth finger on the side of the fingertip, midway between the edge and midpoint. The puncture should be made perpendicular to the fingerprint ridges. Puncture parallel to the ridges tends to make the blood run down the ridges and will hamper collection. A heel stick collection on an infant should be done on the plantar surface. Educational objective: When obtaining blood from a client, insert the needle at 15-degree angle, limit attempts to 2, and avoid the side of a mastectomy. A capillary specimen should be obtained at the side of the finger pad. Never draw a specimen above an IV infusion.

Question 11

The nurse observes a client who is postoperative left total knee replacement use a cane.  Which action by the client indicates an understanding of the correct technique when walking down the stairs?

Accepted Answer

11ecbb05_cb77_814d_b433_1b4ec7d58a68_MD0009_00 To prevent falls after a total knee replacement, clients should use a cane to provide maximum support when climbing up and down any stairs. Clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the direction. Clients must also keep 2 points of support on the floor at all times (ie, both feet, foot and cane). When descending stairs, the client should: Lead with the cane Bring the weaker leg down next (in this client, it is the left leg) Finally, step down with the stronger leg (Option A) When ascending stairs, the client should: Step up with the stronger leg first Move the cane next, while bearing weight on the stronger leg Finally, move the weaker leg To remember the order, use the mnemonic "up with the good and down with the bad." The cane always moves before the weaker leg. (Options B, C, and D) These options do not provide enough support to the weaker leg when descending. Educational objective: To prevent falls when descending the stairs using a cane, the client should lead with the cane, follow with the weaker leg, and then step down with the stronger leg.

Question 12

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial action?

Accepted Answer

11ecbb05_cb79_7d20_b433_398e921906fb_MD0009_00 Foreign body aspiration is an emergency that requires immediate intervention when witnessed or highly suspected. The primary rescue intervention for adults and children over age 1 is abdominal thrusts, known as the Heimlich maneuver. This maneuver entails applying upward thrusts with a fist to the upper abdomen just beneath the rib cage. The upward action causes the diaphragm to forcefully expel air out of the airway, carrying the foreign body out with it. If the child is conscious and able to cough or make sounds, the nurse should ask the child to forcefully cough before intervening. These signs indicate a partial obstruction still allowing airflow, which may be cleared with strong coughing. However, any signs of respiratory distress (eg, stridor, inability to speak, weak cough, and cyanosis) require immediate intervention. (Option B) Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Older children require abdominal thrusts to clear an obstructed airway. (Option C) Blind sweeping a child's mouth can force a loosely obstructing object to fully block the airway or cause the object to fall farther into the airway, requiring surgical removal. (Option D) This child is experiencing a blocked airway, which is a medical emergency that requires intervention at the skill level of a nurse. The nurse can ask a bystander to contact 911 while attempting to clear the airway. This differs from a situation such as anaphylaxis, in which the nurse would require epinephrine and would call 911 for immediate assistance. Educational objective: The Heimlich maneuver (ie, upward abdominal thrusts under the rib cage) is the primary rescue intervention for children over age 1 with a foreign body airway obstruction causing respiratory distress. Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Blind sweeping of a child's mouth should not be attempted.

Question 13

A blood transfusion is prescribed for a client experiencing complications of sickle cell anemia with a hemoglobin level of 6 g/dL (60 g/L). Which of the following actions by the registered nurse are appropriate? Select all that apply.

Accepted Answer

Blood transfusions are commonly administered to clients experiencing anemia or acute blood loss. To ensure client safety during blood administration, the nurse should: Verify two client identifiers (eg, name, medical record number, date of birth), the prescription, and the blood products with another licensed health care provider (Option A). Ensure that blood type and Rh type are compatible (Option C). An Rh-positive client can safely receive Rh-positive or Rh-negative blood. Administer the blood via filtered tubing with normal saline to prevent clumping in the tube and hemolysis of red blood cells (Option E). Monitor vital signs during transfusion per facility-specific protocol (eg, before transfusion, 15 minutes after transfusion begins, periodically). Transfuse blood products within 4 hours due to the risk for bacterial growth. (Option B) The nurse remains with the client for the first 15 minutes (ie, approximately 50 mL) of the transfusion and obtains vital signs directly to monitor for adverse reactions (eg, fever, chest pain). Delegating vital signs to unlicensed assistive personnel after the initial 15-30 minutes may be appropriate for stable clients. (Option D) Infusing blood over 6 hours increases the risk of bacterial contamination and hemolysis of the blood product. Educational objective: The nurse facilitates safe blood administration by verifying the prescription, blood type, and at least two client identifiers with another licensed health care provider; administering blood with normal saline; obtaining vital signs directly for the first 15 minutes (ie, approximately 50 mL of the transfusion); and transfusing blood within 4 hours.

Question 14

The nurse attempts to flush a client's subclavian vein central venous access device with normal saline using a 10-mL syringe, but meets resistance, is unable to aspirate blood, and suspects an occlusion. What should the nurse do next?

Accepted Answer

11ecbb05_cb74_e93a_b433_cb14b35ca7f7_MD0009_00 Catheter occlusion is the most common complication of central venous access devices. Kinked tubing, catheter malposition, medication precipitate, or thrombus can occlude the lumen, preventing the ability to flush or aspirate blood. The nurse should first assess for mechanical, nonthrombotic problems by: Repositioning the client (eg, head, arm) as the catheter tip may be resting against a vessel wall (Option D) Assessing IV tubing for clamps, kinks, and precipitate The nurse should then attempt to flush the device again. If the occlusion remains, the nurse should not flush against resistance as applying force may damage the catheter or dislodge a thrombus. Instead, the nurse should contact the health care provider (HCP), who may prescribe medication (ie, alteplase) to dissolve a thrombus or fibrin sheath. (Option A) Most needleless connector manufacturers recommend flushing with normal saline. Some facilities may use heparinized saline flushes; the nurse should follow HCP prescriptions and institution guidelines. Heparin flushes should be at the lowest acceptable dose (eg, 10 units/mL) to prevent heparin-induced thrombocytopenia. (Option B) Flushing with a syringe smaller than 10 mL causes increased intraluminal pressure and may damage the catheter. (Option C) The nurse should rule out a mechanical problem before notifying the HCP. Educational objective: Occlusion of a central venous access device can be related to mechanical, medication precipitate, or thrombotic causes. The nurse should first attempt to remove the occlusion by eliminating a possible mechanical obstruction (eg, reposition client to adjust catheter tip location) before notifying the health care provider.

Question 15

The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW).  The site must be assessed for a reaction afterward.  The nurse instructs the HCW to return in how many hours?

Accepted Answer

11ecbb05_cb73_3b88_b433_cbf0556fa11d_MD0009_00 TST (Mantoux) is the standard method for conducting tuberculosis (TB) surveillance of HCWs and involves 2 steps: Injection of purified protein derivative solution under the first layer of skin of the forearm Evaluation of the injection site 48-72 hours later The health care practitioner inspects and palpates the site to determine if a local skin reaction has occurred. Induration (not redness) indicates a positive test, which means that the individual has been exposed to TB, has developed antibodies, and is infected with TB bacteria. Further testing is needed to determine the presence of latent TB infection or active TB disease. Presence of symptoms, positive sputum culture, and chest x-ray abnormalities confirm active TB. Induration The QuantiFERON-TB (QFT) blood test is an alternative to TST that measures how the immune system reacts to TB bacteria. Like TST, a positive QFT test only indicates that the individual has been infected with TB bacteria. Although the test is more expensive, it requires only a single visit to the health care provider and results are available in 24 hours. (Options A, B, and C) The 12-, 24-, and 36-hour time frames are incorrect. Educational objective: The presence of an indurated area at the injection site 2-3 days after the tuberculin solution is administered indicates a positive TST.

Question 16

The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside.  The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now.  How should the nurse respond?

Accepted Answer

With procedural moderate sedation at the bedside, the nurse takes on the role of an anesthetist. The nurse's role is to monitor the client's condition while the health care provider focuses on performing the procedure. The nurse should never leave the client during the procedure. The best response is to have an available nurse (the charge nurse) go assess and deal with the needs of the client next door. (Option A) This action would place the UAP in the role of assessing and prioritizing, which is beyond the scope of the UAP's practice. In addition, the nurse must stay in the room and cannot meet the other client's need as a result. (Option B) Taking on the role of assessing/monitoring (related to anesthesia) and/or administering additional intravenous drugs during the procedure is beyond the scope of the UAP's practice. (Option C) The UAP has already communicated that the client's need is urgent. The client should not be kept waiting without further assessment to evaluate the situation. Educational objective: The nurse takes on the role of anesthetist when assisting with bedside procedural moderate sedation and cannot leave the client during the procedure.

Question 17

The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply.

Accepted Answer

Sputum culture and sensitivity testing is used to identify infectious organisms in the respiratory tract and determine which antimicrobials are most effective at treating the identified organism. Nurses assisting a client to collect sputum should instruct the client to: Rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen contamination by oral flora (Option A) Rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen contamination by oral flora (Option A) Avoid touching the inside of the sterile container or lid to avoid accidental specimen contamination by normal flora of the skin (Option B) Avoid touching the inside of the sterile container or lid to avoid accidental specimen contamination by normal flora of the skin (Option B) Inhale deeply several times and then cough forcefully, which promotes expectoration of lower lung secretions and increases sample volume (Option C) Inhale deeply several times and then cough forcefully, which promotes expectoration of lower lung secretions and increases sample volume (Option C) Assume a sitting or upright position before specimen collection, if possible, to promote cough strength during collection (Option E) Assume a sitting or upright position before specimen collection, if possible, to promote cough strength during collection (Option E) (Option D) Sputum specimens should be collected early in the morning after awakening, which improves the quality of the sample because secretions accumulate overnight due to cough inhibition. A nebulizer treatment may be prescribed to help mobilize thick secretions. Educational objective: Collection of a sputum specimen by expectoration is a sterile procedure that requires the client to breathe deeply and cough effectively. The nurse should instruct the client to rinse the mouth with water, sit upright, inhale deeply several times, and cough prior to expectorating. The client should avoid touching the inside of the sterile container or lid. Sputum should be collected in the morning to improve sample quality.

Question 18

The nurse is assessing a client's peripheral pulses.  The nurse palpates the top portion of the client's foot.  The right pulse is easily palpable, and the left pulse is diminished but still palpable.  How should the nurse document these findings?

Accepted Answer

11ecbb05_cb75_5e6b_b433_6b00a6418a26_MD0009_00 The DP pulse is located on the top or dorsal part of the foot. The nurse should compare the characteristics of the arteries on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated on the following scale. 11ecbb05_cb75_5e6c_b433_af21181061e0_MD0009_00 (Option B) DP is the correct artery being assessed, but 3+ would indicate a full, bounding pulse and 2+ would indicate a normal pulse. (Option C) The popliteal pulse is assessed just behind the knee area, not on the foot. The description of the right foot being greater than the left foot does not indicate the force of the individual pulse. (Option D) Posterior tibial pulses are palpated just behind the medial malleolus bone on the foot. The description of 2+ and 1+ is accurate. Educational objective: The nurse should palpate and compare the characteristic and quality of the pulses on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated as 0, absent; 1+, weak; 2+, normal; and 3+, increased, full, bounding. These descriptions should be documented in the client's record.

Question 19

Ten minutes after an infusion of packed red blood cells (PRBCs) is initiated through a central venous catheter (CVC), the client has shortness of breath and slight chest tightness. What initial actions would be appropriate for the nurse to complete? Select all that apply.

Accepted Answer

Signs and symptoms of a blood transfusion reaction typically will occur within the first 15 minutes after initiation of the transfusion. These include shortness of breath, chest tightness, fever, back pain, anxiety, tachycardia, and hypotension. When a transfusion reaction is suspected, the first step is to stop the infusion (Option E). An infusion of normal saline is typically started. It is important that normal saline be administered through a different port of the CVC using new tubing or at the closest access point to the client. Flushing the blood in the IV tubing into the client will expose the client to more of the causative agent and increase complications from the transfusion reaction (Option B). The HCP must then be notified (Option C). Because the client has shortness of breath and chest tightness, an assessment of breath sounds is appropriate. Adventitious sounds could indicate bronchospasm or excess fluid in the lungs (Option A). (Option D) A CVC will not be discontinued due to the transfusion reaction. IV access will be required for administration of fluids and medications. Educational objective: If an adverse blood transfusion reaction is suspected, the first action is to stop the infusion. An infusion of normal saline through a different port for the CVC is typically started. A client assessment and notification of the HCP are also required.

Question 20

A nurse is assisting with the care of a newborn during circumcision.  Which is an appropriate intervention?

Accepted Answer

Application of a blanket restraint or the use of a special board prevents injury during circumcision. Swaddling and the use of non-nutritive sucking are nonpharmacologic approaches to manage pain during circumcision. (Option A) A loose-fitting diaper is put on the newborn after circumcision to avoid irritation to the penis. (Option B) Sterile technique is used during the surgical procedure of circumcision. (Option C) The infant should not be fed during circumcision to prevent the risk of aspiration. A pacifier dipped in a concentrated sucrose solution is offered as a nonpharmacologic pain management technique. Educational objective: During circumcision, the newborn is restrained in a wrapped blanket or placed on a special board to prevent injury. Non-nutritive sucking of a concentrated sucrose solution is offered for pain management.

Exam 4: Fundamentals

A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for further instruction?

A client with a dislocated shoulder is prescribed a shoulder sling. The nurse applies the sling and evaluates the fit before discharge from the emergency room. Which assessment finding indicates an incorrect fit?

A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take?

An elderly client is brought to the emergency department with lethargy, chills, and sharp chest pain with deep breathing. Pulse oximeter shows 93% on room air and respirations are 24/min. What is the nurse's initial action?

The nurse is preparing a client for a magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment data? Select all that apply.

A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate? Select all that apply.

Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube? Select all that apply.

The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulsus paradoxus?

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply.

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply.

The nurse observes a client who is postoperative left total knee replacement use a cane. Which action by the client indicates an understanding of the correct technique when walking down the stairs?

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial action?

A blood transfusion is prescribed for a client experiencing complications of sickle cell anemia with a hemoglobin level of 6 g/dL (60 g/L) . Which of the following actions by the registered nurse are appropriate? Select all that apply.

The nurse attempts to flush a client's subclavian vein central venous access device with normal saline using a 10-mL syringe, but meets resistance, is unable to aspirate blood, and suspects an occlusion. What should the nurse do next?

The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW) . The site must be assessed for a reaction afterward. The nurse instructs the HCW to return in how many hours?

The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond?

The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply.

The nurse is assessing a client's peripheral pulses. The nurse palpates the top portion of the client's foot. The right pulse is easily palpable, and the left pulse is diminished but still palpable. How should the nurse document these findings?

Ten minutes after an infusion of packed red blood cells (PRBCs) is initiated through a central venous catheter (CVC) , the client has shortness of breath and slight chest tightness. What initial actions would be appropriate for the nurse to complete? Select all that apply.

A nurse is assisting with the care of a newborn during circumcision. Which is an appropriate intervention?