Ati nur 213 lifespan final exam
Total Questions : 47
Showing 25 questions, Sign in for moreA nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
Explanation
A. Raising the foot of the bed to a 90° angle is not an appropriate intervention for a chest wound as it may impair respiratory function further.
B. Preparing to insert a central line is not a priority action in managing a sucking chest wound and may delay more immediate life-saving interventions.
C. Removing the dressing to inspect the wound can worsen the condition by allowing more air to enter, increasing the risk of a tension pneumothorax.
D. Administering oxygen via nasal cannula provides essential oxygen support, addressing hypoxia caused by the impaired respiratory function from the chest wound.
A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition. Which of the following instructions should the nurse include?
Explanation
A. Sleeping on the left side can reduce acid reflux symptoms because it keeps the stomach below the esophagus, potentially preventing stomach acid from entering the esophagus.
B. Waiting only 1 hour after eating may not be enough; generally, clients with GERD are advised to wait at least 2-3 hours before lying down.
C. Eating four small meals each day may not be sufficient; GERD patients are often advised to eat smaller, more frequent meals to reduce stomach pressure and prevent reflux.
D. Drinking milk may temporarily soothe the stomach but can stimulate acid production and worsen GERD symptoms over time.
A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?
Explanation
A. Placing a pillow under the affected limb helps elevate the extremity, which can reduce swelling and promote circulation, enhancing recovery.
B. Applying cool compresses every 6 hours is not typically recommended postoperatively, as frequent, direct cooling could impede blood flow to the surgical area.
C. Promoting bed rest for 5-7 days is not advised; early mobility is encouraged to prevent complications such as deep vein thrombosis and improve joint function.
D. Encouraging increased fluid intake is important for general recovery, but it does not specifically address postoperative care for a knee replacement.
A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization?
Explanation
A. Urge incontinence may occur but is not necessarily an indicator for immediate catheterization in a paraplegic patient, as they may lack bladder control.
B. Weight gain is unrelated to the need for catheterization and may indicate other issues like fluid retention.
C. Rectal distention relates to bowel function, not bladder function, and does not indicate the need for catheterization.
D. Dribbling of urine can suggest bladder overfilling and is an indication that the bladder needs emptying through catheterization to prevent urinary retention complications.
A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity?(Select All that Apply.)
Explanation
A. Ecchymosis, or bruising, may be present but does not directly evaluate neurovascular status.
B. Skin integrity is important for general wound assessment but does not specifically indicate neurovascular function.
C. Sensation assessment helps evaluate nerve function, which is critical in identifying potential neurovascular compromise.
D. Color of the affected limb provides information on blood flow, with pale or cyanotic coloring suggesting potential compromise.
E. Temperature can indicate adequate blood flow; a cooler extremity may suggest poor circulation, indicating neurovascular compromise.
A nurse is caring for a client who is postoperative following a below-the knee-amputation and will soon undergo fitting for a leg prosthesis. Which of the following is an appropriate nursing intervention for this client at this time?
Explanation
A. Wrapping the residual limb in a figure-eight configuration provides compression and support, shaping the limb for prosthesis fitting, and promoting proper circulation.
B. Wrapping in a proximal-to-distal direction can restrict blood flow and does not provide the appropriate support needed for prosthetic shaping.
C. The bandage should be rewrapped more frequently than once a day to maintain compression and limb shape.
D. Securing the bandage at the lowest joint is inadequate as it may allow loosening and improper shaping of the residual limb.
A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?
Explanation
A. Offering the bedpan every 2 hours helps manage elimination but does not specifically reduce the risk of urinary tract infections (UTIs).
B. Cleansing from back to front increases the risk of contamination from the anal area and is incorrect hygiene practice.
C. An indwelling catheter can increase the risk of UTIs, so intermittent catheterization is generally preferred.
D. Encouraging fluid intake helps flush the urinary system, reducing the risk of bacterial growth that can lead to UTIs.
Á nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?
Explanation
A. Obtaining a dietary history is relevant for ongoing management but is not the initial priority.
B. Reviewing electrolyte values is essential because exacerbations of ulcerative colitis can lead to severe fluid and electrolyte imbalances, which need prompt correction.
C. Investigating emotional concerns is important but does not take precedence over addressing potential electrolyte imbalances that can be life-threatening.
D. Checking perianal skin integrity is relevant for comfort but is not the priority in stabilizing the client during an acute exacerbation.
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Explanation
A. Mottled skin is more likely observed in the later, progressive stage of shock when tissue perfusion is severely compromised.
B. Hypokalemia is not a typical finding in the compensatory stage of shock; electrolyte imbalances are usually more evident in later stages.
C. A heart rate of 160/min is typically associated with more advanced shock; in the compensatory stage, the increase is usually moderate.
D. Blood pressure is often within normal or slightly decreased ranges in the compensatory stage, as the body is working to maintain perfusion.
A nurse is admitting a client who was prescribed antibiotic therapy and now has a Clostridium difficile infection. Which of the following actions should the nurse take?
Explanation
A. A protective environment is not necessary; Clostridium difficile requires contact precautions.
B. Alcohol-based hand sanitizers are ineffective against Clostridium difficile spores; handwashing with soap and water is essential.
C. Wearing a mask is not necessary as C. difficile is transmitted through spores that survive on surfaces.
D. Disinfecting equipment daily helps reduce the risk of C. difficile spore transmission within the environment.
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?
Explanation
A. An increase in heart rate is an early compensatory response to hypovolemia, as the body attempts to maintain cardiac output in the face of reduced blood volume.
B. A decrease in respiratory rate is not a typical early sign of hypovolemic shock; usually, respiratory rate would increase to improve oxygen delivery.
C. A decrease in urinary output is also a sign of hypovolemia but may not be as immediately indicative as the heart rate change.
D. An increase in temperature is not directly related to hypovolemic shock and may be due to other factors, such as infection or inflammation.
A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?
Explanation
A. Pernicious anemia affects red blood cell production and does not typically cause blood-tinged urine.
B. Prostate enlargement may cause urinary retention or difficulty urinating, but it does not commonly lead to blood-tinged urine in a catheter bag.
C. A bladder infection (cystitis) can lead to hematuria (blood in the urine), especially when the bladder wall is inflamed.
D. Dehydration can cause concentrated urine but does not usually result in blood-tinged urine.
A nurse is preparing a presentation at a community center about osteoarthritis. The nurse should plan to include which of the following information? (Select All that Apply.)
Explanation
A. Osteoarthritis causes joint pain due to the deterioration of cartilage in the joints.
B. Crepitus, a grating sound, can occur in affected joints due to bone rubbing on bone.
C. Osteoarthritis primarily affects weight-bearing joints such as the hips, knees, and spine.
D. Osteoarthritis often affects joints asymmetrically rather than in a bilateral symmetrical pattern, which is more characteristic of rheumatoid arthritis.
E. Joint stiffness, particularly after periods of inactivity, is a common symptom of osteoarthritis.
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate?(Select All that Apply.)
Explanation
A. A turning schedule every 4 hours is insufficient; repositioning should ideally be done every 2 hours to prevent pressure injuries.
B. Reducing skin exposure to moisture helps maintain skin integrity, especially in areas prone to breakdown due to moisture accumulation.
C. Powder is not recommended as it can lead to skin irritation and potential breakdown.
D. Elevating heels with pillows relieves pressure on areas that are susceptible to pressure injuries in immobilized clients.
E. Massaging erythematous bony prominences can damage capillaries and increase the risk of pressure injury formation.
A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?
Explanation
A. Auscultating blood pressure may not be as reliable in burn patients due to fluid shifts and potential damage to peripheral tissues.
B. Monitoring pulmonary artery pressure provides crucial information about the cardiovascular system's status, including fluid balance and cardiac function, which are essential in the care of clients with severe burns.
C. Palpating pulse pressure alone is insufficient for thorough cardiovascular monitoring in critically ill burn patients.
D. Central venous pressure provides information about fluid status but does not offer the comprehensive cardiovascular data needed for extensive burn management.
A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select All that Apply)
Explanation
A. A weakened gag reflex is a possible complication due to impaired nerve function, increasing the risk of aspiration.
B. Polyuria is not typically associated with cervical spinal cord injuries.
C. Hypotension may occur due to neurogenic shock from impaired autonomic function following a cervical spinal cord injury.
D. Hyperthermia can develop if the injury affects thermoregulatory control.
E. Absence of bowel sounds may indicate paralytic ileus, a common complication in clients with spinal cord injuries.
A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner should indicate to the nurse that the teaching was effective?
Explanation
A. A 30° angle is too low and may increase the risk of aspiration; a 90° sitting position is preferred for safe swallowing.
B. Coughing while swallowing is not recommended as it may increase the risk of choking.
C. Tilting the head forward while swallowing helps to close the airway and reduce the risk of aspiration, which is crucial in dysphagia management.
D. Food should be placed on the stronger side to improve control and reduce aspiration risk.
A nurse is teaching a client who has fibromyalgia about self-care strategies for managing the disorder. Which of the following information should the nurse include in the teaching?
Explanation
A. High-impact activities like jogging or running may worsen symptoms; low-impact exercise is preferred.
B. Increased calcium intake is not specifically recommended for fibromyalgia.
C. Avoiding all exercise during flare-ups is not advised, as gentle stretching or low-impact activities can often help alleviate pain.
D. A regular sleep pattern is essential, as quality sleep can improve symptoms and overall functioning in clients with fibromyalgia.
A nurse is caring for a client who has a femur fracture. The nurse suspects that the client has fat embolism syndrome. Which of the following findings should the nurse identify as an early manifestation of fat embolism syndrome?
Explanation
A. Hypoxemia is an early sign of fat embolism syndrome due to the presence of fat globules in the pulmonary circulation.
B. Headache can be associated with hypoxemia but is not as specific or immediate as hypoxemia itself.
C. Petechiae, while a classic sign, usually appear later in the progression of fat embolism syndrome.
D. Precordial chest pain may occur but is not typically the first sign; hypoxemia is usually noted first.
Á nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?
Explanation
A. Moving objects away prevents injury during the seizure and is a critical safety measure.
B. Placing the client on their side, rather than on their back, helps maintain an open airway and prevents aspiration.
C. Inserting anything into the client's mouth, including a padded tongue blade, is not recommended as it may cause injury.
D. Restraining the client could result in injury and is not advised.
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
Explanation
A. A GCS score of 3 for eye opening indicates that the client does not open their eyes spontaneously, while a score of 5 for best verbal response suggests that they can respond verbally, likely indicating that they can open their eyes when spoken to or when commanded. This conclusion aligns with the score of 5 for verbal response, which indicates a higher level of responsiveness.
B. This option is incorrect because a score of 5 for best verbal response indicates that the client can produce vocal sounds, meaning they are capable of making verbal responses.
C. While the eye opening score of 3 suggests significant impairment, the overall GCS score of 13 (3 + 5 + 5) does not support the conclusion that the client is completely unconscious. The presence of verbal and motor responses indicates some level of consciousness.
D. This conclusion is incorrect because a score of 5 for best motor response suggests that the client can follow commands and respond to stimuli, which is inconsistent with being unable to follow commands.
Á nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
Explanation
A. Lifelong heparin usage is not the standard treatment for DIC, as treatment focuses on addressing the underlying cause and managing symptoms.
B. DIC is a condition characterized by abnormal, excessive coagulation involving the use of clotting factors, particularly fibrinogen, leading to widespread clotting and bleeding.
C. DIC is not a genetic disorder or directly related to vitamin K deficiency.
D. DIC typically leads to a decreased platelet count due to consumption of platelets in widespread clotting, not an elevated count.
A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching?
Explanation
A. While the client's close contacts may be screened and tested for TB, they do not typically need preventive treatment unless they test positive.
B. Treatment for TB usually involves a 6 to 9-month regimen of multiple medications to effectively eradicate the bacteria and prevent drug resistance.
C. A negative Mantoux test would not indicate that TB is cured; it is used for screening, not for monitoring treatment effectiveness.
D. TB medications are not taken lifelong; they are taken for a specified period to cure the infection.
A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?
Explanation
A. A high-purine diet can worsen gout symptoms, so the client should avoid high-purine foods.
B. Limiting alcohol intake can help reduce gout attacks, as alcohol can increase uric acid levels.
C. Limiting fluid intake is not recommended; instead, increased hydration is beneficial for flushing uric acid from the system.
D. Aspirin is generally avoided in gout, as it can increase uric acid levels and worsen symptoms.
A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?
Explanation
A. Widening pulse pressure is more indicative of increased intracranial pressure or septic shock, not hypovolemic shock.
B. Deep tendon reflexes are typically not increased in hypovolemic shock.
C. Increased heart rate is a compensatory response to hypovolemic shock as the body attempts to maintain cardiac output.
D. A pulse oximetry reading of 96% would not typically indicate hypovolemic shock; decreased oxygen saturation is more consistent with hypoxia.
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