Nursing Comprehensive Exam 5

A client with renal failure does not eliminate sufficient fluid, which increases the risk of fluid overload and the resulting respiratory and electrolyte problems. This client is exhibiting signs of fluid volume excess and is acutely ill. Fear and toileting self-care deficit may be problems but are not as high a priority because they are not life-threatening. Urinary retention maybe a cause of renal failure but is not as urgent a concern as the fluid problem.

Encouraging verbalization of feelings is an example of therapeutic communication, which is used to help the client express and work through feelings and problems related to his or her condition. Administering drugs, limiting visits, and reminding the client of responsibilities are techniques that do not help the client work through feelings.

The first priority is to arrange for colostomy care, because many clients are discharged so quickly from acute care settings that they do not receive complete instructions. Notifying the American Cancer Society and requesting Meals On Wheels and an occupational therapy evaluation are important but can occur later in rehabilitation.

The Patient's Bill of Rights addresses the client's rights to information, informed consent, timely responses to requests for services, and treatment refusal. It is a legal document and serves as guideline for decision making by the nurse. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurse contain nursing practice parameters and primarily describe the use of the nursing process in providing care.

Subjective data (data from the client) about the chest pain help identify the specific health problem. For example, asking about the setting in which chest pain developed can provide necessary information about its cause. Options A and D do not elicit information related to a cardiac problem. Option B presumes a particular diagnosis and asks a "Why" question (a nontherapeutic technique).

Elevating the head of the bed during an enteral feeding minimizes the risk of aspiration and allows the formula to flow into the intestines. When elevation of the head of the bed is contraindicated, the client should be positioned on the right side, not the left side. Enteral feedings should be given at room temperature to minimize GI distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused in 3 hours.

Behavioral manifestations of dysfunctional grieving include alterations in eating habits, sleep patterns, and activity levels. None of the other nursing diagnoses include these manifestations among their defining characteristics.

A common goal of discharge planning in all settings is teaching the client self-care. This action facilitates the transition between different settings and is designed to shorten hospital stays. Providing financial assistance is not a goal for discharge planning, although the nurse may make referrals to the appropriate department for financial assistance. The nurse should encourage the client to return for follow-up visits, rather than prevent them.

Although the nurse is assessing pain relief, this action is considered part of the evaluation - not assessment - because the nurse has performed an intervention and is evaluating whether the goal has been met. During the nursing diagnosis step, the nurse labels or describes the client's health problems or needs, such as pain. During the implementation step, the nurse performs interventions to meet the client's needs, such as administering medication.

A client with renal failure does not eliminate sufficient fluid, which increases the risk of fluid overload and the resulting respiratory and electrolyte problems. This client is exhibiting signs of fluid volume excess and is acutely ill. Fear and toileting self-care deficit may be problems but are not as high a priority because they are not life-threatening. Urinary retention maybe a cause of renal failure but is not as urgent a concern as the fluid problem.

During CPR, the carotid artery is the most accessible and may persist when peripheral pulses (radial and brachial) are no longer palpable due to decreased cardiac output and decreased peripheral perfusion. The chest compressions performed during CPR make it impossible to accurately assess the apical pulse.

Body image disturbance is a disruption in the way one perceives one's body and is indicated by a verbal response to an actual change in physical appearance or structure. Anxiety may be present in this situation but is not specifically reflected in the client's statement. The client does not report an existing difficulty with sexual behavior, which would indicate an altered sexuality pattern She also has expressed an inability to cope.

The goal for a client with a nursing diagnosis of social isolation is to identify at least one way to increase social interaction or to participate in social activities at least weekly. The other options are not goals that address the nursing diagnosis of social isolation.

Primary prevention precedes disease and is applied to healthy clients. Secondary prevention focuses on clients who have health problems and are at risk for developing complications. Tertiary prevention is applied to clients who already have a disease or disability; it focuses on rehabilitation. Passive prevention enables clients to gain health from others' activities without doing anything themselves.

Because the administration of blood products may cause adverse effects, such as allergic reactions, the nurse must monitor the client for them. Signs and symptoms of life-threatening allergic reactions include itching, swelling, and dyspnea. The nurse should inform the client of the transfusion's duration and should document its administration. However, theses actions are not as critical to the client's immediate health. The nurse should assess the client's vital signs hourly during the transfusion.

Because safety is imperative for nurses and clients, the nurse should obtain another pump. Using the pump as is could lead to electrical shock. Damaged equipment should never be used, even if the nurse performs a temporary repair. It should be labeled "broken" and reported to the appropriate department for repair.

Hospices provide supportive, palliative care to terminally ill clients (such as those with late-stage AIDS) and their families. Hospice services would not be appropriate for the other clients because their health problems are not necessarily terminal.

Demonstration by the nurse with a return demonstration by the client ensures that the client can perform wound care using the correct technique. Clients may claim to understand discharge instructions when they do not. An interpreter or family member may communicate the verbal or written instructions inaccurately.

Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. Arm and leg weakness may be present or the gag reflex may be absent after a CVA, but these are unrelated to aphasia. Difficulty with swallowing describes dysphagia.

The authoritarian leader retains all authority and responsibility and is concerned primarily with tasks and goal accomplishment. The democratic leader is people-centered, allows greater individual participation in decision making, and maintains open communication. The permissive or laissez-faire leader denies responsibility and abdicates authority to the group.

Normally, urine appears light yellow; dark amber urine is concentrated and, in this client, suggests continued fluid volume deficit. The serum sodium level normally ranges from 135 to 145 mEq/liter. A temperature of 99.6oF (37.5oC) is only slightly elevated and does not indicate fluid volume deficit. Neck vein distention is a sign of fluid volume overload.

Adhering to the client's wishes and calling the physician for an oral pain medication is the most appropriate action. Administering an injection without client consent is considered battery and may lead to a lawsuit. Withholding medication without providing an alternative violates the standards of care. Any attempt to manipulate the client into taking the medication (as in option D) also violates the standards of care.

To obtain urine properly, the nurse should aspirate it from a port, using a sterile syringe after cleaning the port. Opening a closed urine drainage system, as in options B and C, increases the risk of urinary tract infection. Universal precautions specify the use of gloves during contact with body substances; however, sterile gloves are not necessary.

Heat application increases blood flow (vasodilation); therefore, it is contraindicated in active bleeding. For this same reason, however, applying heat to a reddened abscess, edematous lower leg, or wound with purulent drainage promotes healing.

The nurse should always swab around a wound drain, moving from the center outward in ever-enlarging circles. This technique is used because the skin near the drain site is more contaminated than the site itself. The drain should never be removed before cleansing the skin. Alcohol is never used to clean around the drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination, but a mask is not necessary.

Theoretical models of nursing provide the foundation for all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment, and nursing. Scientific breakthroughs, technological advances, and medical practices may affect nursing but are not frameworks for nursing education and practice.

The most accurate measurement of weight loss is daily weighing of the client at the same time of the day, in the same clothes and using the same scale. Options B, C and D measure nutrition and hydration status.

Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body utilize all available glucose. The body then breaks down glycogen and fat for fuel. The byproducts of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis. Options A, B, and D are incorrect

Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Assessing the client's temperature every 8 hours is not frequent enough for a client with a fever. Monitoring fluid intake and output may be required, but placing the client in isolation should be done first. The nurse should wear gloves only for contact with mucous membranes, broken skin, and body substances.

Universal precautions are based on the concepts that all body substances are potentially infectious and that direct contact with them must be avoided. The nurse should wear gloves when contact with body substances is anticipated - not when in contact with unsoiled articles or intact skin. Because all body substances from all clients are considered potentially infectious, signs on doors are unnecessary. Gowns and gloves are inappropriate when caring for a client in respiratory isolation because they do not prevent the transmission of airborne respiratory infections; masks must be used as barriers to such infections.

Using the proportion method, the nurse solves for X in the following equations and then adds the total number of milliliters together as shown: (1 ml/100 mg = X ml/50 mg = 0.5 ml of meperidine) (2 ml/100 mg = X ml/25 mg = 0.5 ml of hydroxyzine) (1 ml/0.2 mg = X ml/0.3 mg = 1.5 ml of glycopyrrolate) (0.5 + 0.5 ml + 1.5 ml = 2.5 ml of all preoperative medications)

All IV solutions should be free of particles or precipitates. A tourniquet is to be applied above the chosen vein site. Cool compresses will cause vasoconstriction, making the vein less visible. Armboards are applied after the IV is started.

The client with late stage salicylate poisoning is at risk for metabolic acidosis because of the effects of acety salicylic acid in the body. Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul's respirations, headache, nausea, vomiting, diarrhea, fruity - smelling breath because of improper fat metabolism, central nervous system depression, twitching, convulsions, and hyperkalemia. The other laboratory values listed are within the normal reference ranges.

The client needs protein to repair the tissue breakdown from the decubitus ulcers, and meat is an excellent source of complete protein. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies some incomplete protein, making it less helpful in tissue repair.

Repositioning the client every 2 hours helps prevent secretions from pooling in dependent areas of the lungs. Fluid restriction makes secretions thicker and more tenacious, thus hindering secretion removal. Administering oxygen and keeping the head of the bed at 30 degrees may make the client's respirations easier and more effective, but these interventions do not help mobilize secretions.

By tickling the uvula with a tongue blade, the nurse can assess the gag reflex safety and accurately. The nurse may encourage coughing to maintain an open airway, but not to assess.The gag tongue extension is not a reliable gauge of the gag reflex because the client can extend the tongue before the ability to swallow returns. The nurse should not provide fluids before verifying that gag reflex has returned.

Documentation should include data obtained by the nurse using only observations that are heard, seen, smelled, or felt. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documentation of observed client behaviors or conversations is appropriate, but drawing conclusions about a client's feelings is not. Stating that the client had a good day is not precise enough information to be useful.

It may be necessary to modify a client’s diet to a soft or mechanically chopped diet if the client has difficulty chewing. Food preferences should be ascertained on admission assessment. Appetite will affect the amount of food eaten, but not the type of diet ordered. Bowel sounds should be present before introducing any diet, including liquids.

Because this client shows signs of fluid overload, the nurse should slow the infusion first to prevent additional fluid overload and then notify the physician and obtain further orders. Notifying the physician without slowing the infusion puts the client at risk for pulmonary complications or respiratory failure. Discontinuing the infusion is inappropriate because vascular access still may be needed to administer I.V. fluids (at a decreased rate) or additional I.V. medications. Administering a diuretic without changing the I.V. infusion rate cannot prevent fluid overload from recurring.

Hyperglycemia is a complication of TPN, and nurse reports abnormalities to the physician. Options A, B and C are not done without a physician’s order.

Sodium chloride 0.9% is the same solution as normal saline solution 0.9%. This solution is isotonic, and isotonic solutions are frequently used for IV infusion because they do not affect the plasma osmolarity.

The passage of liquid or semi-liquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction do not pass hard, brown formed stools because the feces cannot move past the impaction. Clients usually report the urge to defecate - though they cannot pass stool - and decreased appetite.

The client's ABG values reveal hypoxia (insufficient oxygen in the blood), which causes altered thought processes and thus is associated with a high risk for injury. Fatigue, activity intolerance, and sleep pattern disturbance may apply to this client, but safety is the first concern.

Malignant hyperthermia is genetic disorder in which a combination of anesthetic agents (succinylcholine and inhalation agents such as halothanes) trigger uncontrolled skeletal muscle contractions. This quickly leads to a potentially fatal hyperthermia. Questioning the client about any family history of general anesthesia problems may reveal this as a possibility for the client. Options A, B and D are unrelated to this surgical complication.

Because shock signals a severe fluid volume loss (750 to 1,300 ml), its treatment includes rapid replacement of I.V. fluids to promote homeostasis and prevent death. In fact, the nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. rate of 83 ml/hour cannot begin to replace the necessary fluids and reverse the problem. The remaining options are appropriate orders for this client.

Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis. This is because of the loss of hydrochloric acid, which is a potent acid in the body. Thus this situation results in an alkalotic condition. The respiratory system is not involved.

The normal pH is 7.35 to 7.45. The normal PaCO2 is 35 to 45 mm Hg and the normal HCO3 is 22 to 27 mEq/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory condition, an opposite effect will be seen between the pH and the PaCO2. In a metabolic condition, the pH and the bicarbonate move in the same direction. Since the pH is within the normal range of 7.35 to 7.45, compensation has occurred.

A heart rate 144 beats/minute indicates a decreased diastolic filling time and a reduced amount of blood ejected with each contraction, which results in decreased cardiac output. The client's temperature and respiratory rate are elevated, but not enough to take precedence over decreased cardiac output. The client's vital signs do not suggest altered renal tissue perfusion.

D In the Z-track method for I.M. injections, which is used for medications that cause irritation or discolor subcutaneous tissue, the needle should remain in place for 10 seconds to allow the medication to dispense. The skin is released after the needle is withdrawn to seal medication in the muscle tissue. Deltoid muscles are used infrequently for Z-track injections because they are small and their use increases the risk of injuring the brachial or radial nerve. Aspiration must be done for Z-track and all other I.M. injections to check for blood.

A major risk associated with central line placement is the possibility of a pneumothorax developing from an accidental puncture of the lung. Assessing the results of a chest x-ray examination is one of the best methods to determine whether this complication has occurred and to verify catheter tip placement before initiating intravenous (IV) therapy. A temperature elevation would not likely occur immediately after placement. Although BP assessment is always important in assessing a client’s status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started. Labeling the dressing site is important but is not the priority.