Will You Be A Perfect Nurse?

1. The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pres- sure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the cli- en t's sacral area?

Intactskin.

Full-thickness skin loss.

Exposed bone, tendon, or muscle.

Partial-thickness skin loss of the dermis.

In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It pre- sents as a shallow open ulcer with a red-pink wound bed, with- out slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

Explanation

In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It pre- sents as a shallow open ulcer with a red-pink wound bed, with- out slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

2. The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note docu- mentation of which most common sign or symptom of this type of cancer?

Dysuria.

Hematuria.

Urgency on urination.

Frequency of urination.

The most common sign in clients with cancer of the bladder is hematuria. The client also may experience irritative voiding symptoms such as frequency, urgency, and dysuria, and these symptoms often are associated with carcinoma in situ. Dysuria, urgency, and frequency of urination are also symptoms of a bladder infection.

Explanation

The most common sign in clients with cancer of the bladder is hematuria. The client also may experience irritative voiding symptoms such as frequency, urgency, and dysuria, and these symptoms often are associated with carcinoma in situ. Dysuria, urgency, and frequency of urination are also symptoms of a bladder infection.

3. The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included?

Out-of-bed activities as desired.

Bed rest with the affected extremity kept flat.

Bed rest with elevation of the affected extremity.

Bed rest with the affected extremity in a dependent position.

For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. A flat or dependent position of the leg would not achieve this goal. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking. 

Explanation

For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. A flat or dependent position of the leg would not achieve this goal. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking. 

4. The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

Ambulation.

Rest between contractions.

Change positions frequently.

Consume oral food and fluids.

The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips should be provided. Changing positions fre- quently is not the primary physiological need. Food and fluids are likely to be withheld at this time.

Explanation

The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips should be provided. Changing positions fre- quently is not the primary physiological need. Food and fluids are likely to be withheld at this time.

5. The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sun- screens are most effective when applied at which times?

Immediately before swimming.

5 minutes before exposure to the sun.

Immediately before exposure to the sun.

At least 30 minutes before exposure to the sun.

Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can pene- trate the skin. All sunscreens should be reapplied after swim- ming or sweating.

Explanation

Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can pene- trate the skin. All sunscreens should be reapplied after swim- ming or sweating.

6. A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a his-tory of a severe allergy to which substance?

Eggs.

Penicillin.

Sulfonamides.

A previous dose of hepatitis B vaccine or component.

A contraindication to receiving the hepatitis B vac- cine is a previous anaphylactic reaction to a previous dose of hepatitis B vaccine or to a component (aluminum hydroxide or yeast protein) of the vaccine. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.

Explanation

A contraindication to receiving the hepatitis B vac- cine is a previous anaphylactic reaction to a previous dose of hepatitis B vaccine or to a component (aluminum hydroxide or yeast protein) of the vaccine. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.

7. Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication?

Tinnitus.

Diarrhea.

Constipation.

Decreased respirations.

Salicylic acid is absorbed readily through the skin, and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism. Test-Taking Strategy: Focus on the subject, systemic toxicity. Noting the name of the medication will assist in directing you to the correct option if you can recall the toxic effects that occur with acetylsalicylic acid (aspirin).

Explanation

Salicylic acid is absorbed readily through the skin, and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism. Test-Taking Strategy: Focus on the subject, systemic toxicity. Noting the name of the medication will assist in directing you to the correct option if you can recall the toxic effects that occur with acetylsalicylic acid (aspirin).

8. The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nurs-ing action?

Document the finding.

Check the mother’s heart rate.

Notify the health care provider (HCP).

Tell the client that the fetal heart rate is normal.

The FHR depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester, but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the HCP. Options 2 and 4 are inappropriate actions based on the information in the ques- tion. Although the nurse documents the findings, based on the information in the question, the HCP needs to be notified.

Explanation

The FHR depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester, but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the HCP. Options 2 and 4 are inappropriate actions based on the information in the ques- tion. Although the nurse documents the findings, based on the information in the question, the HCP needs to be notified.

9. Which car safety device should be used for a child who is 8 years old and 4 feet tall?

Seatbelt

Booster seat.

Rear-facing convertible seat.

Front-facing convertible seat.

All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt- positioning booster seat until the vehicle seat belt fits properly typically when they have reached 4 feet, 9 inches in height (145 cm) and are between 8 and 12 years of age. Infants should ride in a car in a semireclined, rear-facing position in an infant- only seat or a convertible seat until they weigh at least 20 pounds (9 kg) and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manu- facturer of the convertible car safety seat but is generally at a body weight of 9 kilograms (20 pounds) and 1 year of age.

Explanation

All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt- positioning booster seat until the vehicle seat belt fits properly typically when they have reached 4 feet, 9 inches in height (145 cm) and are between 8 and 12 years of age. Infants should ride in a car in a semireclined, rear-facing position in an infant- only seat or a convertible seat until they weigh at least 20 pounds (9 kg) and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manu- facturer of the convertible car safety seat but is generally at a body weight of 9 kilograms (20 pounds) and 1 year of age.

10. The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take?

Call the health care provider (HCP).

Place the tube in a bottle of sterile water.

Replace the chest tube system immediately.

Place asterile dressing over the disconnection site.

If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified, but this is not the initial action. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dress- ing over the disconnection site will not prevent complications resulting from the disconnection.

Explanation

If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified, but this is not the initial action. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dress- ing over the disconnection site will not prevent complications resulting from the disconnection.