NLE Practice Test 3a - Pt. 1 - Quiz, Flashcards & Trivia

1. When assessing a client for Cournadin therapy, the condition that will eyclude this client from Coumadin therapy is:

Diabetes

Arthritis

Pregnancy

Peptic ulcer disease

Pregnancy is the condition that will exclude the client from Coumadin therapy. This is because Coumadin is a blood thinner medication that can potentially harm the developing fetus. Therefore, it is contraindicated in pregnant women to avoid any potential risks to the baby.

Explanation

Pregnancy is the condition that will exclude the client from Coumadin therapy. This is because Coumadin is a blood thinner medication that can potentially harm the developing fetus. Therefore, it is contraindicated in pregnant women to avoid any potential risks to the baby.

2. If a client continues to hypoventilate, the nurse will continually assess for a complication of this condition;

Respiratory acidosis

Respiratory alkalosis

Metabolic acidosis

Metabolic alkalosis

If a client continues to hypoventilate, it means they are not exhaling enough carbon dioxide, leading to an accumulation of carbon dioxide in the bloodstream. This can result in respiratory acidosis, which is characterized by an increase in carbon dioxide levels and a decrease in pH. The nurse will continually assess for this complication because it can lead to symptoms such as confusion, drowsiness, and even coma if left untreated.

Explanation

If a client continues to hypoventilate, it means they are not exhaling enough carbon dioxide, leading to an accumulation of carbon dioxide in the bloodstream. This can result in respiratory acidosis, which is characterized by an increase in carbon dioxide levels and a decrease in pH. The nurse will continually assess for this complication because it can lead to symptoms such as confusion, drowsiness, and even coma if left untreated.

3. If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:

Flexion of both upper and lower extremities

Extension of elbows and knees, plantar flexion of feet, and flexion of the wnsts

Flexion of elbows, extension of the knees, and plantar flexion of the feet

Extension of upper extremities, flexion of lower extremities

If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe flexion of elbows, extension of the knees, and plantar flexion of the feet. Decorticate posturing is characterized by the arms flexed and held close to the body, with the wrists and fingers flexed. The legs are extended and internally rotated, with the feet pointed downward. This posture suggests damage to the cerebral cortex or corticospinal tracts, and is often seen in clients with brain injuries or increased intracranial pressure.

Explanation

If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe flexion of elbows, extension of the knees, and plantar flexion of the feet. Decorticate posturing is characterized by the arms flexed and held close to the body, with the wrists and fingers flexed. The legs are extended and internally rotated, with the feet pointed downward. This posture suggests damage to the cerebral cortex or corticospinal tracts, and is often seen in clients with brain injuries or increased intracranial pressure.

4. A client with alcoholic cirrhosis with ascites and portal hypertension is to receive neomydn. The desired effect of this drug is to;

Sterilize the bowel

Reduce abdominal distention

Decrease the serum ammonia

Prevent infection

Neomycin is an antibiotic that is used to decrease the serum ammonia levels in patients with hepatic encephalopathy, which is a condition commonly seen in patients with alcoholic cirrhosis. Elevated ammonia levels in the blood can lead to neurological symptoms such as confusion and altered mental status. Neomycin works by reducing the number of ammonia-producing bacteria in the intestines, thus decreasing the serum ammonia levels. It does not directly sterilize the bowel, reduce abdominal distention, or prevent infection.

Explanation

Neomycin is an antibiotic that is used to decrease the serum ammonia levels in patients with hepatic encephalopathy, which is a condition commonly seen in patients with alcoholic cirrhosis. Elevated ammonia levels in the blood can lead to neurological symptoms such as confusion and altered mental status. Neomycin works by reducing the number of ammonia-producing bacteria in the intestines, thus decreasing the serum ammonia levels. It does not directly sterilize the bowel, reduce abdominal distention, or prevent infection.

5. The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:

Act as a vasoconstrictor

Act as a vasodilator

Block beta stimulation in the heart

Increase the heart rate

Propranolol (Inderal) is a beta-blocker medication, which means it blocks the stimulation of beta receptors in the heart. By blocking these receptors, propranolol reduces the effects of adrenaline and other stress hormones on the heart, leading to a decrease in heart rate and blood pressure. This can be beneficial for clients with angina, as it helps to reduce the workload on the heart and improve blood flow to the heart muscle. Therefore, the correct answer is that propranolol blocks beta stimulation in the heart.

Explanation

Propranolol (Inderal) is a beta-blocker medication, which means it blocks the stimulation of beta receptors in the heart. By blocking these receptors, propranolol reduces the effects of adrenaline and other stress hormones on the heart, leading to a decrease in heart rate and blood pressure. This can be beneficial for clients with angina, as it helps to reduce the workload on the heart and improve blood flow to the heart muscle. Therefore, the correct answer is that propranolol blocks beta stimulation in the heart.

6. Preparing for an intravenous pyelosram (IVP), the nurse instructs a 25-year-old male client to restrict her:

Fluid intake

Physical activity

Use of stimulants such as tobacco

Use of any medications

The nurse instructs the client to restrict fluid intake before an intravenous pyelogram (IVP) because excessive fluid intake can interfere with the accuracy of the test results. By restricting fluid intake, the client's bladder will be empty, allowing for better visualization of the urinary tract during the procedure. Restricting physical activity, use of stimulants such as tobacco, and use of medications are not necessary for an IVP.

Explanation

The nurse instructs the client to restrict fluid intake before an intravenous pyelogram (IVP) because excessive fluid intake can interfere with the accuracy of the test results. By restricting fluid intake, the client's bladder will be empty, allowing for better visualization of the urinary tract during the procedure. Restricting physical activity, use of stimulants such as tobacco, and use of medications are not necessary for an IVP.

7. A retention catheter for a male client is correctly taped if it is:

On the lower abdomen

On the umbilicus

Under the thigh

On the inner thigh

A retention catheter for a male client is correctly taped on the lower abdomen because this placement allows for proper drainage of urine from the bladder. Placing the catheter on the umbilicus or under the thigh would not provide the same level of comfort and effectiveness. Additionally, placing it on the inner thigh may cause discomfort and potential skin irritation. Therefore, taping the catheter on the lower abdomen is the most appropriate and correct placement.

Explanation

A retention catheter for a male client is correctly taped on the lower abdomen because this placement allows for proper drainage of urine from the bladder. Placing the catheter on the umbilicus or under the thigh would not provide the same level of comfort and effectiveness. Additionally, placing it on the inner thigh may cause discomfort and potential skin irritation. Therefore, taping the catheter on the lower abdomen is the most appropriate and correct placement.

8. The nurse is collecting a urine specimen from a client who has been catheterized. When the urine begins to flow through ths catheter, the next action is to:

Inflate the catheter balloon with sterile water

Place the catheter tip into the specimen container

Connect the catheter into the drainage tubing

Place the catheter tip into the urine collection receptacle

When collecting a urine specimen from a client who has been catheterized, the next action is to place the catheter tip into the specimen container. This is because the purpose of collecting a urine specimen is to obtain a sample of the client's urine for laboratory analysis. By placing the catheter tip directly into the specimen container, the urine can flow directly into the container without any contamination or loss of the sample. This ensures that an accurate and uncontaminated urine specimen is obtained for testing.

Explanation

When collecting a urine specimen from a client who has been catheterized, the next action is to place the catheter tip into the specimen container. This is because the purpose of collecting a urine specimen is to obtain a sample of the client's urine for laboratory analysis. By placing the catheter tip directly into the specimen container, the urine can flow directly into the container without any contamination or loss of the sample. This ensures that an accurate and uncontaminated urine specimen is obtained for testing.

9. Immediately following a thoracentesis, which clinical manifestations indicate that a complication has occurred and the physician should be notified?

Serosanguimeous drainage from the puncture site

Increased temperature and blood pressure

Increased pulse and pallor

Hypotension and hypothermia

Increased pulse and pallor are clinical manifestations that indicate a complication following a thoracentesis. Increased pulse can be a sign of hypovolemia or hemorrhage, which may occur if there is damage to blood vessels during the procedure. Pallor can indicate decreased blood flow or anemia, which may also be a result of bleeding. These symptoms suggest that the patient may be experiencing significant blood loss and should be immediately reported to the physician for further evaluation and management.

Explanation

Increased pulse and pallor are clinical manifestations that indicate a complication following a thoracentesis. Increased pulse can be a sign of hypovolemia or hemorrhage, which may occur if there is damage to blood vessels during the procedure. Pallor can indicate decreased blood flow or anemia, which may also be a result of bleeding. These symptoms suggest that the patient may be experiencing significant blood loss and should be immediately reported to the physician for further evaluation and management.

10. During a retention catheter insertion or bladder irrigation, the nurse must use:

Sterils equipment and wear sterile gloves

Clean equipment and maintain surgical asepsis

Sterile equipment and maintain medical asepsis

Clean equipment and technique

During a retention catheter insertion or bladder irrigation, it is important for the nurse to use clean equipment and maintain surgical asepsis. This means that the equipment used should be free from any dirt or contaminants, and the nurse should follow strict sterile techniques to prevent the introduction of any microorganisms into the patient's bladder. Maintaining surgical asepsis is crucial in preventing infections and complications during these procedures.

Explanation

During a retention catheter insertion or bladder irrigation, it is important for the nurse to use clean equipment and maintain surgical asepsis. This means that the equipment used should be free from any dirt or contaminants, and the nurse should follow strict sterile techniques to prevent the introduction of any microorganisms into the patient's bladder. Maintaining surgical asepsis is crucial in preventing infections and complications during these procedures.