Ultimate Flashcards

A nurse is assisting in the care of a client who has ARDS with absent breath sounds in the lower lobes and dyspnea. Which of the following actions should the nurse take first?

Answer: Administer oxygen via a high-flow mask

The client has dyspnea and absent breath sounds, indicating significant respiratory distress and impaired gas exchange. The immediate priority is to address the hypoxemia by administering oxygen via a high-flow mask to improve oxygenation. Ensuring adequate oxygenation is a life-saving intervention that takes precedence over other diagnostic or less immediate actions.

The nurse is providing care to a client diagnosed with bipolar disorder. The client's family asks the nurse what this is. Which response by the nurse is appropriate?

Answer: Bipolar disorder means there are cycles of depression as well as hyperactivity, or mania

Bipolar disorder is characterized by significant mood swings that include distinct episodes of both depression (low mood, loss of interest) and mania or hypomania (elevated, expansive, or irritable mood, increased energy). This explanation accurately describes the core features of the disorder, helping the family understand the client's condition as a cyclical mood illness.

A nurse is evaluating a client's understanding about the risk for cancer. Which of the following client statements indicates the need for further teaching?

Answer: I used to smoke but switched to chewing tobacco 3 years ago

Switching from smoking to chewing tobacco does not eliminate the risk of cancer; it merely shifts the type of cancer risk. Chewing tobacco is a known carcinogen and significantly increases the risk of oral, esophageal, and pancreatic cancers. This statement indicates a misunderstanding of cancer risk reduction and highlights the need for further education on tobacco cessation.

Which nursing task should the nurse on the renal unit assign to the LPN?

Answer: Insert an indwelling urinary catheter before surgery

Inserting an indwelling urinary catheter is a common procedure that falls within the scope of practice for an LPN, especially an experienced one, under the supervision of an RN. LPNs are trained in sterile technique and catheter insertion. The other tasks either involve higher-level assessment or are routine care that could be assigned to various personnel.

Which of the following sensory-perceptual deficits is associated with left-brain stroke (right hemiplegia)?

Answer: Slow and possibly fearful performance of tasks

A left-brain stroke typically results in right hemiplegia and is associated with deficits in language, analytical thinking, and a cautious, slow, and often fearful approach to tasks. Patients may be hesitant to perform tasks due to a fear of making mistakes or not being able to complete them correctly. This contrasts with the impulsivity often seen in right-brain strokes.

While the nurse is assisting with an admission history for a client at 39 weeks of gestation, the client tells the nurse that water has been leaking from her vagina for 2 days. The nurse should know that this client is at risk for which of the following?

Answer: Infection

Prolonged rupture of membranes (PROM), especially for 2 days, significantly increases the risk of intrauterine infection (chorioamnionitis) for both the mother and the fetus. The protective barrier of the amniotic sac is lost, allowing bacteria to ascend into the uterus. This is a critical concern requiring close monitoring and potential intervention to prevent serious complications.

A patient has been receiving palliative care for the past several weeks in light of her worsening condition following a series of strokes. The caregiver has rung the call bell, stating that the patient now "stops breathing for a while, then breathes fast and hard, and then stops again." The nurse would recognize that the patient is experiencing

Answer: Cheyne-Stokes respirations

Cheyne-Stokes respirations are a pattern of breathing characterized by cycles of progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop (apnea). This pattern is commonly seen in patients nearing the end of life, especially those with severe neurological conditions like stroke, and indicates severe brainstem dysfunction.

A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate assisting with the administration of if magnesium sulfate toxicity is suspected?

Answer: Calcium gluconate

Calcium gluconate is the specific antidote for magnesium sulfate toxicity. If a client receiving magnesium sulfate shows signs of toxicity, such as decreased deep tendon reflexes, respiratory depression, or decreased urine output, calcium gluconate should be administered intravenously. It rapidly reverses the effects of hypermagnesemia, preventing severe complications.

Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN who is caring for a patient with a permanent tracheostomy?

Answer: Suctioning the tracheostomy when needed

LPNs, especially experienced ones, are trained and competent in performing routine procedures like tracheostomy suctioning for stable patients. This task falls within their scope of practice as it is a technical skill rather than requiring complex assessment, diagnosis, or teaching. The other options involve higher-level assessment, critical thinking, and patient education, which are typically within the RN's scope.

The nurse is instructing the spouse of a client with a stroke on how to do passive range of motion to the affected limbs. Which rationale for this intervention will the nurse include in the teaching session?

Answer: Maintain joint flexibility

Passive range of motion (PROM) exercises involve a caregiver moving a client's limb without client effort. The primary goal of PROM is to prevent contractures, maintain joint mobility, and improve circulation, thereby preserving joint flexibility. It does not directly improve muscle strength, cardiopulmonary function, or endurance, which typically require active client participation.

For early detection of an anaphylactic reaction in a patient who has received allergen testing using the cutaneous scratch method, which action should the nurse take first?

Answer: Assess the arm at the site of the skin testing

For early detection of an anaphylactic reaction after allergen skin testing, the nurse should first assess the immediate site of the skin testing. Localized reactions at the test site, such as rapidly spreading urticaria or significant swelling, can be the earliest indicators of a severe allergic response. This initial assessment helps identify a rapidly progressing reaction before systemic symptoms become critical.

A nurse is reinforcing teaching with a client who is pregnant about the amniocentesis procedure. Which of the following statements by the client requires clarification?

Answer: I need to have a full bladder at the time of the procedure

For an amniocentesis performed in the second or third trimester, a full bladder is generally not required; an empty bladder is often preferred to reduce the risk of bladder puncture. A full bladder is typically needed for an ultrasound in early pregnancy to help visualize the uterus. Therefore, the client's statement about needing a full bladder indicates a misunderstanding and requires clarification.

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious because she feels that she cannot get enough air. Vital signs are HR 117/min, RR 38/min, Temp 38.4C (101.2F), BP 100/54 mmHg. Which of the following actions is the priority action at this time?

Answer: Administer oxygen therapy

The client is experiencing acute dyspnea, diaphoresis, anxiety, a high heart rate, high respiratory rate, and low blood pressure, indicating significant respiratory distress and potential hypoxemia. Administering oxygen therapy is the priority action to address the immediate physiological need for oxygen and improve the client's respiratory status. Stabilizing the client's breathing is crucial before further diagnostic tests or provider notification.

A nurse is reinforcing discharge teaching with a client following a stapedectomy. Which of the following statements by the client indicates understanding of the teaching?

Answer: I will cover my ear when washing my hair

Following a stapedectomy, it is crucial to protect the operative ear from water to prevent infection and avoid dislodging the graft or prosthesis. Covering the ear when washing hair demonstrates understanding of this important post-operative care instruction. Hearing typically improves gradually over several weeks, and activities like flying are restricted for a period due to pressure changes.

A nurse is reinforcing teaching a client who has tuberculosis. Which of the following statements should the nurse include when reinforcing the teaching?

Answer: You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication

Monitoring the effectiveness of tuberculosis treatment involves regular sputum cultures to confirm the absence of Mycobacterium tuberculosis. Sputum samples are typically collected periodically, such as every 2-4 weeks, until two consecutive samples are negative. This is a critical aspect of ensuring successful treatment, confirming the client is no longer infectious, and preventing further transmission.

A client tells the nurse, "My mother spent many years in a mental institution, and my father would abuse me when my mother was not around." Based on tis data, which is the client at greatest risk for developing?

Answer: A personality disorder

A history of parental mental illness and childhood abuse are significant risk factors for developing personality disorders. These early traumatic experiences and unstable family environments can profoundly impact an individual's development of self-identity, emotional regulation, and interpersonal functioning. These impacts are core features of personality disorders, making this the greatest risk.