Select All That Apply Practice Exam Flashcards

A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply.

Answer: Early onset cough

Chronic bronchitis is characterized by a persistent cough that produces sputum for at least three months in two consecutive years. Key signs include an early onset cough, often worse in the morning, and the production of purulent (pus-filled) mucus due to chronic inflammation and infection. Mild episodes of dyspnea (shortness of breath) are also common, especially with exertion, as the airways become narrowed and obstructed.

A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client's efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?

Answer: Inquiring about the client's feelings that may affect coping

To help a client work through a crisis, the nurse must first understand the client's emotional response and how they are processing the traumatic event. Inquiring about their feelings allows the client to express grief, guilt, or other emotions, which is a crucial step in identifying coping mechanisms and facilitating emotional processing. This helps the nurse tailor interventions to support the client's psychological recovery.

A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client's hospital gown?

Answer: Disconnecting the IV tubing from the catheter in the vein

Disconnecting the IV tubing from the catheter in the vein should be avoided as it breaks the sterile closed system, increasing the risk of infection and air embolism. It also disrupts the continuous infusion of medication or fluids. Instead, the nurse should use a hospital gown with snaps or carefully thread the IV bag and tubing through the sleeve to change the gown without disconnecting the line.

A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first?

Answer: A client on a ventilator

When prioritizing client care, the nurse should always assess clients with the most unstable or potentially life-threatening conditions first. A client on a ventilator requires continuous monitoring of respiratory status, ventilator settings, and potential complications, making them the highest priority due to the critical nature of their airway and breathing support.

A nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection?

Answer: Psychosocial

In an ambulatory care unit for a scheduled hernia repair, the immediate priority during data collection is to assess physiological systems directly relevant to the surgery and anesthesia, such as respiratory, neurological, and cardiovascular status. While psychosocial data is important for holistic care, it is typically of least priority for immediate pre-operative assessment compared to vital physiological functions that could impact surgical safety or recovery.

A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply.

Answer: Wearing gloves when emptying the client's bedpan

When caring for a client with an internal radiation implant, safety measures are crucial to minimize radiation exposure. Wearing gloves for contact with body fluids (which may contain radioactive isotopes), keeping linens in the room to contain potential contamination, wearing a dosimeter badge to monitor personal exposure, and wearing a lead apron during direct care are all essential to protect staff and others from radiation.

The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply.

Answer: In a semi-Fowler's position

After a supratentorial craniotomy, the primary goal is to prevent increased intracranial pressure (ICP) and promote venous drainage. A semi-Fowler's position (head of bed elevated 30-45 degrees) and maintaining the head in a midline position facilitate venous outflow from the brain, reducing ICP. Avoiding extreme flexion, rotation, or lying on the operative side helps prevent compression of vessels and further increases in ICP.

A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to:

Answer: Treat hypocalcemic tetany.

Thyroidectomy can sometimes inadvertently damage or remove the parathyroid glands, which are responsible for regulating calcium levels. This can lead to hypocalcemia, a dangerously low calcium level, which manifests as tetany (muscle spasms, tingling, and twitching). Calcium gluconate is administered intravenously to rapidly raise serum calcium levels and treat or prevent these severe symptoms.

A nurse is caring for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure?

Answer: Gloves, a gown, and goggles

For a client on contact precautions with MRSA, gloves and a gown are essential to prevent direct contact transmission during colostomy care. Additionally, colostomy care involves potential splashing of body fluids (stool), which necessitates wearing goggles to protect the eyes from contamination. This combination ensures comprehensive protection against pathogen transmission.

The nurse is caring for a client with a history of diverticulitis. The client complains of abdominal pain, fever, and diarrhea. Which food was responsible for the client’s symptoms?

Answer: Whole-grain cereal

Diverticulitis is an inflammation of diverticula, small pouches in the colon. Foods with small seeds, nuts, or high fiber content, like whole-grain cereal, were historically thought to exacerbate diverticulitis by getting lodged in the diverticula or irritating them. While current evidence is mixed, in an acute flare-up, a low-fiber diet is often recommended to reduce bowel irritation, making whole-grain cereal a likely culprit for symptoms.

The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client’s cancer is located in:

Answer: The head of the pancreas

The Whipple procedure, also known as a pancreaticoduodenectomy, is a complex surgical operation primarily performed to remove tumors in the head of the pancreas. This procedure also involves removing parts of the duodenum, gallbladder, and bile duct, making it a major surgery for cancers located specifically in this region.

A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:

Answer: Sore throat

Pulmozyme (dornase alfa) is an inhaled medication used in cystic fibrosis to thin respiratory secretions. Common side effects associated with its use include voice alteration (hoarseness), pharyngitis (sore throat), and laryngitis. These are typically mild and related to irritation of the upper airway from the inhaled medication.

The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is to:

Answer: Alleviate pain

The primary objective of administering an opiate analgesic like Percocet (oxycodone) after surgery is to effectively manage and alleviate the client's pain. Pain relief is crucial for client comfort, promotes early mobilization, reduces stress, and facilitates recovery. While other factors like preventing addiction are important, the immediate and main goal of the medication itself is pain control.

The nurse should be concerned with alleviating the client’s pain.

Answer: Progressive weakness that is worse at the day’s end

Myasthenia gravis is an autoimmune neuromuscular disorder characterized by fluctuating muscle weakness and fatigue. A hallmark symptom is progressive weakness that worsens with activity and improves with rest, often becoming most pronounced at the end of the day or after prolonged exertion. This is due to a decrease in acetylcholine receptors at the neuromuscular junction.

The nurse is teaching the parents of a newborn with osteogenesis imperfecta. The nurse should tell the parents:

Answer: To lift the baby by the buttocks when diapering

Osteogenesis imperfecta is a genetic disorder causing extremely fragile bones that break easily. When handling an infant with this condition, it is crucial to minimize pressure on the long bones. Lifting the baby by the buttocks when diapering, rather than by the ankles, supports the trunk and reduces the risk of fractures in the legs.

Physician’s orders for a client with acute pancreatitis include the following: strict NPO, NG tube to low intermittent suction. The nurse recognizes that these interventions will:

Answer: Reduce the secretion of pancreatic enzymes

In acute pancreatitis, the pancreas becomes inflamed due to autodigestion by its own enzymes. Keeping the client NPO and using an NG tube to low intermittent suction helps to "rest" the pancreas by reducing gastric and duodenal secretions, thereby decreasing the stimulation for pancreatic enzyme production and release. This minimizes further autodigestion and inflammation, promoting healing.