The nurse is teaching a group of student nurses about radiation therapy. Which would the nurse include in the teaching? Select all that apply.
Rationale:
Clients receiving brachytherapy are radioactive. This type of therapy involves placing radioactive sources inside or near the tumor, which emits radiation to target cancer cells, leading to patient radioactivity.
A: The dose is always more than the exposure. This statement lacks accuracy, as exposure levels can vary significantly depending on treatment protocols and individual patient circumstances.
D: Beta particles are the most common type of radiation therapy. While beta particles are utilized, they do not dominate the landscape of radiation therapy, which includes a variety of particle types and energy levels.
E: Bodily waste from a client receiving brachytherapy does not require special handling. In fact, waste from such patients poses potential radiation risks and requires careful management to ensure safety for caregivers and the public.
A 2-month-old infant has been brought to the ED. Which finding by the nurse would raise suspicion for shaken baby syndrome?
Rationale:
Greater-than-expected head circumference and bulging fontanels raise suspicion for shaken baby syndrome. These signs indicate possible increased intracranial pressure or brain swelling, commonly associated with abusive head trauma in infants.
A: failure to track with the eyes. While this could suggest developmental issues, it does not specifically indicate trauma or abuse, making it a less reliable indicator.
B: crying without tear production. This symptom can occur in many normal infants, especially at a young age, and does not provide direct evidence of physical abuse or injury.
C: bruising to the arms and shoulders. Bruising in these areas can suggest trauma; however, it is not definitive for shaken baby syndrome and could result from other non-abusive causes.
The nurse is preparing to perform a focused abdominal assessment on a client. Which is the correct order of this assessment?
Rationale:
Inspection, auscultation, palpation, percussion. This sequence is essential for an effective abdominal assessment, allowing the nurse to visually evaluate first, listen for sounds, and then proceed to tactile examinations for accurate findings.
B: inspection, palpation, percussion, auscultation. This order disrupts the proper sequence by performing palpation before auscultation, which can lead to altered bowel sounds due to manipulation.
C: inspection, percussion, auscultation, palpation. This arrangement misplaces auscultation after percussion, potentially missing vital sounds that could be obscured by the percussion process, leading to incomplete evaluation.
D: inspection, percussion, palpation, auscultation. Placing percussion before auscultation can distort sound assessment, allowing physical manipulation to interfere with accurate auditory cues necessary for a thorough abdominal evaluation.
The nurse is caring for a client with a history of cirrhosis of the liver. Lab values reveal rising ammonia levels. Which of the following actions should the nurse anticipate performing? Select all that apply.
Rationale:
Encourage frequent periods of rest and monitor the client's mental status. These actions are essential in managing the complications of cirrhosis, particularly due to the increased risk of hepatic encephalopathy from rising ammonia levels.
A: replace electric razor with a straight razor. This action poses an increased risk of bleeding, which is not appropriate for a client with liver dysfunction and coagulopathy.
C: instruct on a potassium-restricted diet. This dietary restriction is not necessary for clients with cirrhosis unless they exhibit specific complications such as hyperkalemia, which is not indicated here.
A nurse is teaching a client with left-sided hemiparesis to walk with a cane. The nurse should include which points about safe cane use when teaching the client? Select all that apply.
Rationale:
A: hold the cane in the right hand, C: move the cane and step forward with the right leg. Using a cane in the opposite hand helps provide balance, while advancing the cane with the stronger leg promotes stability and effective weight distribution during ambulation. These techniques facilitate safer mobility for clients with left-sided hemiparesis.
B: hold the cane in the left hand. This positioning would not enhance balance, as it conflicts with the body's support needs due to left-sided hemiparesis, making walking more difficult.
D: move the cane and step forward with the left leg. Advancing the weaker leg simultaneously with the cane does not provide adequate support, risking potential falls and instability in movement.
The nurse is caring for a homeless client brought to the emergency department with a diagnosis of heat stroke. Which key features of heat stroke would the nurse expect to note upon assessment? Select all that apply.
Rationale:
A: A body temperature of 104.2°F indicates a critical elevation consistent with heat stroke, which is characterized by hyperthermia. Elevated temperature is a hallmark feature of this serious condition requiring immediate medical intervention.
B: Heart rate of 116 and blood pressure of 78/52 reflect signs of heat stroke, as tachycardia and hypotension are common due to dehydration and thermoregulatory failure affecting the cardiovascular system.
C: Heart rate of 49 and blood pressure of 152/90 represent bradycardia and hypertension, which are atypical for heat stroke; such vital signs suggest an alternative cardiovascular issue rather than heat-related illness.
D: Heart rate of 120 and respiratory rate of 9 breaths per minute indicate tachycardia and bradypnea, which are inconsistent with heat stroke, where increased respiratory rates typically occur due to metabolic stress.
E: Blood pressure of 82/48 and respiratory rate of 26 breaths per minute align with heat stroke symptoms, as hypotension and hyperventilation often arise from the body's response to extreme heat and dehydration.
An elderly man is admitted to the ED during the night shift. He reports slipping and hitting his forehead on the bathtub several hours earlier. The nurse is assessing the client's frontal lobe function. Which of the following questions/statements should the nurse ask the client?
Rationale:
D: How much is two plus four plus seven? This question effectively assesses cognitive function and mathematical ability, which are controlled by the frontal lobe, making it appropriate for evaluating the patient's condition.
A: Tell me when you feel me touch your arm. This statement evaluates sensory perception, primarily involving the parietal lobe, rather than assessing frontal lobe function.
B: Tell me when you stop hearing the tuning fork sound. This option tests auditory processing rather than cognitive or executive functioning related to the frontal lobe.
C: Do you have problems with balance? This question pertains to motor coordination and equilibrium, which are not directly indicative of frontal lobe function.
The nurse is caring for a client who has a lithium level of 2.2 mEq/L. Based on this lab value, what would the nurse anticipate to do in order to care for this client? Select all that apply.
Rationale:
Prepare to administer IV fluids, notify the health care provider, and observe the client for confusion and slurred speech are essential actions due to the critically high lithium level of 2.2 mEq/L, indicating potential toxicity.
C: order a mechanical soft diet for the client. This option does not address the immediate risks associated with elevated lithium levels, which require urgent medical attention rather than dietary modifications.
D: administer the next dose of lithium when it is due. Continuing lithium administration is inappropriate and dangerous given the elevated level, which necessitates stopping the medication to prevent further toxicity.
The nurse is assessing a client with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. Which finding would be expected for this client?
Rationale:
Chronic obstructive pulmonary disease (COPD) exacerbation typically results in hypoxemia due to inadequate oxygen exchange and hypercarbia from carbon dioxide retention. This combination reflects the compromised respiratory function prevalent in this condition, making option C the most appropriate finding.
A: hypoxemia and hypocarbia. This combination suggests low oxygen levels and low carbon dioxide, which does not align with the typical respiratory failure seen in COPD exacerbations.
B: hyperoxemia and hypocarbia. Elevated oxygen levels with low carbon dioxide are not characteristic of COPD exacerbation, where respiratory distress leads to carbon dioxide retention instead.
D: hyperoxemia and hypercarbia. High oxygen levels paired with carbon dioxide retention indicates a different respiratory issue, such as acute respiratory failure, rather than the expected findings in COPD exacerbation.
While preparing a client for a colonoscopy, the nurse would be correct to implement which interventions? Select all that apply.
Rationale:
B: Instruction that a sedative will be administered before the procedure. This is essential as sedation helps the client remain comfortable and relaxed during the colonoscopy, ensuring a smoother experience and accurate results.
A: Instruction on high fiber diet the day before the procedure. A high-fiber diet can interfere with the colonoscopy preparation, potentially leading to inadequate bowel cleansing before the procedure.
D: Instruction not to eat or drink 18 hours before the procedure. While fasting is necessary, the standard duration is typically 6-12 hours, making this option excessively cautious and not aligned with the guidelines.
The nurse is preparing to remove a peripheral IV from a client. Which nursing action is the priority with this procedure?
Rationale:
E: Holding pressure on the site until hemostasis is achieved is the priority action when removing a peripheral IV, as it prevents bleeding and promotes clot formation at the insertion site.
A: Checking for an intact catheter tip focuses on catheter integrity but does not address immediate patient safety and bleeding control, which are critical during IV removal.
B: Washing hands and donning gloves are essential for infection control, yet these actions do not directly manage the immediate risk of bleeding post-IV removal.
C: Charting the client's tolerance to the procedure is important for documentation but occurs after ensuring the patient's safety and controlling any potential bleeding from the IV site.
D: Removing the catheter slowly using the dominant hand is a necessary technique, but it does not prioritize the essential action of applying pressure to ensure hemostasis.
A nurse is caring for a client, diagnosed with Parkinson's disease, who scored as a high-risk fall candidate on the St. Thomas Risk Assessment Tool in Falling Elderly Inpatients. Which nursing interventions should the nurse implement? Select all that apply.
Rationale:
A: provide the client with a call-light device, B: keep the bed in the lowest position, D: implement a bed alarm.
The selected interventions enhance patient safety by ensuring the client can easily call for assistance, minimizing the risk of falling during transfers, and alerting staff if the client attempts to get out of bed unsupervised, crucial for managing Parkinson's disease-related mobility challenges.
C: use a beveled floor mat at bedside. While this may reduce tripping hazards, it does not address immediate communication or alerting needs, which are vital for high-risk fall clients.
A 10-year-old is sent home from school with a report of having lice. The nurse should instruct the parent on which intervention?
Rationale:
Treat with an approved pediculicide agent according to directions.
Using an approved pediculicide is the most effective method to eliminate lice infestations. These treatments are specifically designed to target and kill lice and their eggs, ensuring complete eradication when used as directed. Proper application maximizes effectiveness and minimizes the risk of re-infestation.
A: wash the hair for three continuous days with dandruff shampoo. Dandruff shampoo lacks the active ingredients necessary to eliminate lice, rendering it ineffective for treating an infestation.
B: isolate all clothing of the child for one week. While isolation may prevent spread, it does not address the actual lice problem and can lead to unnecessary inconvenience.
D: shave the child's head, then cleanse with herbal shampoo. Shaving is extreme and unnecessary; effective lice treatments exist that do not require such drastic measures, making this option impractical.
A client is scheduled for a CT of the brain with and without IV contrast dye to evaluate a possible hemorrhage. Which finding in the client's history should the nurse report immediately to the health care provider?
Rationale:
A: allergy to shellfish. Shellfish allergies may indicate a potential sensitivity to iodinated contrast dye, posing a risk of anaphylactic reactions during the CT scan, necessitating immediate reporting to ensure patient safety.
B: history of schizophrenia. A psychiatric history does not directly impact the administration of contrast dye or the safety of the CT procedure, thus does not require urgent communication with the healthcare provider.
C: allergy to cephalosporins. While allergies to cephalosporins are important, they do not correlate with the use of iodinated contrast dye and do not necessitate immediate attention in this situation.
D: presence of a pacemaker. The presence of a pacemaker does not directly influence the use of contrast dye in a CT scan, making it less critical to report urgently compared to a shellfish allergy.
The nurse is caring for a client who just arrived in the PACU following a colonoscopy with polyp removal. The client's level of sedation is assessed using the Ramsay Sedation Scale (RSS). The client responds quickly, but only to commands. What Ramsay score would the nurse chart for this client?
Rationale:
C: RSS 3. The client, responding quickly but only to commands, indicates a moderate level of sedation, which aligns with Ramsay Sedation Scale score 3, where patients are cooperative but require stimulation for a response.
A: RSS 1. This score indicates the client is anxious and agitated, not showing any response to commands, which does not match the client's behavior.
B: RSS 2. This score reflects a client who is cooperative but requires light stimulation to respond, which does not accurately describe the client's quick response to commands.
D: RSS 4. A score of 4 suggests a client who is sleeping but can be easily awakened, differing from the client's ability to respond promptly to commands.
E: RSS 5. This score indicates a client who is difficult to arouse, unresponsive to commands, which is contrary to the client's observed responsiveness.
F: RSS 6. This score represents a client who is comatose and unresponsive, which contradicts the client's ability to respond quickly to commands.
The nurse is educating a client who has been ordered to wear a Holter monitor. Which statement by the client indicates a need for further education by the nurse?
Rationale:
I can wear the monitor while I shower. Wearing a Holter monitor during showering is inappropriate, as water can damage the device and hinder its ability to accurately record heart activity.
B: I should keep the monitor on when I sleep. Continuous monitoring during sleep is essential for capturing any irregularities that may occur during rest periods.
C: I should avoid metal detectors and electric razors while wearing the monitor. Metal detectors and electric razors do not interfere with the Holter monitor's recording capabilities and can be used safely.
D: I should keep a log of any chest pain, shortness of breath, or skipped beats while wearing the monitor. Maintaining a log provides valuable information that aids in the assessment of the heart's condition.
A client in the emergency department is complaining of abdominal pain after an episode of nausea and vomiting. Which statement by the client to the nurse necessitates prompt notification of the health care provider?
Rationale:
D: The pain is worse when I cough or move but feels better when I bend my right hip. This statement indicates potential irritation of the peritoneum, suggesting an acute abdominal condition that requires immediate evaluation by the health care provider to prevent complications.
A: I started hurting when I got up this morning to go to work. This statement provides a timeline but lacks specificity regarding the nature or severity of the pain.
B: My grandmother had to have her appendix out many years ago. Family history alone does not indicate an immediate concern for the client’s current symptoms or necessitate urgent intervention.
C: I haven't eaten anything because I've been so nauseated and throwing up. While concerning, this statement primarily relates to nutritional status and does not indicate an acute, emergent issue requiring prompt notification.
A college student presents at the emergency department after being thrown off a horse. Head injury with increased intracranial pressure (ICP) is suspected. The nurse understands that late signs of increased ICP include which manifestations? Select all that apply.
Rationale:
Late signs of increased intracranial pressure (ICP) include seizures, severe headache, and nausea and vomiting, as they indicate significant brain distress and require immediate medical intervention to prevent further complications.
B: irritability A symptom often related to mild brain injury or anxiety, irritability does not specifically indicate late-stage increased ICP, which often presents with more severe and physical manifestations.
C: restlessness This is typically an early sign of increased ICP or anxiety, rather than a late manifestation. Late-stage symptoms tend to be more pronounced and critical in nature.
D: disorientation While disorientation can occur with increased ICP, it is generally associated with early changes in mental status rather than definitive late signs requiring urgent attention.
The nurse is caring for a client with dementia who has pulled out three peripheral IVs. Which intervention by the nurse is the best way to manage this client?
Rationale:
Replace the IV and wrap it in gauze to hide it from view. This intervention addresses the immediate issue while minimizing the client's awareness of the IV, reducing anxiety and potential further attempts to remove it. It allows for continued treatment without resorting to more restrictive measures, supporting the client's dignity and comfort.
A: Place the client in restraints or mitts. This option may compromise the client's autonomy and dignity, potentially leading to increased agitation and distress, which could exacerbate the situation.
B: Tell the family that they need to stay with the client. While family support is valuable, this intervention does not directly prevent further IV removal and may not be feasible or effective.
D: Tell the client that if she pulls another IV out, she will have to have a PICC line placed. This approach may instill fear and confusion, failing to address the underlying behavior and potentially worsening the client's anxiety or resistance.
The nurse is caring for a client receiving warfarin therapy for atrial fibrillation. Laboratory results show an INR of 3.9. The nurse would expect which order from the health care provider?
Rationale:
An order to decrease the warfarin dose.
An INR of 3.9 indicates that the client's blood is thinner than desired, putting them at increased risk for bleeding. Therefore, the health care provider should reduce the warfarin dosage to bring the INR within the therapeutic range of 2.0 to 3.0 for effective management of atrial fibrillation.
A: an order to increase the warfarin dose. Increasing the warfarin dose would further elevate the INR, significantly heightening the risk of hemorrhage, which is inappropriate given the current value.
C: an order for protamine sulfate. Protamine sulfate is an antidote for heparin, not warfarin. It would not be relevant or effective in addressing elevated INR levels caused by warfarin therapy.
D: no new order; the INR is therapeutic. An INR of 3.9 exceeds the therapeutic range for atrial fibrillation, indicating the need for intervention rather than maintaining the current warfarin dosage.
The nurse is caring for a client who has just returned from the cardiac catheterization lab. Which complications of cardiac catheterization require immediate intervention by the nurse? Select all that apply.
Rationale:
Chest pain, hematoma formation, and decreased pulses in the affected extremity require immediate intervention by the nurse. These complications can indicate serious issues such as myocardial ischemia, bleeding, or compromised circulation, necessitating prompt assessment and action to prevent further deterioration of the patient's condition.
B: decreased appetite This symptom does not typically indicate an acute complication following cardiac catheterization and is generally less urgent than the other listed options.
C: difficulty swallowing This issue is not a common complication of cardiac catheterization and usually does not necessitate immediate nursing intervention in this context.
A nurse is monitoring a client's intracranial pressure (ICP) after a motor vehicle accident. Upon checking the ICP, the nurse knows to contact the physician. What reading would warrant this action?
Rationale:
22 mm Hg indicates a concerning elevation in intracranial pressure that exceeds normal limits, necessitating immediate medical intervention to prevent potential brain damage or other serious complications following the accident.
A: 8 mm Hg This reading falls well within the normal range for ICP, indicating that the intracranial pressure is stable and does not require immediate physician contact.
B: 14 mm Hg This value is also considered normal for intracranial pressure, suggesting that the client is not in immediate danger and does not require urgent medical attention.
C: 18 mm Hg Although elevated, this reading does not reach the critical threshold that typically requires physician notification, allowing for continued monitoring without immediate intervention.
The nurse is caring for a client receiving hemodialysis. During hemodialysis, the client becomes anxious, experiencing tachypnea and hypotension. The nurse suspects which complication of hemodialysis?
Rationale:
D: Disequilibrium syndrome is suspected due to the client's anxiety, tachypnea, and hypotension during hemodialysis. These symptoms align with rapid changes in fluid and electrolyte balance, leading to neurological complications and discomfort.
A: Air embolism manifests with sudden respiratory distress and cardiovascular instability, typically presenting with more acute symptoms rather than the gradual development observed in this case.
B: Clotting of the graft site primarily leads to altered blood flow and may cause localized pain or swelling, not the systemic symptoms of anxiety and hypotension indicated here.
C: Dialysis encephalopathy involves neurological symptoms like confusion or seizures, which do not correlate with the anxiety and respiratory changes exhibited by the client during the procedure.
A student nurse is discussing fluid overload with the staff nurse. Which statement by the student nurse indicates a need for further explanation by the staff nurse?
Rationale:
Pitting edema is the best indicator of fluid overload. While pitting edema can indicate fluid retention, it is not the most reliable or definitive sign of fluid overload, as other factors may contribute to this condition.
B: The client may have distended veins in the hands and neck. Distended veins are indeed a common manifestation of fluid overload, indicating increased venous pressure and fluid volume.
C: I may hear moist crackles in the lungs during my respiratory assessment. Moist crackles in the lungs are a classic sign of fluid overload, reflecting pulmonary congestion and fluid accumulation in the alveoli.
D: The client may need drug therapy and sodium restriction to treat the overload. Drug therapy and sodium restriction are appropriate interventions for managing fluid overload, addressing both the fluid balance and underlying causes.
The nurse is assessing a client with a stage 3 pressure ulcer. Which finding is consistent with this type of pressure ulcer?
Rationale:
Full-thickness skin loss is present with undermining. Stage 3 pressure ulcers are characterized by extensive tissue damage, exposing subcutaneous fat and often accompanied by undermining, indicating a more severe level of injury.
A: Eschar is present on at least part of the wound. While eschar may appear in deeper ulcers, it is not a definitive characteristic of stage 3 pressure ulcers.
C: Partial-thickness skin loss of the epidermis is present. This description pertains to stage 2 pressure ulcers, where only partial-thickness involvement occurs, not the full-thickness loss seen in stage 3.
D: The area is red and does not blanch with external pressure. This finding describes a stage 1 pressure ulcer, where intact skin shows non-blanchable redness, not the deeper tissue damage of stage 3.
The nurse is caring for a client with diabetes whose HgbA1C level is 6.9. The client asks the nurse what this means. Which response by the nurse is appropriate?
Rationale:
Your level indicates good glycemic control. A HgbA1C of 6.9% is slightly above the typical target range for diabetics, suggesting that while control is generally effective, there may be a need for monitoring or adjustments.
B: Your level is too high, and you will need to increase your medications. A HgbA1C of 6.9% is not excessively elevated, suggesting that medication adjustments may not be immediately necessary.
C: Your level is too low, and you will need to decrease your medications. A HgbA1C of 6.9% does not indicate low blood sugar levels, so decreasing medications would be inappropriate.
D: Your health care provider may want to place you on an insulin pump. The current HgbA1C level does not automatically suggest the need for an insulin pump, as control is generally adequate.
A client is having a tonic-clonic seizure. Which of the following should the nurse do first?
Rationale:
Ensure a safe environment is the priority during a tonic-clonic seizure, as it reduces the risk of injury. This includes moving objects away and positioning the client safely, which is essential for their protection.
A: call for assistance. While calling for help is important, immediate action to secure the environment takes precedence in preventing harm during a seizure.
B: restrain the client. Restraining a client can lead to injury and exacerbate the seizure. Ensuring safety without physical restraint is the best approach.
C: turn the client on her side. Although positioning is helpful, the first step must focus on securing the environment to prevent potential injuries during the seizure.