10/07/2016
5. A postpartum client requires teaching about breast-feeding. To prevent breast engorgement, the nurse should instruct her to:
1. use an electric breast pump.
2. apply warm, moist compresses to the breasts.
3. breast-feed as often as the infant is hungry — typically every 1 to 3 hours.
4. wear a brassiere 24 hours per day.
Frequent breast-feeding empties the breasts and increases circulation, helping to remove fluid that may lead to engorgement. If the infant isn't ill or physically impaired and can breast-feed, the client shouldn't use an electric breast pump because this deprives the infant of optimal sucking and skin-to-skin contact with the mother. Applying warm, moist compresses stimulates the let-down reflex and causes the breasts to fill, which may lead to engorgement. A brassiere supports the breasts but doesn't prevent engorgement unless the client breast-feeds frequently.
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6. A client with delusional thinking shows a lack of interest in eating at meal times. She states that she is unworthy of eating and that her children will die if she eats. Which nursing action would be most appropriate for this client?
1. Telling the client that she may become sick and die unless she eats
2. Paying special attention to the client's rituals and emotions associated with meals
3. Restricting the client's access to food except at specified meal and snack times
4. Encouraging the client to express her feelings at meal times
Restricting access to food, except at specified times, prevents the client from eating when she feels anxious, guilty, or depressed; this, in turn, decreases the association between these emotions and food. Telling the client she may become sick or die may reinforce her behavior because illness or death may be her goal. Paying special attention to rituals and emotions associated with meals also would reinforce undesirable behavior. Encouraging the client to express feelings at meal times would increase the association between emotions and food; instead, the nurse should encourage her to express feelings at other times.
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7. A 33-year-old client who tested positive for human immunodeficiency virus (HIV) and has pancreatitis is admitted to the medical unit. The nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director about reading the client's chart. The director states that the client is her neighbor's son. What action should the nurse take to protect the client's right to privacy?
1. Inform the nurse director she's violating the client's right to privacy and ask her to return the chart.
2. Remind the nurse director not to share the client's medical information with anyone because of his HIV status.
3. Report the incident to the medical director.
4. Ask the nurse director if she has permission to read the client 's chart, and if she does not, tell her she needs to obtain it before further reading.
Under the Health Insurance Portability and Accountability Act (HIPAA), personal health information may not be used for purposes not related to health care. The nurse director found reading the chart isn't providing health care to the client and, therefore, doesn't require access to the chart. The nurse should confront the nurse director and ask her to return the client's chart. The director shouldn't have access to this client's healthcare information regardless of his HIV status. If she doesn't comply with the nurse's request, the nurse should report the incident to her nurse manager, so the infraction can be reported through the proper channels. The staff nurse shouldn't report the incident to the medical director. Option 4 doesn't protect client confidentiality.
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8. A client calls to schedule a pregnancy test. The nurse knows that most pregnancy tests measure which hormone?
1. Human chorionic gonadotropin (hCG)
2. Human placental lactogen
3. Human chorionic thyrotropin
4. Estradiol
Widely used pregnancy tests detect hCG in the blood and urine by immunologic tests specific for the beta subunit of hCG. Human placental lactogen, human chorionic thyrotropin, and estradiol are hormones produced by the placenta; however, they aren't used to detect pregnancy.
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9. A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should:
1. place the client in a private room.
2. wear a mask when handling the client's bedpan.
3. wash the hands after touching the client.
4. wear a gown when providing personal care for the client.
To maintain enteric precautions, the nurse must wash the hands after touching the client or potentially contaminated articles and before caring for another client. A private room is warranted only if the client has poor hygiene — for instance, if the client is unlikely to wash the hands after touching infective material or is likely to share contaminated articles with other clients. For enteric precautions, the nurse need not wear a mask and must wear a gown only if soiling from f***l matter is likely.
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10. A client with a bleeding peptic ulcer is admitted to an acute care facility. As part of therapy, the physician prescribes cimetidine (Tagamet) I.V. The nurse must avoid administering this drug too rapidly because doing so may cause:
1. tetany.
2. bronchospasms.
3. hallucinations.
4. bradycardia.
When given by rapid I.V. injection, cimetidine may cause profound bradycardia and other cardiotoxic effects. Tetanyand bronchospasms aren't associated with cimetidine. Although the drug may cause hallucinations, this adverse reaction doesn't result simply from rapid administration.
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11. A client with advanced breast cancer is prescribed tamoxifen (Nolvadex). When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?
1. Vision changes
2. Hearing loss
3. Headache
4. Anorexia
The client must report changes in visual acuity immediately because this adverse effect may be irreversible. Tamoxifen isn't associated with hearing loss. Although the drug may cause anorexia, headache, and hot flashes, the client need not report these adverse effects immediately because they don't warrant a change in therapy.
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12. The nurse is teaching a female client about preventing osteoporosis. Which teaching point is correct?
1. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.
2. To avoid fractures, the client should avoid strenuous exercise.
3. The recommended daily allowance of calcium may be found in a wide variety of foods.
4. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.
Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. It's often, though not always, possible to get the recommended daily requirement in the foods we eat. Supplements are available but not always necessary. Osteoporosis doesn't show up on ordinary X-rays until 30% of the bone loss has occurred. Bone densitometry can detect bone loss of 3% or less. This test is sometimes recommended routinely for women over 35 who are at risk. Strenuous exercise won't cause fractures.
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13. The nursery nurse performs an assessment on a 1-day-old neonate. During the assessment, the nurse notes discharge from both of the neonate's eyes. The nurse should take which step to help determine whether the neonate has ophthalmia neonatorum?
1. Do nothing; discharge is a normal finding in the eyes of a 1-day-old neonate.
2. Notify the physician immediately.
3. Ask the physician for an order to obtain cultures of both of the neonate's eyes.
4. Obtain a nasal viral culture.
Ophthalmia neonatorum, caused by Neisseria gonorrhea, causes neonatal blindness if left untreated. The nurse should ask the physician for an order to obtain cultures of both eyes so antibiotic treatment can be initiated. Eye discharge isn't normal in a 1-day-old neonate. Neisseria gonorrhea is caused by a gram-negative bacteria, not by a virus.
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14. A client with colorectal carcinoma is devastated after learning that the cancer has spread to the liver and lungs and the client has only a 5% chance of surviving for 5 years. Which comment by the nurse would best help the client cope with this news?
1. "I've seen clients in your situation who have lived almost 20 years."
2. "It must be hard to hear that prognosis. Would it help you to talk to me or the chaplain?"
3. "This might be a good time to think about an advance directive in case you run into problems while you're here."
4. "Those are just numbers. You have to live each day fully and not worry about dying."
This response is most therapeutic because it encourages the client to express feelings and concerns. Options 1 and 4 offer false hope and reflect the nurse's empirical observations, not statistics. Option 3 is inappropriate because an informed person who isn't a member of the health care team should discuss (at the client's request) which level of care the client wishes to receive in case of an emergency.
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15. The nurse is providing inservice education for the staff about evidence collection after s*xual assault. The educational session is successful when the staff focuses their initial care on which step?
1. Collecting semen
2. Performing the pelvic examination
3. Obtaining consent for examination
4. Supporting the client's emotional status
The teaching session is successful when the nurses focus on supporting the client's emotional status first. Next, the nurses should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.
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16. The nurse is preparing a client for chemotherapy to treat colon cancer. The client says, "I don't know about this treatment. After everything is said and done, it may not do a bit of good. This thing may get me anyway." Which response by the nurse would be most therapeutic?
1. "You're wondering whether you've made the right decision about the treatment."
2. "Many people beat cancer. You need to keep a positive attitude."
3. "Colon cancer can now be cured in many cases. Let's hope you'll be one of the lucky ones."
4. "Everyone with cancer worries, but you have every reason to be hopeful."
By rephrasing the client's statement and focusing on the client's concerns, the nurse encourages further discussion of feelings. Telling the client to keep a positive attitude incorrectly implies that the nurse knows how to deal with the situation best. Saying that cancer of the colon may be cured ignores the client's feelings. Mentioning that everyone with cancer worries overlooks the uniqueness of the client's feelings and implies that these feelings aren't acceptable.
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17. The nurse is talking with a client who recently attempted su***de. The client asks her not to tell anyone about their conversation. How should the nurse respond?
1. "I'll need to share information with the rest of your health care team if it's important to your care."
2. "I promise I won't tell anyone about the information you share with me today."
3. "I promise I won't tell anyone about the information you share with me today unless you give me permission to do so."
4. "Please don't tell me anything that you wouldn't want others on your health care team to know."
The nurse must tell the client that she'll share information if it affects his safety or his care. The nurse shouldn't promise to withhold information because she may not be able to uphold her promise if the information must be shared with others. The nurse shouldn't promise to ask permission before disclosing information to others. The nurse also shouldn't encourage the client to withhold information from her. Doing so violates the nurse's responsibility to develop a therapeutic relationship with the client. The nurse — not the client — should judge what specific information must be shared with others on the health care team.
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18. The nurse administers basic cardiac life support to a client in cardiac arrest. Which action does the nurse perform?
1. Assessing the patency of the airway
2. Administering I.V. medications
3. Administering a countershock of 200 joules
4. Breathing for the client after inserting an endotracheal (ET) tube
A nurse certified in basic cardiac life support can assess airway patency. I.V. medications given to maintain blood pressure, correct acidosis, or restore a cardiac rhythm are administered by a provider of advanced cardiac life support. Administering a countershock of 200 joules and breathing for the client after inserting an ET tube are measures carried out during advanced life support.
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19. A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment?
1. To hasten formation of scar tissue
2. To prevent vision loss
3. To eliminate the need for medical care
4. To serve as a stopgap measure until help arrives
ANSWER:
A nurse certified in basic cardiac life support can assess airway patency. I.V. medications given to maintain blood pressure, correct acidosis, or restore a cardiac rhythm are administered by a provider of advanced cardiac life support. Administering a countershock of 200 joules and breathing for the client after inserting an ET tube are measures carried out during advanced life support.
