EspanClex



Implementation # 2

Questions Answers and Clinical Reasoning

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1. To prevent infection when obtaining a sterile urine specimen from a patient's indwelling urinary catheter, the nurse should:

A. aspirate urine from the tubing port, using a sterile syringe and needle

B. disconnect the catheter from the tubing and obtain urine

C. open the drainage bag and pour out some urine

D. wear sterile gloves when obtaining urine[pic]

2. Which action should the nurse take first when preparing to administer a blood transfusion. ?

A. Arrange for typing and crossmatching of the patient's blood

B. Compare the patient's identification wristband with the tag on the unit of blood

C. Start an I.V. infusion of normal saline solution

D. Measure the patient's vital signs[pic]

3. A preschool-age child with sickle cell anemia is admitted to the health care facility in vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's highest priority when caring for this child?

A. Providing fluids

B. Maintaining protective isolation

C. Applying cool compresses to affected joints

D. Administering antipyretics, as prescribed[pic]

4. A child, age 5, is hospitalized for treatment of Kawasaki disease. Which nursing action would best identify potential complications of this disease?

A. Auscultating breath sounds

B. Instituting cardiac monitoring

C. Monitoring blood pressure

D. Assessing the skin daily[pic]

5. The nurse must administer an oral medication to a 3-year-old child. The best way for the nurse to proceed is by saying:

A. "It's time for you to take your medicine right now."

B. "If you take your medicine now, you'll go home sooner."

C. "Here's your medicine. Would you like apple juice or grape drink after?"

D. "See how Jimmy took his medicine? He's a good boy. Now it's your turn."[pic]

6. A woman becomes increasingly afraid of riding in elevators. One morning, she experiences shortness of breath, palpitations, dizziness, and trembling while in an elevator. A doctor can find no physiological basis for these symptoms and refers her to a psychiatric clinical nurse specialist for outpatient counseling sessions. Which of the following is most likely to reduce the patient's anxiety level?

A. Psychoanalytically oriented psychotherapy

B. Group psychotherapy

C. Systematic desensitization

D. Referral for evaluation for electroconvulsive therapy[pic]

7. The nurse in a psychiatric inpatient unit is caring for a patient with obsessive-compulsive disorder. As part of the patient's treatment, the psychiatrist orders lorazepam (Ativan), 1 mg P.O. t.i.d. During lorazepam therapy, the nurse should remind the patient to:

A. avoid caffeine

B. avoid aged cheeses

C. stay out of the sun

D. maintain an adequate salt intake[pic]

8. A patient with Alzheimer's disease says, "I'm so afraid. Where am I? Where is my family?" How should the nurse respond?

A. "You are in the hospital and you're safe here. Your family will return at 10 o'clock--that's 1 hour from now."

B. "You know where you are. You were admitted here 2 weeks ago. Don't worry, your family will be back soon."

C. "Why do you keep asking the same questions over and over?"

D. "The name of the hospital is on the sign over the door. Let's go read it again."[pic]

9. Before the nurse administers the first dose of lithium (Lithonate) to a patient, she reviews information about the drug. Which statement accurately describes the metabolism and excretion of lithium?

A. It is metabolized in the liver and excreted in the feces.

B. It is metabolized and excreted by the kidneys.

C. It is not metabolized and is excreted unchanged by the kidneys.

D. It is metabolized in the liver and excreted by the kidneys.[pic]

10. A patient is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise her to use which body position?

A. Right lateral

B. Left lateral

C. Supine

D. Semi-Fowler's[pic]

11. The nurse is providing dietary teaching to a pregnant patient. To help meet the patient's iron needs, the nurse should advise her to eat:

A. grains and milk

B. tomatoes and fish

C. eggs and citrus fruit

D. spinach and beef[pic]

12. Before discharge, which instruction should the nurse give to a patient receiving flecainide (Tambocor) to reduce the risk of congestive heart failure?

A. "Limit your fluid intake."

B. "Take a diuretic before going to bed."

C. "Limit your potassium intake."

D. "Have your serum electrolyte levels measured weekly."[pic]

13. Which nursing intervention is most appropriate for a patient with multiple myeloma?

A. Monitoring respiratory status

B. Balancing rest and activity

C. Restricting fluid intake

D. Preventing bone injury[pic]

14. A patient is scheduled to undergo a left hemicolectomy for colorectal cancer. The doctor prescribes phenobarbital sodium (Luminal), 100 mg I.M. 60 minutes before surgery for sedation. Which statement accurately describes administration of phenobarbital sodium?

A. The preferred route of administration for this drug is I.M.

B. This drug can be mixed and given with other medications.

C. This drug should be used within 24 hours after opening.

D. This drug should be injected into a large muscle mass.[pic]

15. At a health fair, a woman, age 43, with a family history of osteoporosis asks the nurse how much calcium she should consume. The nurse tells her that the recommended daily calcium intake for premenopausal women is:

A. 250 to 500 mg

B. 600 to 800 mg

C. 1,000 to 1,200 mg

D. 1,500 to 2,000 mg

Implementation # 2 ~ Answers and Clinical Reasoning

Question

1. The nurse is obtaining a sterile urine specimen from a patient's indwelling urinary catheter. To prevent infection, the nurse should:

THE CORRECT ANSWER IS: A. aspirate urine from the tubing port, using a sterile syringe and needle.

CLINICAL REASONING: To obtain urine properly, the nurse should aspirate it from a port, using a sterile syringe after cleaning the port. Opening a closed urine-drainage system, as in options B and C, would increase the risk of urinary tract infection. Although standard precautions specify wearing gloves during contact with body fluids, sterile gloves are not necessary.

NURSING INTERVENTION : PATIENT NEED : Safe, effective care environment TAXONOMY:

2. The nurse is preparing to administer a blood transfusion. Which action should the nurse take first?

THE CORRECT ANSWER IS: A. Arrange for typing and crossmatching of the patient's blood.

CLINICAL REASONING: The nurse first arranges for typing and crossmatching of the patient's blood to ensure compatibility with donor blood. The other options, although appropriate when preparing to administer a blood transfusion, come later.

NURISNG INTERVENTION : Implementation

PATIENT NEEDS: Safe, effective care environment TAXONOMY : Knowledge

Question

3. A preschool-age child with sickle cell anemia is admitted to the health care facility in vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's highest priority when caring for this child?

THE CORRECT ANSWER IS: A. Providing fluids.

CLINICAL REASONING: During a vaso-occlusive crisis, sickle-shaped red blood cells (RBCs) clump together and obstruct blood vessels, causing ischemia and tissue damage. Providing I.V. and oral fluids promotes hemodilution, which aids the free flow of RBCs through blood vessels. The patient must be kept away from known infection sources but does not require protective isolation. Warm compresses may be applied to painful joints to promote comfort; cool compresses would cause vasoconstriction, which exacerbates sickling. Antipyretics may be administered to reduce fever but do not play a crucial role in resolving the crisis.

NURISNG INTERVENTION : Implementation

PATIENT NEEDS : Physiological integrity

TAXONOMY : Evaluation

4. A child, age 5, is hospitalized for treatment of Kawasaki disease. Which nursing action would best identify potential complications of this disease?

THE CORRECT ANSWER IS: B. Instituting cardiac monitoring

CLINICAL REASONING: Kawasaki disease sometimes causes cardiac complications, including arrhythmias. Instituting cardiac monitoring is crucial in detecting such complications. Auscultating breath sounds, monitoring blood pressure, and assessing the skin daily are important but to a lesser degree.

NURSING INTERVENTIO : Implementation

PATIENT NEEDS : Physiological integrity

TAXONOMY : Application

Question

5. The nurse must administer an oral medication to a 3-year-old child. The best way for the nurse to proceed is by saying:

THE CORRECT ANSWER IS: C. "Here's your medicine. Would you like apple juice or grape drink after?"

RATIONALES: Involving the child promotes cooperation, and permitting the child to make choices provides a sense of control. Telling a child to take the medicine "right now" could provoke a negative response. Promising that the child will go home sooner could decrease the child's trust in nurses and doctors. Comparing one child with another would not encourage cooperation.

NURSING INTERVENTION : Implementation

PATIENT NEEDS : Safe, effective care environment

TAXONOMY : Evaluation

Question

6. A woman becomes increasingly afraid of riding in elevators. One morning, she experiences shortness of breath, palpitations, dizziness, and trembling while in an elevator. A doctor can find no physiological basis for these symptoms and refers her to a psychiatric clinical nurse specialist for outpatient counseling sessions. Which of the following is most likely to reduce the patient's anxiety level?

THE CORRECT ANSWER IS: C. Systematic desensitization

RATIONALES: Phobias commonly are viewed as learned responses to anxiety that can be unlearned through certain techniques, such as behavior modification. Systematic desensitization, a form of behavior modification, attempts to reduce anxiety and thereby eradicate the phobia through gradual exposure to anxiety-producing stimuli. Psychoanalytically oriented therapy also may be effective in this situation but requires years of treatment. Group psychotherapy could be used as an adjunct treatment to increase the patient's self-esteem and reduce generalized anxiety. Electroconvulsive therapy is reserved primarily for patients with severe depression or psychosis who respond poorly to other treatments. It is rarely indicated for phobic disorders.

NURSING INTERVENTION : Implementation

PATIENT NEEDS : Psychosocial integrity

TAXONOMY : Evaluation

7. The nurse in a psychiatric inpatient unit is caring for a patient with obsessive-compulsive disorder. As part of the patient's treatment, the psychiatrist orders lorazepam (Ativan), 1 mg P.O. t.i.d. During lorazepam therapy, the nurse should remind the patient to:

THE CORRECT ANSWER IS: A. avoid caffeine

RATIONALES: Ingesting 500 mg or more of caffeine can significantly alter the anxiolytic effects of lorazepam. Other dietary restrictions are unnecessary. Staying out of the sun or using sunscreens is required when taking phenothiazines. An adequate salt intake is necessary for patients receiving lithium.

NURSING INTERVENTION : Implementation

PATIENT NEEDS : Physiological integrity

TAXONOMY : Knowledge

Question

8. A patient with Alzheimer's disease says, "I'm so afraid. Where am I? Where is my family?" How should the nurse respond?

THE CORRECT ANSWER IS: A. "You are in the hospital and you're safe here. Your family will return at 10 o'clock--that's 1 hour from now."

RATIONALES: Providing the specific information requested comforts and reassures the patient, who is lost and confused, and promotes orientation. The nurse should not assume that a patient with Alzheimer's disease will remember being admitted to the hospital (option B) and should supply specific information about when the family will visit. The nurse should not scold or infantilize the patient (option C) or assume that the patient will remember the name of the hospital after seeing the sign (option D).

NURSING INTERVENTION : Implementation

PATIENT NEEDS : Psychosocial integrity

TAXONOMY : Comprehension

Question

9. Before the nurse administers the first dose of lithium (Lithonate) to a patient, she reviews information about the drug. Which statement accurately describes the metabolism and excretion of lithium?

THE CORRECT ANSWER IS: C. It is not metabolized and is excreted unchanged by the kidneys.

RATIONALES: Lithium is not metabolized and is excreted unchanged by the kidneys.

NURSING INTERVENTION : Implementation

PATIENT NEEDS : Physiological integrity

TAXONOMY : Analysis

Question

10. A patient is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise her to use which body position?

THE CORRECT ANSWER IS: B. Left lateral

RATIONALES: The left lateral position shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function. The right lateral and semi-Fowler positions do not alleviate pressure of the enlarged uterus on the vena cava. The supine position reduces sodium and water excretion because the enlarged uterus compresses the vena cava and aorta; this decreases cardiac output, leading to decreased renal blood flow, which in turn impairs kidney function.

NURSING INTERVENTION : Implementation

PATIENT NEEDS : Health promotion and maintenance

TAXONOMY : Knowledge

Question

11. The nurse is providing dietary teaching to a pregnant patient. To help meet the patient's iron needs, the nurse should advise her to eat:

THE CORRECT ANSWER IS: D. spinach and beef

RATIONALES: Common food sources of iron include spinach, beef, liver, prunes, pork, broccoli, legumes, and whole wheat breads and cereals. Grains are good sources of carbohydrates; milk is high in vitamin D; and fish, eggs, and calcium are high in protein. Tomatoes and citrus fruits are high in vitamins A and C.

NURSING INTERVENTIONS : Implementation

PATIENT NEEDS : Physiological integrity

TAXONOMY : Knowledge

Question

12. Before discharge, which instruction should the nurse give to a patient receiving flecainide (Tambocor) to reduce the risk of congestive heart failure?

THE CORRECT ANSWER IS: A. "Limit your fluid intake."

RATIONALES: The nurse should tell the patient receiving flecainide to limit fluid intake. The patient should not take a diuretic unless prescribed by the doctor; if prescribed, the diuretic should be taken early in the day to prevent nocturia. Sodium (not potassium) should be limited because excessive sodium intake causes water retention. The patient's electrolyte levels do not need to be measured weekly.

NURSING INTERVENTION : Implementation

PATIENT NEEDS : Health promotion and maintenance

TAXONOMY : Comprehension

Question

13. Which nursing intervention is most appropriate for a patient with multiple myeloma?

THE CORRECT ANSWER IS: D. Preventing bone injury

RATIONALES: When caring for a patient with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any patient. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the patient well hydrated--not restrict his fluid intake.

NURSING INTERVENTION : Implementation

PATIENT NEEDS : Safe, effective care environment

TAXONOMY : Application

Question

14. A patient is scheduled to undergo a left hemicolectomy for colorectal cancer. The doctor prescribes phenobarbital sodium (Luminal), 100 mg I.M. 60 minutes before surgery for sedation. Which statement accurately describes administration of phenobarbital sodium?

THE CORRECT ANSWER IS: D. This drug should be injected into a large muscle mass.

RATIONALES: Phenobarbital sodium should be injected into a large muscle mass. The I.M. route of administration is usually avoided because the alkalinity of the soluble preparations causes pain and necrosis at the injection site. Barbiturates are involved in many drug interactions, so the drug should not be mixed and given with other medications. The drug solution should be used within 30 minutes after opening to minimize deterioration.

NURSING INTERVENTION : Implementation

PATIENT NEEDS : Physiological integrity

TAXONOMY : Analysis

Question

15. At a health fair, a woman, age 43, with a family history of osteoporosis asks the nurse how much calcium she should consume. The nurse tells her that the recommended daily calcium intake for premenopausal women is:

THE CORRECT ANSWER IS: C. 1,000 to 1,200 mg.

RATIONALES: Most authorities recommend that premenopausal women consume 1,000 to 1,200 mg of calcium daily. Less than 1,000 mg may not provide adequate protection against osteoporosis; more than 1,200 mg is not necessary and may be harmful.

NUSING INTERVENTION : Implementation

PATIENT NEEDS : Health promotion and maintenance

TAXONOMY : Knowledge

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