NUR 280 Test 1
- The nurse is reviewing medical prescriptions for newly admitted clients. It would be a
priority for the nurse to follow up with the physician if a client with (a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene) prescribed (b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions (c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen) (d) sensitivity to Penicillin is prescribed Zithromax (azithromycin) Answer
- The normal potassium level is 3.5 - 5.0 mEq/L. Giving Kayexalate in this situation may
cause the client to lose potassium, causing hypokalemia, therefore the drug is not indicated; the therapeutic level for Dilantin is 10 - 20 mcg/ml, a level of 8 is sub therapeutic thereby increasing the risk of seizure activity. Acetaminophen can be safely prescribed to clients with ASA sensitivity. Azithromycin (Zithromax) can be safely prescribed for clients with sensitivity to Penicillin.
- The nurse should intervene if the nurse notes a staff member
(a) obtaining a clients consent prior to their operative procedure after receiving Ativan (lorazepam) (b) placing a client on the affected side following surgical repair of a retinal detachment (c) handling a wet cast with the palms of the hands (d) using a broad base of support while transferring a client Answer
- Informed consent, explanation and decision making must occur before sedation is given;
therapeutic interventions for retinal detachment include bedrest with the area of detachment in a dependent position to promote healing; the cast should be handled with the palms of the hands while wet to prevent denting; a broad base of support is used during transfers to prevent muscle injury.
- The community health nurse is caring for the following clients. It would be a
priority for the nurse to initiate a multidisciplinary conference for the client who is (a) 12 years old with Autism who is starting a new school and recently had a URI (upper 1 / 4
respiratory tract infection) (b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent Hemoglobin A1c of 13% (c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyri- dostigmine) and employed as a mail carrier (d) 70 years old, has schizophrenia, lives alone and reports hearing non threatening voices.
Answer
- An adolescent with uncontrolled Diabetes Mellitus would require the greatest number of
disciplines (multidisciplinary) to manage their care i.e. Medicine, Nursing, Social Work, Nutritionist; the other choices do not require as many providers of care to meet their needs.
- The nurse from the postpartum unit has been temporarily assigned to the medical surgical
unit. It would be most appropriate to assign this nurse to the client who (a) has returned from right total hip replacement surgery four hours ago (b) is being observed for increased intracranial pressure (c) had surgery two hours ago to remove the appendix (d) is two weeks post partum being maintained on a mechanical ventilator for respiratory failure
Answer
- The management of a client following abdominal surgery is standard. The postpartum
nurse routinely cares for mothers following caesarean section; therefore it is appropriate to assign this client; The other choices are not appropriate to assign to this nurse.
- The nurse in a well baby clinic has assessed several children today. It would be a priority for
the nurse to suggest follow up for the child who is (a) 2 months old with a positive babinski reflex (b) 5 months old and does not hold their own bottle (c) 10 months old who cries around strangers (d) 18 months old who needs support while ambulating 2 / 4
Answer
- A child experi- encing normal growth and development should be ambulating
- months
independently by 12 months; the Babinski reflex disappears after 2 years of age; an infant typically holds their own bottle by 6 months; stranger anxiety usually develops at approximately
- The nurse is caring for a mechanically ventilated client who was declared brain
dead. An Advance Directive is not documented on the medical record. It would be most appropriate to obtain consent for organ donation from the (a) client's primary care provider (b) client's nurse manager (c) closest living family member (d) hospital's ethics committee Answer
- Consent for organ donation is given by a client's next of kin in the absence of an Advance
Directive
- The nurse has received report on four clients. The nurse should first assess the client who
has
Answer
(a) Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 90% (b) Parkinson's Disease and is demanding to leave the hospital against med-
ical advice (AMA) (c) been admitted with suspected Guillian Barre Syndrome and has begun plasmapheresis therapy
(d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+) 3 / 4
Answer
- The client admitted with Guillain-Barre' Syndrome should be assessed first because of the
possibility of rapid progression of this illness and neuromuscular respiratory failure; clients with COPD are likely to have pulse oximetry readings
of 90% related to chronic hypoxia; this client along with the other two choices are important, but not the priority.
- It would be appropriate to assign which of these tasks to the CNA?
(a) Feeding a client who is experiencing dysphagia (b) One-on-one client observation for safety (c) Removal of an indwelling catheter
(d) Performing a simple dressing change Answer
B.The Certified Nursing Assistant may be assigned to a client that requires one- to-one observation for safety; the other choices require skilled nursing intervention by a LPN (Licensed Practical Nurse) or RN (Registered Nurse).
- The nurse should intervene if a staff member is observed
Answer
(a) discussing a client's diagnosis with visiting family members (b) collaborating with another nurse to review a prescription for blood trans- fusion (c) interrupting other staff members discussing a client in the cafeteria
(d) reviewing a clients lab values with the nutritionist Answer
- To maintain confi- dentiality the nurse should not discuss the client's diagnosis with family
- / 4
members; it is advisable that two nurses review the prescription for blood transfusion to identify