Q&A Random Selection #4
1 A: 60 year-old with herpes simplex. Clients who have herpes simplex infections must have contact precautions in
addition to standard precautions because of the associated, potentially weeping, skin lesions. Contact precautions
are used for clients who are infected by microorganisms that are transmitted by direct contact with the client,
including hand or skin-to-skin contact.
2 B: Taking high doses of steroids for arthritis for many years. The use of steroids, especially at high doses over time,
increases the risk for osteoporosis. The other options also predispose to osteoporosis, as do low bone mass, poor
calcium absorption andmoderate to high alcohol ingestion. Long-term steroid treatment is the most significant risk
factor, however.
3 C: Depressed immune system. Children who have a depressed immune system related to HIV or chemotherapy
should not begiven routine immunizations.
4 A: Using a moist soft brush or cloth to clean teeth and gums. The nurse should use a soft cloth or soft brush to do
mouth care so that the child can adjust to the routine of cleaning the mouth and teeth.
5 C: "I dip his pacifier in honey so he''ll take it." Honey has been associated with infant botulism and should be
avoided. Olderchildren and adults have digestive enzymes that kill the botulism spores.
6 D: Perform a neurovascular check for circulation. While each of these is an important assessment, the
neurovascular integrity check is most associated with this type of traction. Russell’s traction is Buck’s traction with a
sling under the knee.
7 D: Seizure activity. Other reactions that should be reported include crying for >3 hours, temperature over 104.8
degrees Fahrenheit following DPT immunization, and tender, swollen, reddened areas.
8 A: Decentralized staffing takes into consideration specific client needs and staff interests and abilities.
9 D: Days 17-19. Ovulation occurs 14 days prior to menses. Considering that the woman''s cycle is 32 days,
subtracting 14 from32 suggests ovulation is at about the 18th day.
10 B: Dizzy spells. Cardiac dysrhythmias may cause a transient drop in cardiac output and decreased blood flow to
the brain. Near syncope refers to lightheartedness, dizziness, temporary confusion. Such "spells" may indicate runs
of ventricular tachycardia or periods of asystole and should be reported immediately.
11 B: "Sometimes when I put my shoes on I don''t know where my toes are."
Peripheral neuropathy can lead to lack of sensation in the lower extremities. Clients who do not feel pressure and/or
pain are at high risk for skin impairment.
12 C: 75 year-old with left sided paresthesia who is incontinent of urine and stool
Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and
hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest
number of risk factors.
13 D: radiation and chemotherapy. The initial treatment of choice for Ewing''s sarcoma is a combination of radiation
and chemotherapy.
14 A: "Your child must use a care seat until he weighs at least 40 pounds." Children should use car seats until they
weigh 40 pounds.
15 D: Sleep with head propped on several pillows. Heartburn is a burning sensation caused by regurgitation of gastric
contents. It is best relieved by sleeping position, eating small meals, and not eating before bedtime.
16 B: vena caval interruption. Clients with contraindications to Heparin, recurrent PE or those with complications
related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior
vena cava. A filter can beplaced transvenously to trap clots before they travel to the pulmonary circulation.
17 C: Nephrotoxicity. Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead
poisoning in general.
18 B: Monitor the neonate’s temperature. When using a warming device the neonate’s temperature should be
continuously monitored for undesired elevations. The use of heat lamps is not safe as there is no way to regulate
their temperature. Warming medications and fluids is not indicated. While touching with cold hands can startle the
infant it does not pose a safety risk.
19 A: Set good examples themselves. The preschool years are the time for parents to begin emphasizing safety
principles as well as providing protection. Setting a good example themselves is crucial because of the imitative
behaviors of pre-schoolers; they are quick to notice discrepancies between what they see and what they are told.
20 B: Ensure that the stump is elevated the first day post-op. This priority intervention prevents pressure caused by
pooling of blood, thus minimizing the pain. Without this measure, a firm elastic bandage, opioid narcotics, or guided
imagery will have little effect. Opioid narcotics are given for severe pain.
21 C: oliguria. Kidneys maintain fluid volume through adjustments in urine volume.
22 C: Fetal distress in labor. The effects of earlier distress may alter the findings of reflex responses as measured on
the Ballard tool. Other physical characteristics that estimate gestational age, such as amount of lanugo, sole creases
and ear cartilage are unaffected by the other factors.
23 C: Non-rebreather mask. The non-rebreather mask has a one-way valve that prevents exhales air from entering
the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room
air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of the oxygen is
available.
24 B: Prolonged rupture of membranes. Premature rupture of the membranes (PROM) is a leading cause of newborn
sepsis. After 12-24 hours of leaking fluid, measures are taken to reduce the risk to mother and the fetus/newborn.
25 D: Remove the child''s toys from the immediate area. Nursing care for a child having a seizure includes,
maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Since the
seizure has already started, nothing should be forced into the child''s mouth and the child should not be moved. Of
the choices given, the first priority would be to provide a safe environment.
26 C: The plan to use safety devices (restraints) should be rethought. Restraints are used to protect the client from
harm caused by removing tubes or getting out of bed. In the event that this restricted movement could cause more
harm, such as aspiration, then a sitter should be requested. These are to be provided by the facility in the event the
family cannot do so. This client needs to cough and be watched rather than restricted. Suctioning will not prevent
aspiration in this situation. Cough suppressants should be avoided for this client.
27 C: boost the immune system. The practitioner treats with minute doses of plant, mineral or animal substances
which provide a gentle stimulus to the body''s own defenses.
28 C: Provide water feedings at least every 2 hours. Protecting the eyes of the neonates is very important to prevent
damage when under the ultraviolet lights, but since the blanket is used, extra protection of the eyes is unnecessary. It
is recommended that the neonate remain under the lights for extended periods. The neonate’s skin is exposed to the
light and the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings.
Frequent water or feedings are given to help with the excretion of the bilirubin in the stool.
29 A: restrict visitors to immediate family. Maintaining a quiet environment will assist in minimizing cerebral
rebleeding. When family visit, the client should not be disturbed. If the client is awake, topics of a general nature are
better choices for discussion than topics that result in emotional or physiological stimulation.
30 C: Obtain an interview guide from human resources for consistency in interviewing each candidate
An interview guide used for each candidate enables the nurse manager to be more objective in the decision making.
The nurse should use resources available in the agency before attempts to develop one from scratch. Certain
personal questions are prohibited, and HR can identify these for novice managers.
31 D: remove a mucus plug. While no longer recommended for routine suctioning, saline may thin and loosen viscous
secretions that are very difficult to move, perhaps making them easier to suction.
32 D: Outline the spot with a pencil and note the time and date on the cast. This is a good way to assess the amount
of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with
this type of surgery. The bleeding should also be documented in the nurse’s notes.
33 A: Liver function. INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be
detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.
34 D: Any activity that involves straining should be avoided in clients with glaucoma. Such activities would increase
intraocular pressure.
35 C: humidified air and increased oral fluids. The most important aspects of home care for a child with acute
spasmodic croup are humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate
systemic hydration aids in mucociliary clearance and keeps secretions thin, white, watery, and easily removed with
minimal coughing.
36 C: fastening clean tracheostomy ties before removing old ties. Fastening clean tracheostomy ties before removing
old ones will ensure that the tracheostomy is secured during the entire cleaning procedure. The obturator is useful to
keep the airway open only after the tracheostomy outer tube is coughed out. A second nurse is not needed.
Changing the position may not prevent a dislodged tracheostomy.
37 C: Pulse oximetry. A sudden change in mental status in any post-op client should trigger a nursing intervention
directed toward respiratory evaluation. Pulse oximetry would be the initial assessment. If available, arterial blood
gases would be better. Acute respiratory failure is the sudden inability of the respiratory system to maintain adequate
gas exchange which may result in hypercapnia and/or hypoxemia. Clinical findings of hypoxemia include these
finding which are listed in order of initial to later findings: restlessness, irritability, agitation, dyspnea, disorientation,
confusion, delirium, hallucinations, and loss of consciousness. While there may be other factors influencing the
client''s behavior, the first nursing action should be directed toward maintaining oxygenation. Once respiratory or
oxygenation issues are ruled out then significant changes in glucose would be evaluated.
38 A: After delivery, the high glucose levels which crossed the placenta to the fetus are suddenly stopped. The
newborn continues to secrete insulin in anticipation of glucose. When oral feedings begin, the newborn will adjust
insulin production within a day or two.
39 B: Reduced PaO2. Cold stress causes increased risk for respiratory distress. The baby delivered in such
circumstances needs careful monitoring. In this situation, the newborn must be warmed immediately to increase its
temperature to at least 97 degrees Fahrenheit (36 degrees Celsius).
40 C: Client reports prickling sensation in the right hand. A prickling sensation is an indication of compartment
syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.