1.ID: 2 A nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment? A. A client admitted with pneumonia with a fever of 100° F (37.8°C)
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1.ID: 2 A nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment? A. A client admitted with pneumonia with a fever of 100° F (37.8°C) and some diaphoresis B. C. A client with congestive heart failure with clear lung sounds on the previous shift D. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema Correct E. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms Rationale: The client who should be seen first is the one with SOB and a history of pulmonary edema. In light of such a history, SOB could indicate that fluidvolume overload has once again developed. The client with a fever and who is diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid through the skin, but this client is not the priority. Test-Taking Strategy: Use the process of elimination and focus on the subject of the question, the client who should be seen first. Recall the rule of assessment of the ABCs — airway, breathing, and circulation — which means that the client experiencing SOB should take precedence over the other clients on the unit. This client’s condition could progress to respiratory arrest if the client were not assessed immediately on the basis of the signs and symptoms. Read each option and think about the client in most critical condition and review the disorders to determine which clients have the most critical needs. If you had difficulty with this question, review the various disease processes presented in this question. Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and trends (8th ed., p. 305). St. Louis: Elsevier. Level of Cognitive Ability: Analyzing Client Needs: Physiological IntegrityIntegrated Process: Nursing Process/Assessment Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Clinical Judgment HESI Concepts: Clinical Decision Making/Clinical Judgment, Collaboration/Managing Care Awarded 1.0 points out of 1.0 possible points. 2.ID: 1 A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. A. Decreased pulse B. Decreased urine output Correct C. Increased blood pressure D. Increased respiratory rate Correct E. Decreased respiratory depth Rationale: A client with dehydration has an increased depth and rate of respirations. The diminished fluid volume is perceived by the body as a decreased oxygen level (hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other assessment findings in insufficient fluid volume are decreased urine volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. Increased blood pressure, decreased pulse, and increased urine output occur with fluid-volume overload. Test-Taking Strategy: Use the process of elimination and focus on the subject, dehydration (deficient fluid volume). Think about the pathophysiology of deficient fluid volume. Remember that the body will increase the respiratory rate in an attempt to maintain the oxygen level. If you had difficulty with this question, review the signs of insufficient fluid volume. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 291-292). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment,Fluid and Electrolyte Balance HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes Awarded 2.0 points out of 2.0 possible points. 3.ID: 4 A nurse is reviewing the medical records of the clients to whom she is assigned on the 7 am–7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume? A. A 48-year-old client receiving diuretics to treat hypertension B. A 35-year old client who is vomiting undigested food after eating C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr Correct D. A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk for excessive fluid volume because of the diminished cardiovascular and renal function that occur with aging. Other causes of excessive fluid volume include renal failure, heart failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. A client who is receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at risk for deficient fluid volume. Test-Taking Strategy: Read the question carefully, noting that it asks for the client at risk for excessive fluid volume. Read each option and think about the fluid imbalance that could occur in each situation; in the case of the incorrect options, it is fluid-volume deficiency; the only option reflecting conditions that could result in an excess is the correct option. If you had difficulty with this question, review the causes of excessive fluid volume. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 291, 293). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluid and Electrolytes Giddens Concepts: Care Coordination, Fluid and Electrolyte Balance HESI Concepts: Collaboration/Managing Care, Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible points. 4.ID: 6 A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding causes the nurse to determine that the client’s condition has improved? A. Dyspnea B. 1+ edema in the legs C. Moist crackles in the lower lobes of the lungs D. Weight loss of 4 lb (1.8 kg) in 24 hours E. Correct Rationale: One sign that excessive fluid volume is resolving is loss of body weight. It is important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb (1 liter = 2.2 lb = 1 kg). The other options listed indicate that the client is retaining fluid. Assessment findings associated with excessive fluid volume include cough, dyspnea, rales or crackles, tachypnea, tachycardia, increased blood pressure and bounding pulse, increased central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. These symptoms must be reversed if the fluid-volume excess is to be resolved. Test-Taking Strategy: Use the process of elimination and focus on the subject, a sign that the client’s condition is improving. The only such finding is decreasing body weight. If you had difficulty with this question, review the assessment findings noted in excessive fluid volume and the signs that the condition is resolving. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 292-293). St. Louis: Mosby. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible points. 5.ID: 6 A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which serum potassium reading does the nurse associate this finding? A. 3.1 mEq/L (3.1 mmol/L) Correct B. 4.2 mEq/L (4.2 mmol/L) C. 4.5 mEq/L (4.5 mmol/L) D. 5.4 mEq/L (5.4 mmol/L) Incorrect Rationale: A serum potassium level below 3.5 mEq/L(3.5 mmol/L) is indicative of hypokalemia, the most common electrolyte imbalance, which is potentially life threatening. ECG changes in hypokalemia include peaked P waves, flat T waves, a depressed ST segment, and prominent U waves. Readings of 4.5 mEq/L (4.5 mmol/L)and 4.2 mEq/L (4.2 mmol/L)are normal potassium levels; 5.4 mEq/L (5.4 mmol/L)indicates hyperkalemia. Test-Taking Strategy: Begin to answer this question by recalling the normal range of values for serum potassium. Next it is necessary to know that STsegment depression occurs in hypokalemia. If you had difficulty with this question, review the ECG changes that occur in hypokalemia. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 296, 791). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes Awarded 0.0 points out of 1.0 possible points. 6.ID: 5 A healthcare provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication? A. Insert a Foley catheter in the client B. Prepare the client for insertion of a central IV line C. Administer the medication with the use of a macrodrip IV tubing set D. Ensure that the medication is diluted in an appropriate amount of normal saline solution Correct Rationale: Potassium chloride administered IV must always be diluted in IV fluid. Undiluted potassium chloride given IV can cause cardiac arrest. The intramuscular and subcutaneous routes of administration are not recommended because the medication cannot be adequately diluted for these routes; toxicity could result if the medication is not adequately diluted. Potassium chloride is never administered as a bolus (IV push) injection; an IV push would result in sudden severe hyperkalemia, which could precipitate cardiac arrest. Saline dilution is recommended, but dextrose is avoided because it increases intracellular potassium shifting. Although urine output is monitored carefully during administration, it is not necessary to insert a Foley catheter unless this is specifically prescribed. The health care provider is notified if the urinary output is less than 30 mL/hr. Potassium chloride should be administered with the use of a controlled IV infusion device to avoid bolus infusion and increased risk of cardiac arrest. A central IV line is not necessary; potassium chloride may be administered through a peripheral IV line. Test-Taking Strategy: Use the process of elimination and note the strategic words “intravenous potassium chloride.” Recalling that the medication must be diluted will direct you to the correct option. If you had difficulty with this question, review the guidelines for the administration of potassium chloride. References: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., pp. 1009-1010). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision Making/Clinical Judgment, Evidence Based Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 7.ID: 9 A nurse notes that a client’s serum potassium level is 5.8 mEq/L(5.8 mmol/L). The nurse interprets this as an expected finding in the client with: A. Diarrhea B. Wound drainage C. Addison disease Correct D. Heart failure being treated with loop diuretics Rationale: A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L)indicates hyperkalemia, and the nurse would report the finding to the health care provider. Adrenal insufficiency (Addison disease) is a cause of hyperkalemia. Other common causes of hyperkalemia include tissue damage, such as that in burn injuries, renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or wound drainage or the client being treated with diuretics is at risk for hypokalemia. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they all indicate that the client is experiencing body fluid losses and therefore a loss of potassium. If you had difficulty with this question, review the risk factors associated with hyperkalemia. Reference: Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 296, 1211). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible points. 8.ID: 4 A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. A. Slow pulse B. Decreased urine output Incorrect C. Skeletal muscle weakness Correct D. Hyperactive bowel sounds Correct E. Hyperactive deep tendon reflexes Incorrect Rationale: Signs of hyponatremia include a rapid, thready pulse; skeletal muscle weakness; diminished deep tendon reflexes; abdominal cramping and hyperactive bowel sounds; increased urine output; headache; and personality changes. The nurse must assess these changes from baseline. If muscle weakness is detected, the nurse should immediately check respiratory effectiveness, because ventilation depends on strength of the respiratory muscles. Test-Taking Strategy: Specific knowledge of the manifestations of hyponatremia is needed to answer this question. Remember that muscle weakness and hyperactive bowel sounds are characteristics of hyponatremia. If you had difficulty with this question, review these clinical manifestations. Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 181-182). St. Louis: Saunders. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes Awarded -1.0 points out of 2.0 possible points. 9.ID: 4 A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply. A. Paresthesias B. Muscle weakness Correct C. Increased urine output Correct D. Chvostek sign E. Hyperactive deep tendon reflexes Rationale: Signs of hypercalcemia include muscle weakness, diminished deep tendon reflexes or an absence thereof, increased urine output, decreased gastrointestinal motility, and increased heart rate and blood pressure. Hyperactive deep tendon reflexes, the presence of the Chvostek sign, and paresthesias are signs of hypocalcemia. Test-Taking Strategy: Use the process of elimination, focusing on the subject, signs of hypercalcemia. Note that all of the incorrect options are comparable or alike in that they reflect hyperactivity of the neuromuscular system. Review the assessment signs noted in hypercalcemia if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 190-191). St. Louis: Saunders.. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes Awarded 2.0 points out of 2.0 possible points. 10.ID: 0 A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mEq/L (0.5 mmol/L). Which assessment findings does the nurse expect to note? Select all that apply. A. Hypotension B. Abdominal distention Correct C. Trousseau sign Correct D. Skeletal muscle weakness E. Decreased deep tendon reflexes Rationale: The normal magnesium level is 1.5-2.5 mEq/L (0.75-1.25 mmol/L). A magnesium level of 1.0 mEq/L(0.5 mmol/L) reflects hypomagnesemia. Assessment signs include hypertension; gastrointestinal manifestations such as anorexia, nausea, abdominal distention, and decreased bowel sounds; shallow respirations; neuromuscular manifestations such as twitches, paresthesias, hyperreflexia, and the Trousseau and Chvostek signs; and irritability and confusion. Test-Taking Strategy: Use the process of elimination, noting the options that are comparable or alike because they reflect neurological, musculoskeletal, and cardiovascular depression. If you had difficulty with this question, review the assessment signs found in magnesium imbalances. Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 193). St. Louis: Saunders. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluid and Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance HESI Concepts: Assessment, Fluid and Electrolytes Awarded 2.0 points out of 2.0 possible points. 11.ID: 7 A nurse enters a client's room and finds the client unconscious. The nurse quickly performs an assessment and determines that the client is not breathing. Which action does the nurse take first? A. Beginning chest compressions Correct B. Checking the client’s pulse oximetry reading C. Placing an oxygen mask on the client D. Counting the client’s carotid pulse for 15 seconds Rationale: According to the American Heart Association, detecting a pulse may be difficult. The healthcare provider should take not more than 10 seconds to check for a pulse; if the rescuer does not definitely feel a pulse within that period, he or she should start chest compressions. The acronym CAB (circulation, airway, and breathing) is used to prioritize the steps of cardiopulmonary resuscitation (CPR). Effective chest compressions are essential for providing blood flow during CPR. To provide effective chest compressions, the provider must push hard and fast. Current guidelines for CPR call for the initiation of compressions before ventilations. Oxygen may be helpful at some point, but the airway is opened before the administration of oxygen. Checking the client’s pulse oximetry reading delays implementation of lifesaving measures. Test-Taking Strategy: Visualize the steps of CPR to answer the question. Recall the guidelines of life support: C (circulation), A (airway), B (breathing). This will direct you to the correct option. Review the steps of basic life support if you had difficulty with this question. Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 685). St. Louis: Mosby. Berg, R. A, et al. (2010). American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care,Circulation 122: S685-S705. Available online at Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision Making/Clinical Judgment, Collaboration/Management of Care Awarded 0.0 points out of 1.0 possible points. 12.ID: 7 A nurse arrives at the scene of a code and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest to a depth of: A. 1 inch B. 1½ inches (3.8 cm) C. D. 2 inches (5 cm) E. Correct F. 4 inches (10 cm) G. Rationale: When CPR is being performed on an adult, the sternum should be depressed at least 2 inches (5 cm). The other options are incorrect because they are too shallow to be effective or too deep, which can cause damage to internal organs. The rescuer should allow complete recoil of the chest after each compression to allow the heart to fill completely before the next compression. Test-Taking Strategy: Knowledge regarding the procedure for performing chest compressions on an adult is necessary to answer the question. Consider the normal body structure of an adult to answer the question correctly. If you had difficulty with this question, review the procedure for CPR for an adult. Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 685). St. Louis: Mosby. Berg, R. A, et al. (2010). American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care,Circulation 122: S685-S705. Available online at Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision Making/Clinical Judgment, Evidence Based Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 13.ID: 9 The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression-ventilation ratio is correct? A. 15:1 B. 15:2 C. 20:2 D. 30:2 Correct Rationale: A 30:2 ratio of compressions to ventilations is recommended for CPR in adults. The other options are incorrect. Test-Taking Strategy: Knowledge regarding the procedure for performing CPR on an adult client is needed to answer this question. Remember that the 30:2 ratio of compressions to ventilations is recommended for CPR in adults. Review this procedure if you had difficulty with this question. Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 685). St. Louis: Mosby. Berg, R. A, et al. (2010). American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care,Circulation 122: S685-S705. Available online at Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision Making/Clinical Judgment, Perfusion/Clotting Awarded 1.0 points out of 1.0 possible points. 14.ID: 7 A pediatric nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver? A. 15 B. 30 C. 50 D. 100 Correct Rationale: In an infant or child, the rate of chest compressions is at least 100/min. Test-Taking Strategy: Knowledge regarding the procedure for performing CPR on a child is needed to answer this question. Remember that the rate of chest compressions is at least 100/min. Review this procedure if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 852). St. Louis: Elsevier. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision Making/Clinical Judgment, Evidence Based Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 15.ID: 0 A nurse attending a recertification course in basic life support (BLS) for healthcare professionals is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant’s pulse? A. Neck B. Wrist C. Behind the knee D. Antecubital fossa of the arm Correct Rationale: An infant’s pulse should be checked at the brachial artery. The relatively short, fat neck of an infant makes palpation of the carotid artery (neck) difficult. Palpation of the pulse in the radial (wrist) and popliteal (behind the knee) area would also be difficult. Test-Taking Strategy: Use the process of elimination and visualize each location identified in the options. This will direct you to the correct option. Review the procedure for performing BLS on an infant if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 852). St. Louis: Elsevier. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Basic Life Support Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision Making/Clinical Judgment, Evidence Based Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 16.ID: 0 A nurse is working in the emergency department. Which client should be assessed first? A. A client with new-onset dizziness B. A client admitted with a recent ear injury C. A client who has been experiencing nausea and vomiting for 12 hours D. A client with new-onset atrial fibrillation with a rate of 118 beats/min Correct Rationale: The client with new-onset atrial fibrillation is at risk for complications associated with the tachydysrhythmia. This dysrhythmia may result in decreased cardiac output because of ineffective atrial contractions. Thrombi form in the atria as a result of the pooling of blood. All of the other clients will require the nurse’s attention, but the client who requires immediate attention and is the most hemodynamically unstable is the one with atrial fibrillation. Test-Taking Strategy: Use the process of elimination and use the ABCs — airway, breathing, and circulation — to find the correct option. The client experiencing atrial fibrillation is the least stable of the clients identified in the other options. Review the principles of prioritization if you had difficulty with this question. References: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 126). St. Louis: Saunders. Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and trends (8th ed., pp. 35-36 ). St. Louis: Elsevier. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision Making/Clinical Judgment, Collaboration/Managing Care Awarded 1.0 points out of 1.0 possible points. 17.ID: 4 A nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly assesses the client, noting that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next? A. Use the AED Correct B. Stop the resuscitation efforts C. Perform CPR until emergency medical services arrives D. Check for a pulse for 30 seconds before continuing CPR Rationale: Basic components of CPR include immediate recognition of the sudden cardiac arrest (unresponsiveness and absence of normal breathing) and activation of the emergency response system, early CPR, and rapid defibrillation with the use of an AED. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they indicate that the resuscitation efforts should be terminated. To select from the remaining options it is necessary to know the components of CPR. Review the components of CPR and the procedure for using an AED if you had difficulty with this question. Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 680-682). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Basic Life Support Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Collaboration/Managing Care, Evidence Based Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 18.ID: 0 A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect? A. Diarrhea B. Dyspnea C. Headache D. Dysphagia Correct Rationale: In general, skin reactions and fatigue may occur with radiation therapy of any site, whereas other side effects occur only when a specific area lies in the treatment field. A client undergoing radiation therapy of the larynx is most likely to experience dysphagia. Diarrhea may occur with irradiation of the gastrointestinal tract. Dyspnea may occur with lung irradiation. Headache may occur with irradiation of the head. Test-Taking Strategy: Use the process of elimination and note the strategic words “related specifically to the site.” Focus on the anatomical location of the radiation therapy to identify the correct option. Review the effects of radiation therapy if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 268). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology Giddens Concepts: Cellular Regulation, Client Education HESI Concepts: Cellular Regulation, Teaching and Learning/Patient Education Awarded 1.0 points out of 1.0 possible points. 19.ID: 1 The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction? A. “I need to keep the sun off the radiation site.” B. “I can use over-the-counter cortisone cream on the radiation site if it gets red.” Correct C. “I need to be careful not to wash off the marks that the radiologist made on my skin.” D. “I need to wash the skin at the radiation site with a mild soap and water and pat it dry.” Rationale: The client should use no powders, ointments, lotions, or creams on the skin at the radiation site unless they have been prescribed by the health care provider. Avoiding sun exposure of the radiation site, not removing marks made on the skin by the radiologist, and washing the skin with mild soap and water and patting it dry are all correct measures. The client should also be instructed to avoid using harsh detergents to wash clothing. Test-Taking Strategy: Note the strategic words “need for further instruction” in the query of the question, which indicate a negative event query and the need to select the incorrect client statement. Noting the words “over-the-counter” will direct you to the correct option. Review client teaching points for skin care during radiation therapy if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 269-270). St. Louis: Mosby. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Oncology Giddens Concepts: Client Education, Tissue Integrity HESI Concepts: Teaching and Learning/Patient Education, Tissue Integrity Awarded 1.0 points out of 1.0 possible points. 20.ID: 6 A nurse develops a nursing care plan for a client with a sealed radiation implant. Which stipulation does the nurse include in the plan? A. Visitors must be limited to one half-hour per day. Correct B. Visitors must remain at least 2 feet (61 cm) from the client C. A dosimeter badge must be placed on the client’s bedside stand. D. The client may be maintained in a semiprivate room as long as the client uses a commode. Rationale: The nurse would limit each visitor to a half-hour per day and be sure that visitors remain at least 6 feet (1.8 metres) from the radiation source. The nurse would wear the dosimeter badge when caring for the client. The dosimeter badge measures an individual’s exposure to radiation and should be used by only one individual. The dosimeter badge is not left in the client’s room. The client is assigned to a private room with a private bath to keep other clients from being exposed to radiation. Test-Taking Strategy: Use the process of elimination. Thinking about the measures that will prevent exposure to radiation direct you to the correct option. Review care of the client with a radiation implant if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 413). St. Louis: Saunders. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Safety Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision Making/Clinical Judgment,Safety Awarded 1.0 points out of 1.0 possible points. 21.ID: 7 A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client’s request? A. “Short walks are OK.” B. “You need to stay in your room for now.” Correct C. “Yes, it’s fine to take a walk around the nursing unit.” D. “Do you think that a walk around the unit will tire you out?” Rationale: The client with a sealed radiation implant must remain in a private room to keep others from being exposed to radiation. The other options are all incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they indicate that the client is permitted to leave the room for ambulation. Review care of the client with a radiation implant if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 413). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision Making/Clinical Judgment,Safety Awarded 1.0 points out of 1.0 possible points. 22.ID: 0 A nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first? A. Calling the health care provider B. Reinserting the implant into the client’s vagina C. Picking up the implant with gloved hands and placing it in sterile water D. Using long-handled forceps to place the implant in a lead container Correct Rationale: A lead container and long-handled forceps should be kept in the client’s room at all times during internal radiation therapy. If the implant is dislodged, the nurse should pick it up with long-handled forceps and place it in the lead container. Reinserting the implant into the vagina and picking up the implant with gloved hands and placing it in sterile water are both incorrect nursing actions. The health care provider is called after action is taken to maintain the safety of the client. Test-Taking Strategy: Use the process of elimination and note the strategic word “first” in the query of the question. Recalling that the nurse needs to protect him or herself from exposure to the radiation will direct you to the correct option. Review the measures for dealing with a dislodged implant if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 413). St. Louis: Saunders. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision Making/Clinical Judgment,Safety Awarded 1.0 points out of 1.0 possible points. 23.ID: 2 A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client’s personal care items: A. Within the client’s reach on the left side B. Within the client’s reach on the right side Correct C. Just out of the client’s reach on the left side D. Just out of the client’s reach on the right side Rationale: Unilateral neglect is unawareness of one side of the body. The client behaves as if that part is not there. The client does not look at the paralyzed limb when moving about. Unilateral neglect results in increased risk for injury. It is possible for the client to relearn to look for and to move the affected limb(s). Therefore in this condition the client’s personal care items are placed within the client’s reach on the right side. Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. This reduces client frustration and aids in ensuring client safety because the client does not have to strain and reach for needed items. The nurse adapts the client’s environment to the deficit by focusing on the client’s unaffected side and by placing the client’s personal care items on the affected side within reach. Placing items out of the client’s reach presents a risk of injury. Test-Taking Strategy: Use the process of elimination. Eliminate the options first that are potentially hazardous to the client. To select from the remaining options, focus on the subject, unilateral neglect. With unilateral neglect, objects are placed on the affected side to train the client to attend to that part of the environment. Review care of the client with unilateral neglect if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1403). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision Making/Clinical Judgment,Safety Awarded 1.0 points out of 1.0 possible points. 24.ID: 3 A client who is recovering from a brain attack (stroke) has residual dysphagia. Which measure does the nurse plan to implement at mealtimes? A. Giving the client thin liquids B. Alternating liquids with solids Correct C. Giving foods that are primarily liquid D. Placing food in the affected side of the client’s mouth Rationale: The client with dysphagia may be started on a diet once the gag and swallow reflexes have returned. Liquids should be thickened to help prevent aspiration. Food is placed on the unaffected side of the mouth. Liquids are alternated with solids whenever possible to prevent food from being left in the mouth. The client is assisted with meals as needed and is given ample time to chew and swallow. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they involve giving thin liquids or primarily liquids. To select from the remaining options, visualize each. Recalling that placing food on the affected side of the mouth will put the client at risk for aspiration will assist you in eliminating this option. Review care of the client with residual dysphagia if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1402). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision Making/Clinical Judgment,Safety Awarded 1.0 points out of 1.0 possible points. 25.ID: 1 A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. The nurse tells the client to: A. Wear eyeglasses 24 hours a day B. Wear a patch on the affected eye C. Turn the head to scan the lost visual field Correct D. Keep all objects in the impaired field of vision Rationale: Homonymous hemianopsia is loss of half of the visual field. The nurse instructs the client to scan the environment to overcome the visual deficit. The nurse encourages the use of personal eyeglasses to improve overall vision, but it is not necessary to wear the glasses 24 hours a day. The client should keep objects in the intact field of vision whenever possible. An eye patch is of no use because the client does not have double vision. Test-Taking Strategy: Use the process of elimination. Recalling that homonymous hemianopsia is loss of half of the visual field will direct you to the correct option. Review care of the client with homonymous hemianopsia if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 1350, 1407). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Neurological Giddens Concepts: Client Teaching, Sensory Perception HESI Concepts: Sensory/Perception,Teaching and Learning/Patient Education Awarded 1.0 points out of 1.0 possible points. 26.ID: 2 A nurse is providing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. The nurse tells the client to: A. Sit in soft, deep chairs B. Rock back and forth to start movement Correct C. Exercise in the evening to combat fatigue D. Perform tasks with only the hand that has the tremor Rationale: The client with Parkinson disease should rock back and forth to initiate movement with bradykinesia (slowed movement). The client should avoid sitting in soft, deep chairs to prevent rigidity and because they are difficult to get up from. The client should exercise in the morning, when the energy level at its highest. The client with a tremor is instructed to use both hands to accomplish a task. Test-Taking Strategy: Use the process of elimination. Eliminate the option that uses the closed-ended word “only” first. To select correctly from the remaining options, recall that bradykinesia means slowed movement to identify the correct option. Review client teaching points for Parkinson’s disease if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1434). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Neurological Giddens Concepts: Client Teaching, Mobility HESI Concepts: Mobility,Teaching and Learning/Patient Education Awarded 1.0 points out of 1.0 possible points. 27.ID: 8 A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his blood pressure has increased, and that his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client’s bed and immediately: A. Documents the event B. Notifies the healthcare provider C. Checks the client’s bladder for distention Correct D. Checks to see whether the client has a prescription for an antihypertensive Rationale: Autonomic dysreflexia is an emergency that occurs as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A variety of stimuli may trigger this response, including a distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (as a result of constipation or impaction); or stimulation of the skin. When autonomic dysreflexia occurs, the client is immediately placed in a sitting position to lower the blood pressure. The nurse then performs a rapid assessment to identify and alleviate the cause. The client’s bladder is emptied immediately by way of a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or compromise. The health care provider is notified, and then the nurse documents the occurrence and the actions taken. Test-Taking Strategy: Focus on the data in the question and note that the nurse has already elevated the head of the client’s bed. Next, recall that autonomic dysreflexia occurs as a result of exaggerated autonomic responses to stimuli, which will direct you to the correct option. Review immediate interventions for autonomic dysreflexia if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 1479-1480). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Giddens Concepts: Care Coordination, Clinical Judgment HESI Concepts: Collaboration/Managing Care, Clinical Decision Making/Clinical Judgment Awarded 1.0 points out of 1.0 possible points. 28.ID: 7 A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client’s blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, the nurse immediately: A. Suctions the client B. Obtains a pulse oximeter C. Contacts the health care provider Correct D. Increases the rate of the client’s intravenous (IV) solution Rationale: In the immediate postoperative period, the nurse assesses the client for stridor (a coarse, high-pitched sound on inspiration when auscultating over the trachea), a sign of airway edema, and for signs of bleeding. A drop in blood pressure and an increase in pulse are indicators of bleeding. The health care provider is notified immediately if either of these events occurs. Suctioning is performed to remove secretions that cannot be expectorated by the client. Increasing the rate of the client’s IV solution is not done without a health care provider’s prescription. A pulse oximeter may be needed, but this is not the action to be taken immediately. Test-Taking Strategy: Use the process of elimination. Focus on the data in the question and note that the nurse’s findings indicate bleeding. This will direct you to the correct option. Review the nursing actions to be taken immediately if bleeding occurs if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 513, 1200-1201). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care Giddens Concepts: Care Coordination, Clinical Judgment HESI Concepts: Collaboration/Managing Care, Clinical Decision Making/Clinical Judgment Awarded 1.0 points out of 1.0 possible points. 29.ID: 2 An emergency department (ED) nurse receives a telephone call from emergency medical services and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first? A. Inserting a Foley catheter B. Initiating an intravenous (IV) line C. Cleansing the burn wound D. Administering 100% humidified oxygen Correct Rationale: When a victim who sustains a burn injury arrives at the ED, breathing is assessed, a patent airway is established, and the client is given 100% humidified oxygen. Inserting a Foley catheter, initiating an IV line, and cleansing the burn wound are also components of the plan of care for a burned client, but these are not the immediate actions. Test-Taking Strategy: Use the ABCs (airway, breathing, and circulation) to answer the question. The correct option is the only one related to the airway. Review care of the burned client if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 456). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Integumentary Giddens Concepts: Care Coordination, Tissue Integrity HESI Concepts: Collaboration/Managing Care, Tissue Integrity Awarded 1.0 points out of 1.0 possible points. 30.ID: 2 A nurse is assessing a client with AIDS for signs of Pneumocystis jiroveci infection. Which sign of the infection is the earliest manifestation? A. Fever B. Dyspnea at rest C. Dyspnea on exertion D. Nonproductive cough Correct Rationale: The client with P. jiroveci infection usually has a cough as the first symptom, which begins as nonproductive then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest. Test-Taking Strategy: Note the strategic word “earliest.” Eliminate the options that are comparable or alike in that they involve dyspnea. To select from the remaining options, focus on the anatomical location of the infection, which will direct you to the correct option. Review the early manifestations of P. jiroveci infection if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 236). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Immune Giddens Concepts: Clinical Judgment, Infection HESI Concepts: Clinical Decision Making/Clinical Judgment, Infection Awarded 1.0 points out of 1.0 possible points. 31.ID: 3 A client arrives at the emergency department with reports of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first? A. Administration of normal saline solution B. Administration of an intravenous (IV) glucocorticoid C. Administration of pain medication to relieve the client’s headache D. Administration of a subcutaneous injection of epinephrine (Adrenalin) Correct Rationale: Once airway has been established, the client would be given subcutaneous epinephrine. IV corticosteroids and IV fluids may also be prescribed. Pain medication may or may not be prescribed. Test-Taking Strategy: Note the strategic word “first” in the query of the question. All of the interventions in the options may be prescribed for the client experiencing a hypersensitivity reaction. Remember that once airway is established, the client will receive epinephrine. Review care of the client who experiences an allergic reaction if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 214). St. Louis: Mosby. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Critical Care Giddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care, Safety Awarded 1.0 points out of 1.0 possible points. 32.ID: 7 A client is found to have AIDS. What is the nurse’s highest priority in providing care to this client? A. Providing emotional support to the client B. Discussing the cause of AIDS with the client C. Instituting measures to prevent infection in the client Correct D. Identifying risk factors related to contracting AIDS with the client Rationale: The client with AIDS has inadequate immune bodies and is at risk for infection. The priority nursing intervention is protecting the client from infection. The nurse would also provide emotional support to the client. Discussing the cause of AIDS and the ways in which AIDS is contracted are not priority interventions. Test-Taking Strategy: Note the strategic words “highest priority.” Use Maslow’s Hierarchy of Needs theory to answer the question. Remember that physiological needs are the priority. This will direct you to the correct option. Review the priority needs of a client with AIDS if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 239-240, 242). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Immune Giddens Concepts: Care Coordination, Immunity HESI Concepts: Collaboration/Managing Care, Immunity Awarded 1.0 points out of 1.0 possible points. 33.ID: 3 A client who sustained a fracture of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves: A. Administering a local anesthetic to the fractured arm B. Soaking the left arm in a warm-water bath for 2 hours before cast application C. Debriding any open wounds and applying antibiotic ointment before the cast material is applied D. Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material Correct Rationale: To apply a cast, the skin is washed and dried well, but it is not soaked in a warm-water bath. Padding is applied and a stockinette is placed smoothly and evenly over the area to be casted. The plaster is then rolled onto the padding and the edges are trimmed or smoothed as needed. Local anesthesia of the fractured extremity is not necessary, although an analgesic may be administered to alleviate pain. A local anesthetic will block nerve sensation, and it is important for the client to be able to report any changes in sensations after the cast is applied. If the client has open wounds on the fractured extremity, a window will be cut in the cast to allow visualization and treatment of the wound. A wound would not be covered with cast material. Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the words “2 hours.” Next eliminate the option that involves administration of a local anesthetic, recalling that a local anesthetic will block nerve sensation. Recognizing that covering an open wound with a cast material would not permit assessment of the wound will allow you to eliminate this option. Review client instructions regarding the application of a plaster cast if you had difficulty with this question. Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 251-253). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Giddens Concepts: Mobility, Client Education HESI Concepts: Mobility, Teaching and Learning/Patient Education Awarded 1.0 points out of 1.0 possible points. 34.ID: 7 A client has just had a plaster leg cast applied, and the nurse has given the client instructions on cast care. Which statement by the client indicates the need for further instruction? A. “I may feel cool while the cast is drying.” B. “I shouldn’t use anything to scratch underneath the cast.” C. “If I smell any odor from the cast, I should call the doctor.” D. “I can dry the cast faster if I use a hairdryer on the hot setting.” Correct Rationale: Using a blow dryer on the hot setting to dry the cast is not advised because it may burn the client’s skin under the cast and crack the cast. While the cast is still damp, the client may feel cold and may experience a decrease in body temperature. The client should never insert any item under the cast because of the risk skin compromise. An odor coming from the cast could indicate the presence of infection, warranting health care provider notification. Test-Taking Strategy: Use the process of elimination and note the strategic words “need for further instruction,” which indicate a negative event query and the need to select the incorrect client statement. Recalling that the use of a hot blow dryer can cause burns will direct you to this option. Review client teaching points in regard to cast care if you had difficulty with this question. Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 253-254). St. Louis: Mosby. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Musculoskeletal Giddens Concepts: Mobility, Client Education HESI Concepts: Mobility, Teaching and Learning/Patient Education Awarded 1.0 points out of 1.0 possible points. 35.ID: 1 A client with a leg fracture who has been placed in skeletal traction is transported to the orthopedic unit after surgery. Which finding would indicate the need to contact the orthopedic specialist? A. The traction knots are intact. B. The traction weights are hanging freely. C. The clamps on the traction frame are tight. D. The traction ropes are unable to move over the pulleys. Correct Rationale: After skeletal traction pins are inserted and traction is applied, all ropes, knots, and pulleys are inspected to ensure that they are positioned properly. Traction knots and ropes must be intact and secure. Ropes should move easily over pulleys and weights, and the weights should hang freely at all times. The clamps on the traction frame should be tight. Test-Taking Strategy: Use the process of elimination and note the strategic words “need to contact the orthopedic specialist,” which indicate the need to select the option that constitutes an unsafe or incorrect observation. Noting the words “unable to move over the pulleys” will help you identify to the correct option. Review care of the client in skeletal traction if you had difficulty with this question. Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 263, 265-266). St. Louis: Mosby. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Giddens Concepts: Clinical Judgment, Mobility HESI Concepts: Clinical Decision Making/Clinical Judgment, Mobility Awarded 1.0 points out of 1.0 possible points. 36.ID: 0 Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse include in the plan of care? A. Assessing the pin sites at least every 8 hours B. Removing the traction weights to provide skin care C. Applying lanolin to the skin of the right leg once per shift D. Checking the skin integrity of the right leg at least every 8 hours Correct Rationale: Buck extension traction is a type of skin traction. It is important with skin traction to inspect the skin underneath at least once every 8 hours for irritation or inflammation. The nurse never releases the weights of traction unless specifically asked to do so by the health care provider. Applying lanolin to the skin could leave the skin slippery, making it difficult to maintain the belt or boot used for the skin traction. There are no pins to care for with skin traction. Test-Taking Strategy: Use the process of elimination. Recalling that Buck extension traction is a type of skin traction will assist you in eliminating the option of assessing the pin sites. Next eliminate the option that indicates that the nurse may remove traction weights without a specific prescription to do so. To select from the remaining options, use the steps of the nursing process. The correct option addresses assessment. Review care of the client in Buck traction if you had difficulty with this question. Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 258, 266). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Giddens Concepts: Clinical Judgment, Mobility HESI Concepts: Clinical Decision Making/Clinical Judgment, Mobility Awarded 1.0 points out of 1.0 possible points. 37.ID: 7 A nurse provides home care instructions to a client with a below-the-knee amputation (BKA) about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction?
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