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Ati nur 213 lifespan final exam
Ati nur 213 lifespan final exam
Total Questions : 52
Showing 10 questions Sign up for moreA nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
Explanation
A. Raising the foot of the bed to a 90° angle is not an appropriate intervention for a chest wound as it may impair respiratory function further.
B. Preparing to insert a central line is not a priority action in managing a sucking chest wound and may delay more immediate life-saving interventions.
C. Removing the dressing to inspect the wound can worsen the condition by allowing more air to enter, increasing the risk of a tension pneumothorax.
D. Administering oxygen via nasal cannula provides essential oxygen support, addressing hypoxia caused by the impaired respiratory function from the chest wound.
A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition. Which of the following instructions should the nurse include?
Explanation
A. Sleeping on the left side can reduce acid reflux symptoms because it keeps the stomach below the esophagus, potentially preventing stomach acid from entering the esophagus.
B. Waiting only 1 hour after eating may not be enough; generally, clients with GERD are advised to wait at least 2-3 hours before lying down.
C. Eating four small meals each day may not be sufficient; GERD patients are often advised to eat smaller, more frequent meals to reduce stomach pressure and prevent reflux.
D. Drinking milk may temporarily soothe the stomach but can stimulate acid production and worsen GERD symptoms over time.
A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?
Explanation
A. Placing a pillow under the affected limb helps elevate the extremity, which can reduce swelling and promote circulation, enhancing recovery.
B. Applying cool compresses every 6 hours is not typically recommended postoperatively, as frequent, direct cooling could impede blood flow to the surgical area.
C. Promoting bed rest for 5-7 days is not advised; early mobility is encouraged to prevent complications such as deep vein thrombosis and improve joint function.
D. Encouraging increased fluid intake is important for general recovery, but it does not specifically address postoperative care for a knee replacement.
A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization?
Explanation
A. Urge incontinence may occur but is not necessarily an indicator for immediate catheterization in a paraplegic patient, as they may lack bladder control.
B. Weight gain is unrelated to the need for catheterization and may indicate other issues like fluid retention.
C. Rectal distention relates to bowel function, not bladder function, and does not indicate the need for catheterization.
D. Dribbling of urine can suggest bladder overfilling and is an indication that the bladder needs emptying through catheterization to prevent urinary retention complications.
A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity?
Explanation
A. Ecchymosis, or bruising, may be present but does not directly evaluate neurovascular status.
B. Skin integrity is important for general wound assessment but does not specifically indicate neurovascular function.
C. Sensation assessment helps evaluate nerve function, which is critical in identifying potential neurovascular compromise.
D. Color of the affected limb provides information on blood flow, with pale or cyanotic coloring suggesting potential compromise.
E. Temperature can indicate adequate blood flow; a cooler extremity may suggest poor circulation, indicating neurovascular compromise.
A nurse is caring for a client who is postoperative following a below-the knee-amputation and will soon undergo fitting for a leg prosthesis. Which of the following is an appropriate nursing intervention for this client at this time?
Explanation
A. Wrapping the residual limb in a figure-eight configuration provides compression and support, shaping the limb for prosthesis fitting, and promoting proper circulation.
B. Wrapping in a proximal-to-distal direction can restrict blood flow and does not provide the appropriate support needed for prosthetic shaping.
C. The bandage should be rewrapped more frequently than once a day to maintain compression and limb shape.
D. Securing the bandage at the lowest joint is inadequate as it may allow loosening and improper shaping of the residual limb.
A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?
Explanation
A. Offering the bedpan every 2 hours helps manage elimination but does not specifically reduce the risk of urinary tract infections (UTIs).
B. Cleansing from back to front increases the risk of contamination from the anal area and is incorrect hygiene practice.
C. An indwelling catheter can increase the risk of UTIs, so intermittent catheterization is generally preferred.
D. Encouraging fluid intake helps flush the urinary system, reducing the risk of bacterial growth that can lead to UTIs.
Á nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?
Explanation
A. Obtaining a dietary history is relevant for ongoing management but is not the initial priority.
B. Reviewing electrolyte values is essential because exacerbations of ulcerative colitis can lead to severe fluid and electrolyte imbalances, which need prompt correction.
C. Investigating emotional concerns is important but does not take precedence over addressing potential electrolyte imbalances that can be life-threatening.
D. Checking perianal skin integrity is relevant for comfort but is not the priority in stabilizing the client during an acute exacerbation.
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Explanation
A. Obtaining a dietary history is relevant for ongoing management but is not the initial priority.
B. Reviewing electrolyte values is essential because exacerbations of ulcerative colitis can lead to severe fluid and electrolyte imbalances, which need prompt correction.
C. Investigating emotional concerns is important but does not take precedence over addressing potential electrolyte imbalances that can be life-threatening.
D. Checking perianal skin integrity is relevant for comfort but is not the priority in stabilizing the client during an acute exacerbation.
A nurse is admitting a client who was prescribed antibiotic therapy and now has a Clostridium difficile infection. Which of the following actions should the nurse take?
Explanation
A. A protective environment is not necessary; Clostridium difficile requires contact precautions.
B. Alcohol-based hand sanitizers are ineffective against Clostridium difficile spores; handwashing with soap and water is essential.
C. Wearing a mask is not necessary as C. difficile is transmitted through spores that survive on surfaces.
D. Disinfecting equipment daily helps reduce the risk of C. difficile spore transmission within the environment.
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