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Solution to Hurst Review Practice
Questions
How does the nurse identify the correct size of crutches for a client?
- Turn the crutches upside down and measure from the heel to the shoulder.
- Obtain a set of crutches and adjust the height until the client can stand comfortably while resting the axilla on the crutch pad.
- Measure the client while standing upright from the axilla to the heel then adjust the crutches so that the elbow flexion is a 30-degree angle.
- Measure the client from 2 inches below the axilla to 6 inches lateral to the client's heel. - answer -
The nurse is caring for a client in the 8th week of pregnancy. The client is spotting, has a rigid abdomen and is on bedrest. What is the most important assessment at this time?
- Protein in the urine
- Fetal heart tones
- Cervical dilation
- Hemoglobin and hematocrit levels - answer - The client may be bleeding, and that is an emergency! Common causes of hemorrhage during the first half of pregnancy include abortion and ectopic pregnancy. Ectopic pregnancy is a significant cause of maternal death from hemorrhage and the classic signs of ectopic pregnancy include positive pregnancy test, abdominal pain and vaginal "spotting". Remember that in the ruptured ectopic pregnancy, bleeding may be concealed and severe pain could be the only symptom. The nurse is discussing television, video games, and internet usage with a group of parents who have 8 to 10 year old children. What should the nurse include?
- Keep TVs, iPads, and other screens out of kids' bedrooms.
The community health nurse is presenting information about birth control measures to a group of young females. The nurse explains that an intrauterine device (IUD) is most appropriate for what individuals?
- A mother of a toddler who wants another child in three years.
- The client with a recent exacerbation of sickle cell anemia.
- A client with stage II breast cancer who has finished chemotherapy.
- An adolescent who has recently become sexually active.
- The client with a double mastectomy seven years ago. - answer -1 & 5. CORRECT: An IUD is a surgically placed method of birth control in which a small, t-shaped piece of plastic, or even copper, is inserted into the uterus to decrease the chance of pregnancy. The client must be very healthy, emotionally amenable to a foreign body to prevent pregnancy, and aware that an IUD is not 100% fail-proof. The mother of a toddler who would like to have another child in a few years is an excellent candidate for the use of an IUD. Also, a client who had a double mastectomy over seven years ago is a good candidate, since treatment that long ago means the client would no longer be receiving any type of immunosuppressant therapy.
- INCORRECT: A client who has had a recent exacerbation of sickle cell anemia is at high risk for several complications, including infection and clots. This is a foreign body in an already compromised client, leading to many potential complications.
- INCORRECT: The client being actively treated for cancer is also immunosuppressed and would not be a good choice for an IUD. The risk of infection is much too high.
- INCORRECT: An adolescent who has recently become sexually active presents a challenge. Remember that an adolescent does not have regular menstrual cycles yet, and can experience intermittent bleeding. Many primary healthcare providers argue that the use of an IUD may be safer since the client would not have to remember a pill, a ring, or a patch. But an even greater concern is the fact that an IUD is NOT 100% effective, still presenting the risk of an unwanted pregnancy. Also, an IUD does not protect against sexually transmitted disease (STDs), which is often a concern in those who have become sexually active. A client admitted to the hospital following a fall has a history of Alzheimer's disease with apraxia. The nurse knows the client will need priority assistance with what activity?
- Ambulating to the bathroom.
In what order should the nurse address these client events that occur at the same time? Place in order of highest to lowest priority. The water seal chamber is empty in a client's closed chest drainage unit. Client reporting urinary frequency and dysuria. UAP reports a heart rate of 40/min in a client. Client's tracheostomy needs to be suctioned. Client who is on bedrest due to a deep vein thrombus attempting to get out of bed. - answer -The client with the highest need is the client who has a tracheostomy that needs to be suctioned. This client has an airway problem. Maintaining a patent airway is vital to life and is always the first priority. The next client to be seen is the client whose water seal chamber is empty which prevents the CDU from being a closed system. This can create a breathing problem. The purpose of the water seal chamber is to allow air to escape from the pleural space and yet prevent air from re-entering the pleural space. It is a one-way system. The water should be at the prescribed level (2 cm) to maintain this one-way water seal. If air is allowed to re-enter the pleural space, the lung
can collapse again (pneumothorax). Once the other client's airway is suctioned, this would be the next priority. The third client to be seen is the client with a heart rate of 40/min which may be affecting cardiac output. This is a circulatory problem. Circulation follows airway and breathing in priority setting. The fourth client to be seen is the client on bedrest for a DVT. If the client gets up and ambulates, the clot can break lose and form an embolus. Although this could potentially be dangerous, it does not take priority over airway or circulatory issues that exist. The fifth client would be the one reporting frequency and dysuria. This client does not have a life-threatening problem. Therefore, this would be the lowest in priority from the events presented. A client with cervical cancer received an internal cervical radiation implant. What should be the initial nursing action if the radiation implant becomes dislodged and is found lying in the bed?
The nurse is caring for a client who is unresponsive during a postictal state. Which position is correct for this client?
- Orthopneic
- Dorsal recumbent
- Sims'
- Reverse trendelenburg - answer -
- Correct: Sim's is a semi prone position where the client is halfway between lateral and prone positions. Often used for enemas or other examinations of the perianal area. Sim's is used for unconscious client's because it facilitates drainage from the mouth and prevents aspiration.
- Incorrect: Orthopneic position places the client in a sitting position with arms resting on an overbed table. It allows maximum expansion of the chest. This would not be a safe position for an unresponsive client.
- Incorrect: Dorsal recumbent is a back lying position where the shoulders are slightly elevated on pillows. it is used after surgeries and anesthetics.
- Incorrect: Reverse trendelenburg is where the body the body is completely straight but the head is elevated and the feet are down. This position helps with gastroesophageal reflux disease, snoring, and with some surgeries.
Four clients are admitted to the medical-surgical unit. The nurse is aware that what client will need standard precautions only?
- The client with chicken pox.
- The client with rubeola.
- The client with impetigo.
- The client with pancreatitis. - answer -
- Correct: Standard precautions are observed with all clients admitted to the hospital, without the need for additional safeguards. The client with pancreatitis is not contagious and does not present any unique concerns other than the need for gloves and hand washing.
- Incorrect: Chicken pox, also known as varicella zoster, requires airborne precautions. The virus can be spread through contact with the droplets, either touching or inhaling the droplet, while providing care for this client.
- Incorrect: Measles, also called rubeola, is spread through droplet contact with the contaminated individual, including inhalation of the droplets. Airborne precautions are necessary when caring for a client diagnosed with rubeola.
- Incorrect: Impetigo is a severe skin infection characterized by itchy, red, fluid-filled blisters caused by either
- Incorrect: Hearing is not affected by neurosyphilis. However, vision changes, including blindness can occur. Neurosyphilis is caused by the bacteria Treponema pallidum, which also causes syphilis. It usually occurs about 10 to 20 years after a person is first infected with syphilis and did not receive treatment. Tabes dorsalis is a complication of untreated syphilis that involves muscle weakness and abnormal sensations. Symptoms of tabes dorsalis are caused by damage to the nervous system. Symptoms may include abnormal sensations often called "lightning pains", abnormal gait problems such as with the legs far apart, loss of coordination and reflexes, joint damage, muscle weakness, vision changes including blindness, bladder control problems, and sexual function problems. Penicillin is the drug of choice to treat neurosyphilis. The client must have follow-up blood tests at 3, 6, 12, 24, and 36 months to make sure the infection is gone. The client will also need follow-up lumbar punctures for CSF fluid analysis every 6 months. A client with a history of eczema has been admitted with cellulitis of the left forearm. Which admission order should the nurse question immediately?
- Start IV of normal saline at 100 mL per hour.
- Keep left arm elevated on pillow at all times.
- Apply ice packs to affected area every shift.
- Ibuprophen 800 mg po every 6 hours prn pain. - answer -3. Correct: Cellulitis is a bacterial skin infection resulting in warm, redden and edematous tissue, sometimes accompanied by fever and chills. Swelling in the affected area impedes blood flow and increases pain. In order to decrease the edema, warm, moist compresses are used to stimulate circulation and speed reabsorption of the fluid within the tissue. This order should be questioned immediately.
- Incorrect: An infection serious enough to require hospitalization indicates this client is either septic or may need intravenous antibiotics. Fluids are a primary treatment for sepsis along with bedrest and antibiotics. A basic solution of normal saline at 100/mL per hour would be an appropriate order for this client.
- Incorrect: The swelling characteristic in cellulitis in painful and diminishes circulation to the area. Elevation on one or two pillows at all times helps to improve blood flow so that healing can take place. In some facilities, clients are provided with a wedge shaped cushion that provides better support of the affected area. This order is appropriate.
- Incorrect: Ibuprophen provides relief from both pain and inflammation associated with cellulitis. A dose of 800
- Incorrect: The colon is ulcerated and unable to absorb water, so 10-20 bloody diarrhea stools are the most common symptom of ulcerative colitis and would not be of immediate concern to the nurse. Ulcerative colitis is a chronic disease that causes inflammation and ulcers on the inner lining of the large intestine. It is a chronic inflammatory disease of the gastrointestinal tract, called inflammatory bowel disease (IBD). Ulcerative colitis most often begins gradually and can become worse over time. Symptoms can be mild to severe. Most people have periods of remission that can last for weeks or years. The goal of care is to keep people in remission long term. The exact cause of ulcerative colitis is unknown. Researchers believe the following factors may play a role in causing ulcerative colitis: overactive intestinal immune system, genes, and environment. The most common signs and symptoms of ulcerative colitis are diarrhea with blood or pus and abdominal discomfort. Other signs and symptoms include an urgent need to have a bowel movement, feeling tired, nausea or loss of appetite, weight loss, fever, and anemia. Less common sy Dietary teaching has been initiated for a client newly diagnosed with acute diverticulitis. The nurse knows that
further instruction is necessary when the client makes what statement?
- "I must include a lot of fluid in my daily routine."
- "I need to take my antibiotics at the same time daily."
- "Rest and mild exercise are important for my recovery."
- "Decreasing fiber in my diet can help prevent recurrences."
- answer -Diverticulosis occurs when small, bulging pouches called diverticula develop in the lining of the digestive tract, most often in the lower colon. Sometimes one or more of these pouches become inflamed or infected, causing the condition known as diverticulitis. Diverticulitis can cause severe abdominal pain, fever, nausea, vomiting and a marked change in bowel habits. Mild diverticulitis can be treated with rest, changes in diet and antibiotics; however, severe or recurring diverticulitis may require hospitalization or even surgery. The greatest concern is the potential for an abscess, a bowel blockage or even bowel rupture leading to peritonitis. Because diverticula remain permanently, it's important for a client to understand how to make life-style and dietary changes. When you noticed "acute diverticulitis" in the question, were you concerned about what you may, or may not, have studied in school? Let's assume you do not remember all the specifics about this disorder. Break down the words to provide some
- Decrease intermediate acting insulin.
- Increase intermediate acting insulin. - answer -1. Correct: Morning hyperglycemia may be the result of dawn's phenomenon or the Somogyi effect. The client must take their blood sugar between two and three o'clock in the morning for several days to determine the cause of morning hyperglycemia. If the client has decreased blood sugar between two and three o'clock in the morning, suspect Somogyi effect.
- Incorrect: This is an intervention; assessment should come first. The nurse must determine the cause of morning hyperglycemia in order to treat the condition appropriately.
- Incorrect: This is an intervention; assessment should come first. The nurse must determine the cause of hyperglycemia in order to treat the condition appropriately. An appropriate intervention for a client with Somogyi effect would be to decrease the evening dose of intermediate acting insulin, however, the nurse must first determine that the client is in fact experiencing the Somogyi effect.
- Incorrect: This is an intervention; assessment should come first. Increasing the intermediate acting insulin would not be appropriate action for a client experiencing Somogyi effect. A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The
client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to do what?
- Remove air from the pleural space
- Create access for irrigating the chest cavity
- Evacuate secretions from the bronchioles and alveoli
- Drain blood and fluid from the pleural space - answer -1. Correct: A chest tube placed in the upper chest is to remove air from the pleural space. Remember air rises and fluid settles down low.
- Incorrect: Chest tubes are placed in the pleural space to get rid of air, blood, fluid, or exudate so that the lung can re- expand. The purpose is not to create an access for irrigating the chest cavity.
- Incorrect: The chest tube is inserted into the pleural space because the lung has collapsed due to air, blood, fluid, or exudate. The chest tube does not go into the lung so secretions can not be removed from the bronchioles and alveoli by way of the chest tube.
- Incorrect: You have to know the purpose of the upper chest tube. Fluid drains down, so the lower one is for fluid.
