Board Vitals Remediation 1st 200 Questions

Board Vitals Remediation 1st 200 Questions Leave the first rating Students also studied Terms in this set (143) Science MedicineNursing Save ATI comprehensive predictor STUDY...198 terms h_trtPreview Adaptive Exam HARD (boardvitals) 111 terms anna_corrine_carollo Preview Sensory Practice Questions 20 terms SamanthaReeves22 Preview BoardV 83 terms gab A nurse has just received reports for 4 clients. Which client should the nurse prioritize?

• a client with afib who missed the last dose of warfarin
• a client with pyelonephritis who has blood in her urine
• a client post surgical repair of a right tibia-fibula

fracture who complains of severe pain after surgery and now has no feeling in the right foot

• a client with COPD who has wheezes and diminished

breath sounds bilaterally with an oxygen saturation reading of 90% on pulse ox

correct answer: C

Rationale: compartment syndrome is a serious complication of fractures and crush injuries that is caused by swelling tissues in the compartments of the leg or forearm. As pressure rises within a compartment as a result of swelling and inflammation, the capillary perfusion pressure is reduced, causing ischemic injury to the tissues within the compartment. Compartment Syndrome is characterized by severe pain, pain with passive stretching, pallor in the distal extremity, paresthesia, and pulselessness or reduced pulses. A fasciotomy is performed surgically to relieve the compartmental pressure. It is an emergency since necrotic muscle will not recover. Failure to recognize compartment syndrome in a timely manner can cause contractures, infections, and amputation.A community health nurse is providing an in-service to a group of clients at a community outreach center about complications related to substance use disorder. Which of the following findings should the nurse identify as the cause of Wernicke-Korsakoff Syndrome?

• alcohol
• caffeine
• cocaine
• hallucinogens

correct answer: A

Rationale: chronic alcohol use disorder has many systemic effects. In the central nervous system, it can cause Wernicke-Korsakoff syndrome, a form of encephalopathy and psychosis. This is actually two disorders that often occur in tandem with different manifestations.

A nurse must interview a 15-year-old client about her health habits and gain some information about her history. Which of the following interventions should the nurse employ while working with a client in this age group? Select all that apply.

• listen and display interest in the client
• ask "yes or no" questions to provide structure and

organization

• remind the client that her information is not

confidential because she is a minor

• take the client's comments seriously
• talk about issues that affect the teen and not just the

parents

correct answer: A, D, & E

Rationale: adolescents can be a difficult group to work with. They are between the ages of young, school-age children but they are not yet adults. The nurse should try to establish rapport with adolescent clients by listening carefully and taking their comments seriously. Often, situations that may not seem important to adults are very meaningful to adolescents and must be recognized as such. A teen's parents may be present at the exam, and the nurse should consider the needs of both the teen and the teen's parents A nurse is caring for a client who was admitted to the med-surg unit with acute diverticulitis. Which of the following orders should the nurse question?

a) Metronidazole (Flagyl)

b) Morphine 2 mg IV q4 hours prn pain

• colon prep for a colonoscopy

d) NS iv infusion at 100 mL/hr

correct answer: C

Rationale: colonoscopy is contraindicated in acute diverticulitis because of the risk of perforation. Diverticulitis is usually found on routine screening colonoscopy, but the diagnosis of diverticulitis is clinical. Barium enema can also be used to diagnose diverticular disease but is contraindicated in acute diverticulitis because of the risk of perforation.A nurse is caring for a client who has been charged with a traffic violation that resulted in injuries to others. After a visit to the victims on the trauma floor,, a local police officer visits your unit requesting info about the client.What is the appropriate response by the nurse?

• provide the police officer with the chart because he is

a law enforcement official

• inform the officer you would be able to provide him

with the needed info yourself, so that you can protect more sensitive data enclosed in the chart

• provide the officer the direct line to the hospital health

records department, since the patient has already been discharged

• provide the officer with info regarding the privacy rule

restriction according to HIPAA

correct answer: D

Rationale: according to HIPAA privacy rules, the RN may provide the following in to a law enforcement officer under six circumstances and subject to specified

conditions:

1) as required by law (including court order, court-ordered warrants, subpoenas) and administrative requests 2) to identify or locate a suspect, fugitive, material witness, or missing person 3) in response to a law enforcement official's request for information about a victim or suspected victim of a crime 4) to alert law enforcement of a person's death, if the covered entity suspects that criminal activity caused the death 5) when a covered entity believes that protected health info is evidence of a crime that occurred on its premises 6) by a covered health care provider in a medical emergency not occurring on its premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime

A nurse is reviewing snake bite management with a group of parents. Which of the following info should the nurse include in the teaching?

• apply ice as soon as possible after the bite occurs
• attempt to orally suck out the venom
• wash the bite area with soap and water
• perform passive ROM exercises to facilitate circulation

correct answer: C

Rationale: washing the bite area with soap and water is part of the initial

management for a snake bite

Management of a snake bite:

-clear the area with soap and water -cover with a clean dry dressing -immobilize the area -keep the child calm -place the child in a reclined position -remove restrictive clothing -arrange for immediate transport to a medical facility -when possible and can be done safely, take a picture of the snake and bring it to the medical facility with the client so that it can be tested A nurse is conducting health teaching concerning HIV for new nursing students. Which of the following individuals is considered to have the highest risk of acquiring the infection?

• volunteer who assists HIV-positive clients with referrals
• phlebotomist who collects blood from high-risk clients
• nurse who is assessing the history of an HIV-positive

client who is coughing

• lab technician who gathers a saliva sample for ELISA

testing

correct answer: B

Rationale: HIV infection is transmitted through blood and body fluids. The virus attacks the T-cells of the body's immune system, making the client vulnerable to other opportunistic infections and some forms of cancer. HIV is also transmitted through sexual contact. The phlebotomist, who is regularly at risk for needlestick injury, is at greatest risk A nurse is caring for a client who sees a geometric design on the wallpaper and perceives it as an animal. This is an

example of:

• an illusion
• a delusion
• a hallucination
• an idea of reference

correct answer: A

Rationale: an illusion is a misinterpretation of actual external stimuli

A nurse is teaching a newly licensed nurse about hemodialysis for clients who have chronic kidney disease.Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

• "hemodialysis restores kidney function"
• "hemodialysis requires the placement of a catheter into

the peritoneal space"

• "hemodialysis allows an unrestricted diet"
• "hemodialysis returns a balance serum electrolytes"

correct answer: D

Rationale: the nurse should explain to the newly licensed nurse that hemodialysis restores balance in the fluid, electrolyte, and acid-base components of the client's blood. This is completed through the use of diffusion of the client's blood and dialysate containing water and electrolytes across a semi-permeable membrane.Diffusion allows the movement of waste products, excess electrolytes, and fluids from the blood across the semi-permeable membrane and into the dialysate solution and movement of needed electrolytes, such as calcium and bicarbonate, from the dialysis solution and into the blood A nurse is caring for a client who complains of itching of the vulva and a frothy grey vaginal discharge that smells "fishy". The nurse knows that these clinical signs and symptoms are associated with which of the following?

• chlamydia
• genital herpes
• syphilis
• trichomoniasis

correct answer: D

Rationale: typically, a female client with trichomoniasis experiences itching,

burning, redness or soreness of the genitals; discomfort with urination; and a change in the character or volume of vaginal discharge (thin discharge or increased volume). Vaginal discharge can be clear, white, yellowish, or greenish, but it is classically described as malodorous, with an unusual fishy smell.

A nurse is planning care for a group of client. Which of the following tasks should the nurse assign to an AP?

• applying antibiotic ointment to the arm of a client who

has dermatitis

• obtaining medical history info from a stable client who

is being admitted

• monitoring VS of a client who had an appendectomy 12

hr ago

• removing the NG tube of a client who has been

receiving enteral feedings

correct answer: C

Rationale: when planning delegation, the nurse should ensure the task can be

legally delegated to the AP. This involves knowledge of the state's nurse practive act and the facility's policies and procedures. Delegating the monitoring of VS of a stable client 12 hr after surgery is within the range of function of an AP A nurse is visiting a home care client at home to assess safety. The nurse notices that there are no fire alarms in the client's home. The client responds that he has never had any fire alarms and doesn't see the need for them.Which of the following is the appropriate response by the nurse?

• without telling the client, call the client's family and

request that they install fire alarms in the home immediately

• educate the client regarding the importance of having

working fire alarms and encourage him to think about having a fire alarm installed on each floor

• advise the client that he will be sent to a nursing home

is a report is filed that states he does not live in a safe environment

• call the client's primary care provider and report the

absence of working fire alarms in his home

correct answer: B

Rationale: the nurse should attempt to provide the client with enough info to

make an informed decision The nurse is assessing a client with Parkinson's disease who experiences unsteadiness when turning. According to this finding, which stage of the disease is the client experiencing?

• second
• first
• third
• fourth

correct answer: C

Rationale: Parkinson's disease is a progressive neurological disorder that causes destruction of dopamine-generating cells in the substantia nigra of the brain. Loss of dopaminergic neurons affects movement. There are 5 stages in the progression of Parkinson's disease. Stage 1 is characterized by unilateral involvement with minimal or no functional impairment in the movement. In stage 2, there is bilateral and midline involvement but without impairment of balance. Stage 3 is characterized by impairment of reflexes, which results in symptoms that include unsteadiness with turning. Tremors become more profound in this stage, often restricting activities. Stage 4 is characterized by fulminant manifestation of symptoms that include tremor, bradykinesia, rigidity, postural instability, and festination. Stage 5 of Parkinson's disease is characterized by confinement to bed or wheelchair as the client's condition worsens.A nurse is caring for a client at risk for falling. Which of the following components are part of a fall risk assessment? (Select all that apply)

a) LOC

b) HR

• elimination status
• gait and ambulation

e) RR

correct answer: A, C, and D

Rationale: fall risk is assessed by identifying conditions that can contribute to the client's risk of falling and subsequent injury. A checklist or designated assessment form can be used, in accordance with the facility policy. Components of a fall risk assessment include the client's LOC, elimination status, gait and ambulation abilities, presence of orthostatic hypotension, and vision status