Which of the following women who made significant contributions to the nursing care of soldiers during the Civil

War? Select all that apply. a. Harriet Tubman b. Florence Nightingale c. Fabiola d. Dorothea Dix e. Sojoumer Truth

Answer: 1, 4, and 5 Florence Nightingale, contributed to the nursing care of soldiers in the Crimean War. Fabiola, used her wealth to provide houses of caring and healing during the Roman Empire

A nurse tells a client who is struggling with cancer pain, it is normal to feel frustrated about the discomfort. Which of the following is most representative of the skills associated with the working phase of the helping relationship? a. Respect b. Genuineness c. Concreteness d. Confrontation

Answer: a. Respect is correct because the nurse is validating the clients feeling. Its not genuineness because the nurse is giving information versus being genuine. Concreteness is giving an example. The nurse is not confronting but supporting through respect for the clients feelings.

Pulse pressure (pp) is considered the _____. a. Difference between the systolic and diastolic pressure b. The sum of the systolic and diastolic pressure c. The inverse of the blood pressure d. Half of the systolic pressure

a. Difference between the systolic and diastolic pressure

For a client who has ataxia, which of the following tests would be performed to assess the ability to ambulate? a. Kernig's b. Romberg's c. Riley-Day's d. Hoffmann's

Answer: b Rationale: Romberg's test is the ability to maintain an upright position without swaying when standing with feet close together and eyes closed. Kernig's sign, a reflex contraction, is pain in the hamstring muscle when attempting to extend the leg after flexing the thigh.

A cyanotic client with an unknown diagnosis is admitted to the emergency room. In relation to oxygen, the first nursing action would be to a. Wait until the client's lab work is done b. Not administer oxygen unless ordered by the physician c. Administer oxygen at 2 liters flow per minute d. Administer oxygen at 10 liters flow per minute and check the client's nail beds

Answer: c Rationale: Administer oxygen at 2 liters per minute and no more, for if the client is emphysemic and receives too high a level of oxygen, he will develop CO2 narcosis and the respiratory system will cease to function

While on a camping trip, a friend sustains a snake bite from a poisonous snake. The most effective initial intervention would be to a. Place a restrictive band above the snake bite b. Elevate the bite area above the level of the heart c. Position the client in a supine position d. Immobilize the limb

Answer: a Rationale: A restrictive band 2 to 4 inches above the snake bite is most effective in containing the venom and minimizing lymphatic and superficial venous return. Elevation of the limb or immobilization would not be effective interventions.

A 24-year-old male is admitted with a possible head injury. His arterial blood gases show that his pH is less than 7.3, his PaCO2 is elevated above 60 mmHg, and his PaO2 is less than 45 mmHg. Evaluating this ABG panel, the nurse would conclude that a. Edema has resulted from a low pH state b. Acidosis has caused vasoconstriction of cerebral arterioles c. Cerebral edema has resulted from a low oxygen state d. Cerebral blood flow has decreased

Answer: c Rationale: Hypoxic states may cause cerebral edema. Hypoxia also causes cerebral vasodilatation particularly in response to a decrease in the PaO2 below 60 mmHg.

Of the following blood gas values, the one the nurse would expect to see in the client with acute renal failure is a. pH 7.49, HCO3 24, PCO2 46 b. pH 7.49, HCO3 14, PCO2 30 c. pH 7.26, HCO3 24, PCO2 46 d. pH 7.26, HCO3 14, PCO2 30

Answer: d Rationale: The client with acute renal failure would be expected to have metabolic acidosis (low HCO3) resulting in acid blood pH (acidemia) and respiratory alkalosis (lowered PCO2) as a compensating mechanism. Normal values are pH 7.35 to 7.45; HCO3 23 to 27 mEg; and PCO2 35 to 45 mmHg.

A 24-year-old client is admitted to the hospital following an automobile accident. She was brought in unconscious with the following vital signs: BP 130/76, P 100, R 16, T 98F. The nurse observes bleeding from the client's nose. Which of the following interventions will assist in determining the presence of cerebrospinal fluid? a. Obtain a culture of the specimen using sterile swabs and send to the laboratory b. Allow the drainage to drip on a sterile gauze and observe for a halo or ring around the blood c. Suction the nose gently with a bulb syringe and send specimen to the laboratory d. Insert sterile packing into the nares and remove in 24 hours

A client in acute renal failure receives an IV infusion of 10% dextrose in water with 20 units of regular insulin. The nurse understands that the rationale for this therapy is to a. Correct the hyperglycemia that occurs with acute renal failure b. Facilitate the intracellular movement of potassium c. Provide calories to prevent tissue catabolism and azotemia d. Force potassium into the cells to prevent arrhythmias

Answer: b Rationale: Dextrose with insulin helps move potassium into cells and is immediate management therapy for hyperkalemia due to acute renal failure. An exchange resin may also be employed. This type of infusion is often administered before cardiac surgery to stabilize irritable cells and prevent arrhythmias; in this case KC1 is also added to the infusion.

In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include a. Walking several times each day as a part of an exercise routine b. Keeping the heat up so that the environment is warm c. Wearing TED hose during the day d. Using hydrotherapy for increasing oxygenation

Answer: b Rationale: The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful in preventing vasoconstriction, but TED hose would not be therapeutic. Walking will most likely increase pain.

Which one of the following conditions could lead to an inaccurate pulse oximetry reading if the sensor is attached to the client's ear? a. Artificial nails b. Vasodilation c. Hypothermia d. Movement of the head

Answer: c Rationale: Hypothermia or fever may lead to an inaccurate reading. Artificial nails may distort a reading if a finger probe is used. Vasoconstriction can cause an inaccurate reading of oxygen saturation. Arterial saturations have a close correlation with the reading from the pulse oximeter as long as the arterial saturation is above 70 percent.

A client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to a. Check that a hemostat is at the bedside b. Monitor IV fluids for the shift c. Regularly assess respiratory status d. Check that the balloon is deflated on a regular basis

Answer: c Rationale: The respiratory system can become occluded if the balloon slips and moves up the esophagus, putting pressure on the trachea. This would result in respiratory distress and should be assessed frequently. Scissors should be kept at the bedside to cut the tube if distress occurs. This is a safety intervention.