COMP EXAM 2 NURS 420

COMP EXAM 2 NURS 420

• A nurse is caring for the client who begins to exhibit seizure activity while in bed. Which of

the following actions does the nurse implement to care for the client? Select all that apply.

• Observing and timing the seizure Correct
• Loosening any restrictive clothing Correct
• Turning the client’s head to the side Correct
• Removing the pads on the side rails
• Inserting an airway into the client’s mouth
• Removing objects that might injure the client from the vicinity Correct

Rationale: Client safety is a priority for the client experiencing a seizure. Nursing actions during a seizure include providing privacy, loosening restrictive clothing, removing the pillow, raising the padded side rails on the bed, removing objects that might cause injury to the client, and placing the client on the side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. (The nurse should not insert anything into the client’s mouth.) The nurse also observes, documents, and times the seizure. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head against injury; and moves furniture that may injure the client if he or she were to come in contact with it during the seizure.

Test-Taking Strategy: Evaluate this question from the perspective of causing harm. No harm can come to the client from any of the options except for removal of the padded side rails and insertion of an airway into the client’s mouth. Review care of the client experiencing a seizure if you had difficulty with this question.

Level of Cognitive Ability: Applying

Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Implementation

Content Area: Adult Health

Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Critical thinking for

collaborative care (6th ed., p. 959). Philadelphia: Saunders.

Awarded 1.0 points out of 1.0 possible points.

2. 2.ID: 383727420

Which of the following infection-control measures would the nurse implement for a client in whom smallpox is diagnosed? Select all that apply.

• Enteric
• Droplet Correct
• Contact Correct
• Standard Correct
• Protective isolation

Rationale: Smallpox is transmitted from person to person in infected aerosols and air droplets spread by way of face-to-face contact with an infected person after fever has begun, especially if the infected person is also coughing. The disease can also be transmitted in contaminated clothes and bedding, although the risk of infection from this source is much lower. Therefore droplet and contact precautions are necessary. Standard precautions are implemented for the care of all clients. Enteric precautions are implemented if the infectious agent is transmitted by way of contact with feces.Protective isolation is implemented when the client is neutropenic and needs to be protected from infection.

Test-Taking Strategy: Use the process of elimination. Recalling the route of transmission of smallpox and remembering that all clients are cared for under standard precautions will direct you to the correct options. Review the infection-control measures that must be taken with smallpox infection if you had difficulty with this question.

Level of Cognitive Ability: Applying

Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Implementation

Content Area: Fundamentals

References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for

positive outcomes (8th ed., p. 1227). St. Louis: Saunders.

Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th

ed., p. 662). St. Louis: Mosby.

Awarded 0.0 points out of 1.0 possible points.

3. 3.ID: 383727418

A nurse is caring for a client in labor who is receiving an oxytocin (Pitocin) infusion. The nurse notes that the client is experiencing uterine hypertonicity. The nurse should immediately:

• Contact the physician
• Stop the oxytocin infusion Correct
• Check the client’s blood pressure
• Place the client in a side-lying position Incorrect

Rationale: If uterine hypertonicity or a nonreassuring fetal heart pattern occurs, the nurse must intervene to increase fetal oxygenation. The oxytocin infusion is stopped immediately and the infusion rate of the nonadditive IV solution is increased. The client is placed in a side-lying position, and oxygen is administered with the use of a snug face mask at 8 to 10 L/min. The physician is notified of the adverse reactions, the nursing interventions implemented, and the client’s response to the interventions. The client’s blood pressure is monitored closely.

Test-Taking Strategy: Use the process of elimination and note the strategic word “immediately.” Noting that the client is experiencing uterine hypertonicity and recalling the effects of oxytocin will direct you to the correct option. If you had difficulty with this question, review care of the client in labor who is receiving oxytocin.

Level of Cognitive Ability: Applying

Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Implementation

Content Area: Delegating/Prioritizing

Reference: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal-child nursing

care (4th ed., p. 508). St. Louis: Elsevier.

Awarded 0.0 points out of 1.0 possible points.

4. 4.ID: 383806671

A physician prescribes morphine sulfate, gr 1/8 intramuscular stat, for a client with cancer. The medication ampule reads, "Morphine sulfate 10 mg/mL." How many milliliters of medication does the nurse prepare to administer the correct dose?

Please enter the number only: Correct

Correct Responses

A. 0.75

.75

Rationale: It is necessary to convert gr 1/8 to mg. After converting grains to milligrams, use the formula to calculate the correct dose.

Conversion:

Formula:

Test-Taking Strategy: In this dose calculation problem, it is necessary to first convert grains to milligrams. Next, follow the formula for the calculation of the correct dose. Recheck your work, using a calculator, and ensure that the answer makes sense. If you had difficulty with this question, review dose calculation problems.

Level of Cognitive Ability: Applying

Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Implementation

Content Area: Nursing Sciences

Reference: Kee, J., & Marshall, S. (2009). Clinical calculations: With applications to general and

specialty areas (6th ed., p. 86). St. Louis: Saunders.