nursing practice-1 rationale

7/30/2019 Nursing Practice-1 Rationale

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1. Answer: (B) A 44 year-old myocardial infarction (MI) client who is complaining of

nausea.Rationale: Nausea is a symptom of impending myocardial infarction (MI) and should be

assessed immediately so that treatment can be instituted and further damage to the heart

is avoided.

2. Answer: (C) Check circulation every 15-30 minutes.

Rationale: Restraints encircle the limbs, which place the client at risk for circulationbeing restricted to the distal areas of the extremities. Checking the clients circulation

every 15-30 minutes will allow the nurse to adjust the restraints before injury from

decreased blood flow occurs.

3. Answer: (A) Prevent stress ulcer

Rationale: Curlings ulcer occurs as a generalized stress response in burn patients. This

results in a decreased production of mucus and increased secretion of gastric acid. Thebest treatment for this prophylactic use of antacids and H2 receptor blockers.

4. Answer: (D) Continue to monitor and record hourly urine outputRationale: Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour).

Therefore, this client's output is normal. Beyond continued evaluation, no nursing action

is warranted.

5. Answer: (A) My ankle looks less swollen now

Rationale: Ice application decreases pain and swelling. Continued or increased pain,

redness, and increased warmth are signs of inflammation that shouldn't occur after iceapplication

6. Answer: (C) HypokalemiaRationale: A loop diuretic removes water and, along with it, sodium and potassium.

This may result in hypokalemia, hypovolemia, and hyponatremia.

7. Answer:(A) Have condescending trust and confidence in their subordinatesRationale: Benevolent-authoritative managers pretentiously show their trust and

confidence to their followers.

8. Answer: (A) Provides continuous, coordinated and comprehensive nursing services.

Rationale: Functional nursing is focused on tasks and activities and not on the care of

the patients.

9. Answer: (B) Standard written order

Rationale: This is a standard written order. Prescribers write a single order formedications given only once. A stat order is written for

medications given immediately for an urgent client problem. A standing order, also

known as a protocol, establishes guidelines for treating a

particular disease or set of symptoms in special care areas such as the coronary careunit. Facilities also may institute medication protocols that specifically designate drugs


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that a nurse may not give.

10. Answer: (D) Liquid or semi-liquid stools

Rationale: Passage of liquid or semi-liquid stools results from seepage of unformed

bowel contents around the impacted stool in the rectum. Clients

with fecal impaction don't pass hard, brown, formed stools because the feces can't movepast the impaction. These clients typically report the urge

to defecate (although they can't pass stool) and a decreased appetite.

11. Answer: (C) Pulling the helix up and back

Rationale: To perform an otoscopic examination on an adult, the nurse grasps the helix

of the ear and pulls it up and back to straighten the ear canal. For a child, the nursegrasps the helix and pulls it down to straighten the ear canal. Pulling the lobule in any

direction wouldn't straighten the ear canal for visualization.

12. Answer: (A) Excessive fetal activity.

Rationale: The most common signs and symptoms of hydatidiform mole includeselevated levels of human chorionic gonadotropin, vaginal bleeding, larger than normal

uterus for gestational age, failure to detect fetal heart activity even with sensitive

instruments, excessive nausea and vomiting, and early development of pregnancy-

induced hypertension. Fetal activity would not be noted.

13. Answer: (B) Absent patellar reflexes

Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, whichrequires administration of calcium gluconate.

14. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines.

Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below theplane of the ischial spines.

15. Answer: (A) Contractions every 1 minutes lasting 70-80 seconds.Rationale: Contractions every 1 minutes lasting 70-80 seconds, is indicative of

hyperstimulation of the uterus, which could result in injury to the mother and the fetus if

Pitocin is not discontinued.

16. Answer: (C) EKG tracings

Rationale: A potential side effect of calcium gluconate administration is cardiac arrest.Continuous monitoring of cardiac activity (EKG) throught administration of calcium

gluconate is an essential part of care.

17. Answer: (D) First low transverse caesarean was for breech position. Fetus in thispregnancy is in a vertex presentation.

Rationale: This type of client has no obstetrical indication for a caesarean section as she

did with her first caesarean delivery.

18. Answer: (A) Talk to the mother first and then to the toddler.


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Rationale: When dealing with a crying toddler, the best approach is to talk to the mother

and ignore the toddler first. This approach helps the toddler get used to the nurse beforeshe attempts any procedures. It also gives the toddler an opportunity to see that the

mother trusts the nurse.

19. Answer: (D) Place the infants arms in soft elbow restraints.Rationale: Soft restraints from the upper arm to the wrist prevent the infant from

touching her lip but allow him to hold a favorite item such as a blanket. Because theycould damage the operative site, such as objects as pacifiers, suction catheters, and

small spoons shouldnt be placed in a babys mouth after cleft repair. A baby in a prone

position may rub her face on the sheets and traumatize the operative site. The suture line

should be cleaned gently to prevent infection, which could interfere with healing anddamage the cosmetic appearance of the repair.

20. Answer: (B) Allow the infant to rest before feeding.Rationale: Because feeding requires so much energy, an infant with heart failure should

rest before feeding.

21. Answer: (C) Iron-rich formula only.

Rationale: The infants at age 5 months should receive iron-rich formula and that they

shouldnt receive solid food, even baby food until age 6 months.

22. Answer: (A) Call for help and note the time.

Rationale: Having established, by stimulating the client, that the client is unconsciousrather than sleep, the nurse should immediately call for help. This may be done by

dialing the operator from the clients phone and giving the hospital code for cardiac

arrest and the clients room number to the operator, of if the phone is not available, bypulling the emergency call button. Noting the time is important baseline information for

cardiac arrest procedure.

23. Answer: (C) Make sure that the client takes food and medications at prescribedintervals.

Rationale: Food and drug therapy will prevent the accumulation of hydrochloric acid, or

will neutralize and buffer the acid that does accumulate.

24. Answer: (B) Continue treatment as ordered.

Rationale: The effects of heparin are monitored by the PTT is normally 30 to 45

seconds; the therapeutic level is 1.5 to 2 times the normal level.

25. Answer: (B) In the operating room.Rationale: The stoma drainage bag is applied in the operating room. Drainage from the

ileostomy contains secretions that are rich in digestive enzymes and highly irritating to

the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin

exposed to these enzymes even for a short time becomes reddened, painful,and excoriated.


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26. Answer: (B) Flat on back.Rationale: To avoid the complication of a painful spinal headache that can last for

several days, the client is kept in flat in a supine position for approximately 4 to 12

hours postoperatively. Headaches are believed to be causes by the seepage of cerebral

spinal fluid from the puncture site. By keeping the client flat, cerebral spinal fluidpressures are equalized, which avoids trauma to the neurons.

27. Answer: (C) The client is oriented when aroused from sleep, and goes back to sleep

immediately.

Rationale: This finding suggest that the level of consciousness is decreasing.

28. Answer: (A) Altered mental status and dehydration

Rationale: Fever, chills, hemortysis, dyspnea, cough, and pleuritic chest pain are the

common symptoms of pneumonia, but elderly clients may first appear with only analtered lentil status and dehydration due to a blunted immune response.

29. Answer: (B) Chills, fever, night sweats, and hemoptysisRationale: Typical signs and symptoms are chills, fever, night sweats, and hemoptysis.

Chest pain may be present from coughing, but isnt usual. Clients with TB typically

have low-grade fevers, not higher than 102F (38.9C). Nausea, headache, and

photophobia arent usual TB symptoms.

30. Answer:(A) Acute asthma

Rationale: Based on the clients history and symptoms, acute asthma is the most likelydiagnosis. Hes unlikely to have bronchial pneumonia without a productive cough and

fever and hes too young to have developed (COPD) and emphysema.

31. Answer: (B) Respiratory arrest

Rationale: Narcotics can cause respiratory arrest if given in large quantities. Its

unlikely the client will have asthma attack or a seizure or wake up on his own.

32. Answer: (D) Decreased vital capacity

Rationale: Reduction in vital capacity is a normal physiologic changes include

decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and anincreased in residual volume.

33. Answer: (C) Leukopenia

Rationale: Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as aresult of myelosuppression.

34. Answer: (C) Avoid foods that in the past caused flatus.

Rationale: Foods that bothered a person preoperatively will continue to do so after a

colostomy.

35. Answer: (B) Keep the irrigating container less than 18 inches above the stoma.


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Rationale: This height permits the solution to flow slowly with little force so that

excessive peristalsis is not immediately precipitated.

36. Answer: (A) Administer Kayexalate

Rationale: Kayexalate,a potassium exchange resin, permits sodium to be exchanged for

potassium in the intestine, reducing the serum potassium level.

37. Answer:(B) 28 gtt/minRationale: This is the correct flow rate; multiply the amount to be infused (2000 ml) by

the drop factor (10) and divide the result by the amount of time in minutes (12 hours x

60 minutes)

38. Answer: (D) Upper trunk

Rationale: The percentage designated for each burned part of the body using the rule of

nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anteriortrunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%;

Perineum 1%.

39. Answer: (C) Bleeding from ears

Rationale: The nurse needs to perform a thorough assessment that could indicate

alterations in cerebral function, increased intracranial pressures, fractures and bleeding.

Bleeding from the ears occurs only with basal skull fractures that can easily contributeto increased intracranial pressure and brain herniation.

40. Answer: (D) may engage in contact sportsRationale: The client should be advised by the nurse to avoid contact sports. This will

prevent trauma to the area of the pacemaker generator.

41. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for

breathing.

Rationale: COPD causes a chronic CO2 retention that renders the medulla insensitive to

the CO2 stimulation for breathing. The hypoxic state of the client then becomes thestimulus for breathing. Giving the client oxygen in low concentrations will maintain the

clients hypoxic drive.

42. Answer: (B) Facilitate ventilation of the left lung.

Rationale: Since only a partial pneumonectomy is done, there is a need to promote

expansion of this remaining Left lung by positioning the client on the opposite

unoperated side.

43. Answer: (A) Perceptual disorders.Rationale: Frightening visual hallucinations are especially common in clients

experiencing alcohol withdrawal.

44. Answer: (D) Suggest that it takes awhile before seeing the results.Rationale: The client needs a specific response; that it takes 2 to 3 weeks (a delayed


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effect) until the therapeutic blood level is reached.

45. Answer: (C) Superego

Rationale: This behavior shows a weak sense of moral consciousness. According to

Freudian theory, personality disorders stem from a weak superego.

46. Answer: (C) Skeletal muscle paralysis.

Rationale: Anectine is a depolarizing muscle relaxant causing paralysis. It is used toreduce the intensity of muscle contractions during the convulsive stage, thereby

reducing the risk of bone fractures or dislocation.

47. Answer: (D) Increase calories, carbohydrates, and protein.Rationale: This client increased protein for tissue building and increased calories to

replace what is burned up (usually via carbohydrates).

48. Answer: (C) Acting overly solicitous toward the child.

Rationale: This behavior is an example of reaction formation, a coping mechanism.

49. Answer: (A) By designating times during which the client can focus on

the behavior.

Rationale: The nurse should designate times during which the client can focus on the

compulsive behavior or obsessive thoughts. The nurse should urge the client to reducethe frequency of the compulsive behavior gradually, not rapidly. She shouldn't call

attention to or try to prevent the behavior. Trying to prevent the behavior may cause

pain and terror in the client. The nurse should encourage the client to verbalize anxietiesto help distract attention from the compulsive behavior.

50. Answer: (D) Exploring the meaning of the traumatic event with the client.Rationale: The client with PTSD needs encouragement to examine and understand the

meaning of the traumatic event and consequent losses. Otherwise, symptoms may

worsen and the client may become depressed or engage in self-destructive behavior

such as substance abuse. The client must explore the meaning of the event and won'theal without this, no matter how much time passes. Behavioral techniques, such

as relaxation therapy, may help decrease the client's anxiety and induce sleep. The

physician may prescribe antianxiety agents or antidepressants cautiously to avoiddependence; sleep medication is rarely appropriate. A special diet isn't indicated unless

the client also has an eating disorder or a nutritional problem.

nursing practice-1 rationale

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