GCC 476 - 500

The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which action should the charge nurse take?

• Change the nurse’s assignment to another client
• Explain to the nurse that there is no risk to the client
• Ask the nurse if the chickenpox have scabbed
• Ask the nurse if she has ever had the chickenpox
• -

Answer explanation

Option 1: Change the nurse’s assignment to another client

Option 2: Explain to the nurse that there is no risk to the client

Option 3: Ask the nurse if the chickenpox have scabbed

Option 4: Ask the nurse if she has ever had the chickenpox

Option 5: -

Correct Option: Option 4 – Ask the nurse if she has ever had the chickenpox

Explanation: The nurse who has had the chickenpox has immunity to the illness. Answer A is incorrect because more information is needed to determine whether a change in assignment is necessary. Answer B is incorrect because there could be a risk to the immune-suppressed client. Answer C is incorrect because the client who is immune-suppressed could still be at risk from the nurse’s exposure to the chickenpox, even if scabs are present.

The nurse is preparing to walk the post-operative client for the first time since surgery. Before walking the client, the nurse should:

• Give the client pain medication
• Assist the client in dangling his legs
• Have the client breathe deeply
• Provide the client with additional fluids
• -

Answer explanation

Option 1: Give the client pain medication

Option 2: Assist the client in dangling his legs

Option 3: Have the client breathe deeply

Option 4: Provide the client with additional fluids

Option 5: -

Correct Option: Option 2 – Assist the client in dangling his legs

Explanation: Before walking the client for the first time since surgery, the nurse should ask the client to sit on the side of the bed and dangle his legs, to prevent postural hypotension. Pain medication should not be given before walking; therefore, answer A is incorrect. Answers C and D have no relationship to walking the client; therefore, they are incorrect.

Delegation of responsibility between members of the multidisciplinary health care team is essential to provide quality and timely client care. Which statement best describes delegation?

• Delegation is the process of overseeing and organizing client care in collaboration with the multidisciplinary team.
• Delegation is the reassigning of responsibility for performance of a job or task from one member of the health care team to another.
• Delegation of responsibility can only be done by the charge nurse or nurse manager.
• Delegation is the process of prioritizing client care to achieve the best possible client outcome.
• -

Answer explanation

Option 1: Delegation is the process of overseeing and organizing client care in collaboration with the multidisciplinary team.

Option 2: Delegation is the reassigning of responsibility for performance of a job or task from one member of the health care team to another.

Option 3: Delegation of responsibility can only be done by the charge nurse or nurse manager.

Option 4: Delegation is the process of prioritizing client care to achieve the best possible client outcome.

Option 5: -

Correct Option: Option 2 – Delegation is the reassigning of responsibility for performance of a job or task from one member of the health care team to another.

Explanation: Delegation of responsibility is the reassigning of responsibility for performance of a job or task from one member of the health care team to another.

On the first day after thoracotomy, the nurse’s assessment of the patient reveals a temperature of 100°F, a heart rate of 96 beats/minute, blood pressure of 136/86 mm Hg, and shallow respirations of 24 breaths/minute, with rhonchi heard at the lung bases. The patient complains of incisional pain. Which nursing action takes priority?

• Medicating the patient for pain
• Helping the patient out of bed
• Administering ibuprofen (Motrin) as ordered to reduce fever
• Encouraging the patient to cough and deep-breathe
• -

Answer explanation

Option 1: Medicating the patient for pain

Option 2: Helping the patient out of bed

Option 3: Administering ibuprofen (Motrin) as ordered to reduce fever

Option 4: Encouraging the patient to cough and deep-breathe

Option 5: -

Correct Option: Option 1 – Medicating the patient for pain

Explanation: Although all the interventions are incorporated in this patient’s care plan, relieving pain and making the patient comfortable take priority. Doing so gives the patient the energy and stamina to achieve the other objectives.

A client delivered a healthy newborn. As part of discharge teaching the nurse informs the client about the need for well child check-ups. The client asks for an explanation. A well child check-up is:

• A clinic visit of a sick child in an attempt to return her to health.
• A rapid in-and-out visit where only the child’s weight and height are determined and plotted on a growth chart.
• The administration of routine childhood vaccinations.
• Regularly scheduled clinic visits encompassing various aspects of health promotion.
• -

Answer explanation

Option 1: A clinic visit of a sick child in an attempt to return her to health.

Option 2: A rapid in-and-out visit where only the child’s weight and height are determined and plotted on a growth chart.

Option 3: The administration of routine childhood vaccinations.

Option 4: Regularly scheduled clinic visits encompassing various aspects of health promotion.

Option 5: -

Correct Option: Option 4 – Regularly scheduled clinic visits encompassing various aspects of health promotion.

Explanation: In addition to physician visits when the child is sick or needs an examination to participate in a particular activity, routine well child check-ups (WCCs) are recommended. WCCs include physical examination, immunizations, tracking growth and development, detecting problems early, and education for both parent and child. Measurements of height and weight and the administration of vaccines are only part of a WCC.

When performing a physical examination on an elderly client, the nurse:

• Assesses the musculoskeletal system by asking the client to hop on one foot and perform deep knee bends.
• Limits distractions because of the client’s sensory deficits in vision and hearing.
• Evaluates the pulmonary status with deep breaths, breath holding, and forced expirations.
• Focuses on different walking maneuvers (heelto- toe, tandem, heel walking) to evaluate neuromuscular function.
• -

Answer explanation

Option 1: Assesses the musculoskeletal system by asking the client to hop on one foot and perform deep knee bends.

Option 2: Limits distractions because of the client’s sensory deficits in vision and hearing.

Option 3: Evaluates the pulmonary status with deep breaths, breath holding, and forced expirations.

Option 4: Focuses on different walking maneuvers (heelto- toe, tandem, heel walking) to evaluate neuromuscular function.

Option 5: -

Correct Option: Option 2 – Limits distractions because of the client’s sensory deficits in vision and hearing.

Explanation: Many elderly clients have sensory deficits and distractions can be confusing and limit the ability to thoroughly assess the client. Hopping, deep knee bends, and walking maneuvers can be difficult due to limited range of motion, decreased reflexes, and diminished sense of balance. Pulmonary changes in the elderly include decreased force of expiration, weakened cough reflex, and shortness of breath. Deep breaths, breath holding, and forced expiration may compound respiratory difficulty.

In which of the following maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks’ gestation is in the left occipitoanterior (LOA) position?

• Near the symphysis pubis.
• Two inches above the umbilicus.
• Below the umbilicus on the left side.
• At the level of the umbilicus.
• -

Answer explanation

Option 1: Near the symphysis pubis.

Option 2: Two inches above the umbilicus.

Option 3: Below the umbilicus on the left side.

Option 4: At the level of the umbilicus.

Option 5: -

Correct Option: Option 3 – Below the umbilicus on the left side.

Explanation: As the uterus contracts, the abdominal wall rises and, when external monitoring is used, presses against the transducer. This movement is transmitted into an electrical current, which is then recorded. With the fetus in the LOA position, the cardiotransducer should be placed below the umbilicus on the side where the fetal back is located and uterine displacement during contractions is greatest. If the fetal back is near the symphysis pubis, the fetus is presenting as a transverse lie. If the fetus is in a breech position, the fetal back may be at or above the umbilicus.

The 5-year-old is being tested for pinworms. To collect a specimen for assessment of pinworms, the nurse should teach the mother to:

• Examine the perianal area with a flashlight 2–3 hours after the child is asleep and to collect any eggs on a clear tape.
• Scrape the skin with a piece of cardboard and bring it to the clinic.
• Obtain a stool specimen in the afternoon.
• Bring a hair sample to the clinic for evaluation.
• -

Answer explanation

Option 1: Examine the perianal area with a flashlight 2–3 hours after the child is asleep and to collect any eggs on a clear tape.

Option 2: Scrape the skin with a piece of cardboard and bring it to the clinic.

Option 3: Obtain a stool specimen in the afternoon.

Option 4: Bring a hair sample to the clinic for evaluation.

Option 5: -

Correct Option: Option 1 – Examine the perianal area with a flashlight 2–3 hours after the child is asleep and to collect any eggs on a clear tape.

Explanation: Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. There is no need to scrape the skin, as stated in answer B. Collecting a stool specimen in the afternoon will probably not reveal the eggs because the worms often are not detected during the day; therefore, answer C is incorrect. Answer D is incorrect because eggs are not located in the hair.

A nurse in the intensive care unit is caring for a critically ill client with an intra-aortic balloon pump (IABP). An IABP provides mechanical support for the client’s failing heart. Even when inserted properly, the client is at risk for complications. Which complication can result from the use of an IABP?

• Aortic dissection.
• Cardiac tamponade.
• Pneumothorax.
• Splenic rupture.
• -

Answer explanation

Option 1: Aortic dissection.

Option 2: Cardiac tamponade.

Option 3: Pneumothorax.

Option 4: Splenic rupture.

Option 5: -

Correct Option: Option 1 – Aortic dissection.

Explanation: The client with the IABP is at risk for an aortic dissection. An IABP is a 26- to 28-mm inflatable balloon surrounding a catheter that is inserted into the descending aorta. Even when inserted properly, there is a risk of aortic dissection, especially when there is pre-existing aortic disease. Cardiac tamponade, pneumothorax, and splenic rupture are not risks associated with IABP insertion.

A patient is admitted to a burn intensive care unit with extensive full-thickness burns. The nurse is most concerned about the patient’s:

• fluid and electrolyte status.
• risk of infection.
• body image.
• level of pain.
• -

Answer explanation

Option 1: fluid and electrolyte status.

Option 2: risk of infection.

Option 3: body image.

Option 4: level of pain.

Option 5: -

Correct Option: Option 1 – fluid and electrolyte status.

Explanation: During the early phase of burn care, the nurse is most concerned with fluid resuscitation and electrolyte balance, to correct large-volume fluid loss through the damaged skin. Infection (Option B), body image (Option C), and pain (Option D) are significant areas of concern, but are less urgent than fluid status.