Deck 4: Reduction of Risk

Question 1

A nurse develops a plan of care for a client at risk for autonomic dysreflexia. Which of the following nursing actions is not included in the care plan?

A)Administer pain medications as ordered
B)Straight catheterization every 8 hours
C)Adherence to bowel retraining program
D)Keeping the client's linen wrinkle-free

Answer 1

Straight catheterization every 8 hours

Question 2

A complication of nasogastric tube insertion for decompression of gastric contents is "silent aspiration." This complication involves the accumulation of gastric contents over a period of time. The nurse should watch out for which one of the following manifestations of silent aspiration?

A)Sudden shortness of breath
B)Sudden hypotension and tachycardia
C)Restlessness and irritability
D)Sudden change in mental status

Answer 2

Restlessness and irritability

Question 3

A nurse is preparing to remove the nasogastric tube of Hannah, a 67-year-old client. The nurse should instruct the client to do which of the following just before removing the tube?

A)Slowly breathe out
B)Slowly breathe in
C)Quickly breath in and then breathe out
D)Hold her breath

Answer 3

Hold her breath

Question 4

A nurse plans to attach the probe of a pulse oximeter on the client's right forefinger. Which of the following conditions could result in inaccurate reading by the probe, necessitating a change in the attachment site?

A)Artificial fingernails
B)Hypothermia
C)Client has chronic respiratory disease
D)Client has Parkinson's disease

Question 5

Tommy, a client diagnosed with diabetes mellitus type II, is asked by his physician to undergo hemoglobin A1c testing every three months. Tommy asks the nurse about the significance of this test. The nurse correctly responds that hemoglobin A1c testing does not:

A)Test the client's compliance with medications
B)Test the client's compliance with diet
C)Test the client compliance with his exercise regimen
D)Test the client's disease progression

Question 6

A nurse is assessing a client who is having a blood transfusion. The blood transfusion was ordered after the laboratory test revealed a hemoglobin level of nine g/dL While transfusing the first unit of blood, the client complained of flank pain. The client's blood pressure is dropping and the heart rate is racing. These symptoms indicate:

A)Delayed hemolytic reaction
B)Anaphylactic reaction
C)Febrile reaction
D)Acute hemolytic reaction

Question 7

A client has a serum calcium level of 5.0 mg/dL. As the nurse reviews the client's records, which information is the most likely cause of the laboratory result?

A)Over activity of parathyroid glands
B)Excessive vitamin D levels
C)Intake of furosemide
D)Renal failure

Question 8

A client who had just undergone hemodialysis is ordered for a laboratory test. Which of the following parameters will show a significant improvement after dialysis?

A)Creatinine
B)Hemoglobin
C)Phosphorus
D)Calcium