Q&A Random Selection #7 Rationale

1 A: The escalation of fees with a decreased reimbursement percentage. The percentage of the gross national product
representing health care costs rose dramatically with reimbursement based on fee for service. Reimbursement for Medicare and
Medicaid recipients based on fee for service also escalates health care costs.

2 C: Participative. A participative style of management involves staff in decision-making processes. Staff/manager interactions
are open and trusting. Most work efforts are joint endeavors.

3 A: encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class. While all suggestions are appropriate, the
education of the parents/caregivers should include techniques of cardiopulmonary resuscitation in order to provide for emergency
care of their child.

4 A: A 5 month-old infant who has audible wheezing and grunting. The age and the findings suggest this client is at immediate
risk for respiratory complications.

5 C: Alteration in comfort. Relieving pain is the number one objective of this client's plan of care.

6 B: Ask a family member to supervise daily compliance. Direct-observed therapy (DOT) is a recognized method for ensuring
client compliance to the drug regimen. A program can be set up to directly observe the client taking the medication in the clinic,
home, workplace or other convenient location.

7 A: Tranquilization, numbing of emotions. The anti-anxiety drugs produce tranquilizing effects and may numb the emotions.

8 C: Ask the client to stay on the line, get the address and send an ambulance to the home. The woman is at risk for seizure
activity. The ambulance needs to bring the woman to the hospital. For at risk clients, PIH (preeclampsia and eclampsia) may
occur prior to, during or after delivery. After delivery, the window of time can be up to ten days.

9 A: Avoid Alka-Seltzer because it contains aspirin. Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin, an
antiplatelet drug, will potentiate the anticoagulant effect of warfarin, which may result in excess bleeding.

10 C: Antihistamine. Elderly people are susceptible to the side effect of anticholinergic drugs, such as antihistamines.
Antihistamines often cause confusion in the elderly, especially at high doses.

11 C: Limiting physical activity in an otherwise healthy, young client should not be necessary. If exercise intolerance exists, the
asthma management plan should include specific medications to treat the problem such as using an inhaled beta-agonist 5
minutes before exercise. The goal is always to return to a normal lifestyle.

12 B: Genital lacerations. Continuous bleeding in the absence of a boggy fundus indicates undetected genital tract lacerations.

13 A: Extreme fatigue. Extreme fatigue and weakness are common, early signs of digitalis toxicity, which would be confirmed
by a high blood serum level of digitalis.

14 D: Foods rich in vitamin K. Vitamin K acts as an antidote to the pharmacologic action of Coumadin therapy, decreasing
Coumadin''s effectiveness. Foods high in vitamin K include dark greens, tomatoes, bananas, cheese, and fish.
15 D: Assess the client''s ability to speak English. Despite the cultural heritage, the nurse cannot make assumptions. Stereotyping
is to be avoided. The nurse should assess the client''s comfort and ability in speaking English.

16 B: eyes. Keratitis is a corneal ulcer or abrasion. Keratitis is caused by exposure and requires application of moisturizing
ointment to the exposed cornea and a plastic bubble shield or eye patch.

17 C: Playing hand held games. Immobilization with traction must be maintained until bone ends are in satisfactory alignment.
Activities that increase mobility interfere with the goals of treatment.

18 D: Smoking cessation. Stopping smoking is the priority for clients at risk for cardiac disease, because of its effects of
reducing oxygenation and constricting blood vessels.
19 C: Ascites. Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension
can lead to ascites due to the increased portal pressure as well as a lowered colloid osmotic pressure because of low albumin.
When liver functioning deteriorates, protein metabolism suffers.

20 D: Slow, irregular respirations. A slow and irregular respiratory rate is a sign of fatigue in an acutely ill child. Fatigue can
rapidly lead to respiratory arrest.

21 A: Death is personified as the bogeyman or devil. Personification of death is typical of this developmental level.

22 C: assess level of consciousness. An altered level of consciousness suggests increasing intracranial pressure related to
cerebral edema.

23 D: Fluid volume deficit. In fluid volume deficit, serum BUN, Na+ and hematocrit may be elevated secondary to
hemoconcentration.

24 B: An open, reddened wound on the heel. When signs of trauma and/or infection occur in their feet, elderly clients who have
diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved. Without
treatment, serious infection, gangrene, limb loss, and death may result.

25 A: Assist the client with activities of daily living. The person to whom the activity is delegated must be capable of performing
it. The UAP is capable of assisting clients with basic needs.

26 C: "I will trim corns and calluses regularly." Clients who are elderly, have diabetes, and/or have vascular disease often have
decreased circulation and sensation in one or both feet. Their vision may also be impaired. Therefore, they need to be taught to
examine their feet daily or have someone else do so. They should wear cotton socks which have not been mended, and always
wear shoes when out of bed. They should not cut their nails, corns, and calluses, but should have them trimmed by their provider,
nurse, or another provider who specializes in foot care.

27 B: Blood lipid levels should be measured on a fasting sample.

28 C: Continue the same analgesic dosage. Dying patients who have been in chronic pain will probably continue to experience
pain even though they cannot communicate their experience. Pain medication should be continued at the same dose, if effective.

29 B: A, D, and K. The uptake of fat soluble vitamins is decreased in children with Cystic Fibrosis. Vitamins A, D, and K are fat
soluble and are likely to be deficient in clients with Cystic Fibrosis.

30 C: Playing with cars on the pavement near burning leaves. Smoke from burning leaves or stems of the poison ivy plant can
produce a reaction. Direct contact with the toxic oil, urushiol, is the most common cause for this dermatitis.

31 B: taking the blood pressure in the left arm. Clients who have had a unilateral mastectomy should not have their blood
pressure measured on the affected side. This helps avoid the possibility of lymphedema post-operatively and in the future.

32 D: assess airway breathing and circulation. The nurse must first assess the client to determine the appropriate next step. In this
case the first step the nurse must take is to evaluate the A, B, C''s.

33 A: "Drink 3000 to 4000 cc of fluid each day for one month." Drinking three to four quarts (3000 to 4000 cc) of fluid each day
will aid passage of fragments and help prevent formation of new calculi.

34 C: "The stomach contents and air must be drained first." After surgery for gastrostomy tube placement, the catheter is left
open and attached to gravity drainage for 24 hours or more.

35 B: magnesium 0.8 mEq/L and creatinine 3 mg/dl. The magnesium is low and the creatinine is high which indicates renal
failure. With the history of hypertension, the findings exhibit the risk of preeclampsia. The client’s lab values are all abnormal
except for the platelets. The client needs to be referred for immediate follow up with a provider.

36 C: Wear gown and gloves during client contact. HAV is usually transmitted via the fecal-oral route, i.e., someone with the
virus handles food without washing his or her hands after using the bathroom. The virus can also be contracted by drinking
contaminated water, eating raw shellfish from water polluted with sewage or by being in close contact with a person who''s
infected — even if that person has no signs and symptoms. In fact, the disease is most contagious before signs and symptoms
ever appear. The nurse should recognize the importance of isolation precautions from the initial contact with the client on
admission until the noncontagious convalescence period.

37 D: "Let’s move to the ‘what if…’ as related to these objections and explore spin off ideas." The goal of brainstorming is to
gather as many ideas as possible without judgment that slows the creative process and may discourage innovative ideas.
Exploration of the nurses objections would encourage the generation of new ideas.

38 B: Insertion of a chest tube. Because a portion of the lung has collapsed, a chest tube will be inserted to restore negative
pressure in the chest cavity.

39 C: Parental anxiety related to knowledge deficit. This hematoma is related to pressure at the time of labor and birth. The
condition resolves within a few days. Parental anxiety must be addressed by listening to their fears and explaining the nature of
this common alteration.

40 B: Retinopathy of prematurity. While there are other causes for retinal damage in the premature infant, maintaining the
oxygen concentration below 40% reduces this important risk factor.