Exit Exam (BSN 366)

Correct Answers:

Report persistent polyuria to the healthcare provider.

Take metformin with a morning and evening meal.

Recognize signs and symptoms of hypoglycemia.

Explanation:

Report persistent polyuria to the healthcare provider:

Polyuria (excessive urination) is a symptom of uncontrolled diabetes and hyperglycemia. If a client continues to experience frequent urination despite taking metformin, their blood glucose levels may not be well controlled. This can lead to dehydration, electrolyte imbalances, and long-term complications like diabetic nephropathy. Educating the client to report persistent polyuria allows for appropriate adjustments in their diabetes management plan.

Take metformin with a morning and evening meal:

Metformin should always be taken with food to reduce common gastrointestinal side effects like nausea, vomiting, and diarrhea. Taking it with morning and evening meals improves drug absorption and helps maintain stable blood glucose levels. Clients should be instructed to never take metformin on an empty stomach to avoid stomach irritation.

Recognize signs and symptoms of hypoglycemia:

Although metformin alone does not usually cause hypoglycemia, clients should still be educated on the signs of low blood sugar—especially if they are on other diabetes medications, skipping meals, or engaging in intense physical activity. Symptoms of hypoglycemia include shakiness, dizziness, sweating, confusion, irritability, and hunger. While the risk of hypoglycemia is lower with metformin compared to insulin or sulfonylureas, it is still essential for clients to recognize and respond to low blood sugar symptoms appropriately.

Why the Other Options Are Incorrect:

Use sliding scale insulin for fingerstick glucose elevations:

This is incorrect because sliding scale insulin is not required for clients on metformin. Metformin helps control blood sugar by increasing insulin sensitivity and reducing glucose production in the liver, but it does not directly lower blood sugar like insulin. Clients should not use insulin unless prescribed, as unnecessary insulin use can increase the risk of hypoglycemia.

Take an additional dose for signs of hyperglycemia:

This is incorrect and potentially dangerous. Metformin dosing should never be adjusted by the client without provider guidance. Taking extra doses can lead to lactic acidosis, a rare but serious complication. If a client experiences persistent hyperglycemia, they should monitor their blood glucose levels, follow dietary recommendations, and contact their healthcare provider for further guidance.

The correct answer is:

Neurovascular checks.

Rationale:

The priority for a client with a fractured femur and a full leg cast is performing neurovascular checks. This includes assessing circulation, motor function, and sensation in the affected leg. Neurovascular checks are crucial for identifying early signs of complications such as compartment syndrome, a medical emergency that can occur when swelling increases within a muscle compartment, reducing blood flow and causing tissue damage. Regular monitoring of pulses, color, temperature, capillary refill, and sensation helps detect potential issues before they escalate, making it the most urgent priority in this scenario.

Why the Other Options Are Incorrect:

Leg elevation

Although leg elevation is important for reducing swelling and promoting circulation, it is not the first priority. The primary concern is ensuring that there are no complications, such as compromised circulation or nerve damage. Neurovascular checks must be performed first to rule out urgent concerns like compartment syndrome. Once the neurovascular status is stable, elevation can be implemented as part of ongoing care.

Pain management

Pain management is an essential part of care, but it is not the priority in the acute phase after a fracture and cast application. The first concern is ensuring that there are no signs of critical complications like compromised circulation or nerve damage. Once neurovascular checks are completed and the leg is stable, appropriate pain management can be administered.

Ambulation teaching

While teaching ambulation is important for the client’s recovery, it can be addressed later once the client's condition is stable and complications have been ruled out. The priority immediately following a femur fracture and cast application is to monitor for signs of severe complications, not to focus on mobility training, which can be done once the situation is under control.

Correct Answers:

Flow meter

The flow meter is essential for regulating the oxygen flow rate from the wall outlet or oxygen tank to the patient. It ensures that the prescribed oxygen flow rate (e.g., 3L/min) is accurately delivered, which is critical for the client’s respiratory needs.

Humidifier bottle

When oxygen is administered at higher flow rates (usually above 3L/min), it can dry out the nasal passages, causing discomfort. A humidifier bottle adds moisture to the oxygen, preventing this dryness and making the therapy more comfortable for the patient.

Nasal cannula

The nasal cannula is the primary device used for delivering low-flow oxygen to the client. It is lightweight, easy to use, and allows the client to carry out activities like eating, drinking, and talking while receiving oxygen therapy.

Why the Other Options Are Incorrect:

Sterile water

Sterile water is not required for oxygen therapy via nasal cannula. Typically, a humidifier bottle, filled with distilled water, is used when needed to prevent nasal dryness, rather than sterile water.

Lambs wool

Lambs wool is not involved in the oxygen therapy process. It is typically used to pad or relieve pressure in different contexts, such as wound care or for comfort, but it is not necessary for oxygen administration.

Suction canister

A suction canister is used to collect secretions during airway suctioning, which is not indicated for this client unless there is a need to clear respiratory secretions. There is no mention of significant respiratory distress with secretions in this case.

Tape

Tape is not needed for securing a nasal cannula, as the tubing is designed to rest over the ears and remain in place on its own without additional support. The cannula’s design is sufficient for comfortable and stable positioning.

Correct Answer: Explore the client's readiness to discuss the situation

When supporting individuals experiencing intimate partner violence (IPV), the nurse must adopt a trauma-informed, client-centered approach. Exploring the client’s readiness helps to create a safe, nonjudgmental space and respects the client’s autonomy. Many individuals in IPV situations may be unwilling or unable to disclose due to fear, emotional attachment, financial dependency, or shame. By respecting the client’s timing and emotional state, the nurse builds trust and increases the likelihood of future engagement and support.

Why the other options are incorrect:

Report the findings to the police department

Mandatory reporting to law enforcement is usually limited to certain circumstances like child abuse or immediate safety threats. Reporting IPV without the client’s consent could breach confidentiality, undermine trust, and potentially put the client at greater risk. Unless required by law or a direct safety threat is present, it’s essential to respect the client’s autonomy and prioritize safety planning.

Determine the frequency and type of client abuse

While knowing details about the abuse is crucial for care planning, asking for specifics too soon can be retraumatizing, especially if the client is not ready to talk. The nurse’s first task should be to build rapport, establish trust, and assess the client’s emotional readiness before asking sensitive questions.

Discuss treatment options for abusive partners

Focusing on the abusive partner's treatment can undermine the client’s agency and may inadvertently suggest that the client’s safety and well-being are dependent on the abuser’s actions. The nurse’s primary responsibility is to support the client, respect their decisions, and focus on their safety, rather than intervening with the abusive partner.

Correct Answer:

Review the need for the UAP to wear a facemask while in close contact with the client

Influenza is transmitted via respiratory droplets, which can spread through coughing, sneezing, or talking. According to CDC guidelines, droplet precautions are necessary, and healthcare workers must wear a surgical mask when within 3 to 6 feet of a client with influenza. Although the unlicensed assistive personnel (UAP) is wearing gloves and a gown, a surgical facemask is also required to prevent transmission and ensure both client and caregiver safety.

Why the other options are incorrect:

“Remind the UAP to apply a fitted respirator mask before entering the client’s room”

This applies to airborne precautions, not droplet precautions. Diseases like tuberculosis or measles require an N95 respirator, but for influenza, a standard surgical mask is sufficient.

“Assign the UAP to provide care for another client and assume full care of the client”

This is unnecessary. The UAP can continue providing care if appropriate droplet precautions—including the use of a facemask—are followed. Delegation is safe when infection control protocols are met.

“Instruct the UAP to notify the nurse of any changes in the client’s respiratory status”

Although monitoring for changes is good practice, this does not address the current problem: the UAP is missing a key component of droplet precautions. The immediate concern is proper PPE use to prevent transmission.

Correct Answer: Stop the irrigation flow.

Explanation:

The first action the nurse should take when there is a discrepancy between the expected output (1000 ml/hour from the continuous irrigation) and the actual output (200 ml) is to stop the irrigation flow. A significant decrease in urine output could indicate a clot, blockage, or kink in the catheter, preventing normal drainage. Stopping the irrigation flow is crucial to prevent further complications, such as bladder distention, which can cause pressure on the bladder or urethra and exacerbate the situation. Once the flow is stopped, the nurse can assess and address the underlying cause.

Why the Other Options Are Incorrect:

Notify the healthcare provider:

While notifying the healthcare provider may be necessary if the issue persists or complications arise, the immediate priority is to stop the irrigation flow to prevent further harm. Notifying the provider should come after the initial intervention (stopping the flow) to assess the situation and determine the next steps.

Document the finding and continue to observe:

While documentation is important, it should not be the first action. Observing without taking immediate action could allow a blockage or clot to worsen, leading to further complications like bladder distention or injury to the urinary system. Immediate intervention is needed to address the problem.

Irrigate the catheter with a large piston syringe:

While irrigating the catheter may be appropriate if a blockage is suspected, it should only be done after stopping the irrigation flow and confirming a blockage. Attempting to irrigate the catheter without first stopping the flow could worsen the problem if there is a significant obstruction or clot, potentially causing injury or further blockage.

Correct Answer: A teacher who seeks information about her disease and wants to continue teaching.

Rationale:

Coping with a cancer diagnosis requires a combination of emotional, psychological, and physical resilience. Studies show that individuals who take an active role in understanding their condition and maintaining a sense of purpose are better equipped to cope with the challenges posed by the diagnosis. In this case, the teacher is proactively seeking information about her disease, which can empower her to make informed decisions and alleviate feelings of helplessness. Additionally, her desire to continue teaching helps preserve her sense of normalcy and purpose, which is crucial for managing stress and emotional distress associated with cancer.

Explanation of Excluded Options:

An older man who is always happy and chooses to view only the good in every situation: While a positive attitude can be beneficial, solely focusing on the good can be a form of denial. Effective coping with cancer often requires acknowledging the full range of emotions, including fear, sadness, and uncertainty. Avoiding or ignoring these emotions can hinder the coping process.

A single mother who seeks the support of her two teenage daughters during difficult times: While seeking support from family is important, relying on her teenage daughters may not be the most effective coping strategy. Teens may lack the emotional maturity to provide the type of support needed for an adult facing a serious illness. It's important for the mother to develop coping strategies outside of her children’s support

 A successful businessman who is accustomed to handling highly stressful situations: Although the businessman may be skilled at managing work-related stress, coping with a cancer diagnosis involves emotional and psychological challenges that are different from professional stress. The skills that help him succeed in business may not fully translate to handling the emotional weight of a serious illness.

Correct Answer:

Assisting the client to push effectively so that expulsion of the fetus can be achieved.

Detailed Explanation:

The second stage of labor begins when the cervix is fully dilated to 10 cm and ends with the birth of the baby. This stage is centered around the delivery of the fetus, which is achieved through maternal pushing efforts and uterine contractions. The nurse’s role during this stage is crucial in supporting the client through effective pushing and guiding them to deliver the baby safely.

Key nursing interventions in the second stage of labor include coaching the client on effective pushing techniques, such as encouraging them to push during contractions while taking deep breaths between efforts. The open-glottis pushing technique is often used to reduce fatigue and maintain oxygenation for the fetus. The nurse should also help the client adopt positions, such as upright or side-lying, which can aid in fetal descent and help with the expulsion of the baby.

Fetal heart rate should be assessed every 5-15 minutes to detect any signs of fetal distress, such as late decelerations or bradycardia. The nurse should also monitor the mother for signs of exhaustion or difficulty pushing. Providing emotional support, encouragement, and reassurance is vital during the pushing phase. Warm compresses can be applied to reduce perineal trauma and support maternal comfort.

Once crowning occurs, the nurse should notify the healthcare provider and assist with positioning for delivery, ensuring all necessary supplies are ready.

Why the Other Options Are Incorrect:

Fetal heart rate (FHR) monitoring is essential and should be done regularly throughout labor, but it is not the primary focus during the second stage. The main priority is the expulsion of the fetus, so assisting the client in pushing effectively takes precedence over continuous fetal monitoring, although it remains important.

Oxytocin is commonly used during the first stage of labor to stimulate contractions and facilitate cervical dilation. By the second stage, the cervix is already fully dilated, and the focus should shift to fetal descent and delivery. Monitoring oxytocin effects is not relevant during the second stage.

While pain management is important, systemic pain medications are generally not administered during the second stage of labor. They can cross the placenta and cause neonatal respiratory depression, which is a risk during the pushing phase. Epidurals are more commonly administered earlier in labor for pain relief.

The correct answer is:

Provide an eye shield to be worn while sleeping.

Explanation:

After intraocular lens implant surgery (such as cataract surgery), protecting the surgical site during sleep is essential. An eye shield helps prevent unintentional rubbing, pressure, or trauma, especially while the client is asleep and unaware of their movements. This is critical because the surgical wound is still healing, and any disruption may lead to complications like infection, bleeding, or increased intraocular pressure. According to postoperative care guidelines, eye protection during rest is one of the highest priorities for safe recovery and preserving vision outcomes.

Why the other options are incorrect:

Encourage deep breathing and coughing exercises

Although deep breathing can promote lung expansion and prevent atelectasis, coughing is discouraged following cataract surgery. Forceful coughing can spike intraocular pressure, potentially disrupting the surgical site and impairing healing. Patients are typically instructed to avoid activities that strain the eyes, including bending, lifting heavy objects, or coughing.

Obtain vital signs every two hours during hospitalization

Routine cataract surgery is typically an outpatient procedure or requires only short observation. There is no clinical need for such frequent monitoring unless the patient has comorbid conditions or complications. Vital signs should be assessed per protocol but not at two-hour intervals unless specifically ordered.

Teach a family member to administer eyedrops

While educating on proper eyedrop administration is an important aspect of postoperative care, it is not the priority immediately after surgery. Ensuring that the eye is physically protected takes precedence in the early recovery phase. Furthermore, many clients can be taught to self-administer drops effectively before discharge.