Exit Exam (BSN 366)

Correct Answer: Start the first transfusion of blood.

Explanation:

The client has a hemoglobin level of 6 gm/dl, which is critically low. Hemoglobin levels below 7 gm/dl typically require a blood transfusion to improve the oxygen-carrying capacity of the blood and prevent complications associated with severe anemia, such as hypoxia. With an oxygen saturation of 82%, the client is experiencing inadequate oxygenation, which further supports the need for immediate intervention. Starting the blood transfusion will raise the hemoglobin level, improving the client's oxygenation and preventing further complications.

Why the other options are incorrect:

Collect blood for hemoglobin and hematocrit

While it is important to monitor hemoglobin and hematocrit levels, the client's hemoglobin is already critically low, and the need for a transfusion is clear. Collecting more blood for lab work would delay the necessary intervention, and addressing the low hemoglobin by starting the transfusion takes precedence.

Insert an indwelling urinary catheter

There is no indication that the client has urinary retention or any related issue that would require catheter insertion. The priority right now is to address the critical hemoglobin level and hypoxia, which will be corrected by starting the blood transfusion.

Encourage alternate rest periods with activity

While rest is important for someone with low hemoglobin, it is not the immediate priority. The client’s critical hemoglobin and oxygen saturation levels require an urgent transfusion to address the hypoxia. Resting and avoiding activity should be considered once the immediate threat to oxygenation is resolved.

Correct Answer: Enzyme release from lysosomes

Explanation:

Free radicals are highly reactive molecules that can cause extensive cellular damage, particularly to lipids in the cell membrane. When free radicals interact with fatty acids in the membrane, they initiate lipid peroxidation. This process damages the cell membrane, leading to the rupture of lysosomes. Lysosomes contain hydrolytic enzymes, such as proteases and hydrolases, which, when released into the cytoplasm, further degrade the components of the cell, worsening the damage and compromising the integrity of the cell.

Why the other choices are incorrect:

Inadequate mitochondrial ATP:

While ATP production is essential for cellular function and energy, it is not the primary mechanism of damage in this scenario. Free radicals primarily cause damage through lipid peroxidation and the release of lysosomal enzymes, rather than through a direct effect on mitochondrial ATP production.

Defective chromosomes for protein:

Free radicals can indeed damage DNA and lead to mutations, but in this case, the focus is on the destruction of the cell membrane. The process of membrane damage from free radicals is caused by lipid peroxidation and the subsequent enzyme release, not defective chromosomes.

Defective integral membrane proteins:

Free radicals can also damage proteins, but in the context of cell membrane destruction, the primary issue is lipid peroxidation. The free radical-induced damage primarily affects the lipids in the membrane, leading to structural changes and eventual membrane rupture. While integral membrane proteins can be affected, they are not the direct cause of the membrane destruction in this case.

The correct answer is:

Initiate a hearing and vision screening program for first graders.

Explanation:

Secondary prevention is aimed at the early detection and intervention of health issues before they cause significant harm or complications. In the case of school-age children, early screening for hearing and vision problems is essential to ensure that any potential impairments are identified before they impact a child's learning and development. By screening for issues like hearing loss or vision impairments, the nurse can ensure timely interventions, such as referrals for treatment, which can significantly improve the child’s academic performance and social interactions. Early detection through screenings helps reduce the long-term effects of untreated health conditions.

Why the Other Options Are Incorrect:

Prepare a presentation on how to prevent the spread of lice

While preventing the spread of lice is important, this action falls under primary prevention, which focuses on preventing health issues before they occur. This is not about early detection or intervention of existing conditions but about avoiding future occurrences. It does not directly address secondary prevention's goal of detecting and treating health issues early.

Observe a person with type one diabetes self-administer a dose of insulin

Although this action is important for patient education and management, it is not an example of secondary prevention. Observing the administration of insulin is part of managing an existing health condition rather than detecting and addressing health issues early. Secondary prevention focuses on identifying and intervening in health problems before they cause serious consequences.\

Collaborate with a science teacher to prepare a health lesson

This action, while valuable for general health education, does not align with secondary prevention. It is focused on educating a group of students, rather than on early detection and intervention of specific health conditions. Secondary prevention targets identifying and addressing health issues as early as possible, rather than promoting broad educational activities.

The correct answer is:

"Tell me about the drugs you use now."

Rationale:

The nurse's role is to gather accurate and comprehensive information during the assessment to ensure the safety and well-being of the client. When a client says, "I do not use many drugs," the nurse should respond in a way that encourages the client to provide specific and detailed information about their current drug use. Asking, "Tell me about the drugs you use now" opens the conversation in a non-judgmental way, allowing the client to describe any substances they may be using, including prescribed medications, over-the-counter drugs, alcohol, or recreational drugs.

Why the Other Choices Are Incorrect:

"Explain what you mean by many drugs."

This question is somewhat unclear and may lead to confusion. The client has already provided some information by stating that they do not use "many drugs." The nurse should seek clarification on the types of drugs being used rather than asking for a definition of "many drugs." The client may interpret the term "many" differently, which could limit the depth of the conversation.

"Do you mean legal drugs or illegal ones?"

This question can come across as judgmental or overly intrusive. It assumes that the client might be using illegal substances and could make the client feel defensive. A better approach is to remain neutral and allow the client to disclose all relevant information, including both legal and illegal substances.

"What kind of drugs are you talking about?"

This is a less ideal question because it places the burden on the client to specify what they meant by "drugs" without encouraging them to discuss all types of substances they may be using. It may seem more limiting than asking them to talk about the drugs they are using currently, as it doesn't convey the same openness to hearing all potential types of drug use.

The correct answers are:

Perform daily surgical dressing change for a client who had an abdominal hysterectomy.

Administer a dose of insulin per sliding scale for a client with type two diabetes mellitus.

Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty.

Explanation:

Practical nurses (PNs) are trained to perform various tasks within their scope of practice, such as wound care, administering certain medications (excluding most IV push medications), and conducting routine assessments. The tasks listed here are appropriate for delegation to a PN under the supervision of a registered nurse (RN).

Perform daily surgical dressing change for a client who had an abdominal hysterectomy:

PNs are qualified to perform routine wound care and surgical dressing changes, assuming there are no complications like severe infection or wound dehiscence. This task falls within their scope of practice as long as the RN provides guidance.

Administer a dose of insulin per sliding scale for a client with type two diabetes mellitus:

PNs are trained to administer subcutaneous injections, including insulin, based on established protocols such as a sliding scale. In some cases, the insulin dose may need to be verified by an RN before administration, but the actual injection can be carried out by the PN.

Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty:

Routine vital sign monitoring is well within the scope of a PN's role. After surgery, PNs routinely assess vital signs to ensure the client’s recovery is progressing appropriately.

Why the Other Options Are Incorrect:

Initiate patient-controlled analgesia (PCA) pumps for two clients immediately postoperatively:

Initiating a PCA pump requires the specialized skills of an RN due to the complexities involved, such as programming the pump correctly, monitoring for complications (e.g., respiratory depression), and ensuring patient safety. While a PN can assist with monitoring, only an RN can initiate a PCA pump.

Start the second blood transfusion for a client 12 hours following a below-knee amputation:

Blood transfusions must be initiated by an RN due to the need for proper protocol adherence, careful monitoring for transfusion reactions, and clinical assessment. Although PNs can assist with monitoring during a transfusion, only an RN can start the process.

Correct Answer: Refer for further diagnostic evaluation

A positive PPD (10 mm induration) along with symptoms such as cough, fever, and night sweats suggests possible active tuberculosis, but a PPD alone does not confirm active disease—it only indicates prior exposure or latent infection. The first and most appropriate action is to refer the patient for further diagnostic testing (such as a chest X-ray and sputum smear or culture) to confirm the presence of active, contagious TB.

Why the other options are incorrect:

Determine exposure of others to tuberculosis

This becomes relevant after confirming active TB. Without confirmation, it's premature to assess contact tracing or exposure risks.

Begin anti-tubercular drug therapy

Treatment should not begin without diagnostic confirmation. Initiating therapy before confirming active TB can lead to unnecessary medication exposure and resistance.

Quarantine or isolate to control communicability

Isolation is reserved for confirmed cases of active and potentially contagious TB. The patient’s diagnosis is still unconfirmed, so immediate isolation isn't yet warranted.

The correct answer is:

Maintain IV therapy.

Explanation:

Tumor lysis syndrome (TLS) is a life-threatening oncologic emergency that occurs when a large number of cancer cells break down rapidly after chemotherapy, releasing intracellular contents like potassium, phosphate, and uric acid into the bloodstream. This causes hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia, which can lead to acute kidney injury (AKI), cardiac dysrhythmias, and seizures.

The priority nursing intervention is to maintain IV therapy to promote adequate hydration and facilitate the excretion of excess electrolytes and waste products. Hydration with IV fluids (typically normal saline) helps dilute potassium and phosphate levels while preventing uric acid crystallization in the kidneys, thus reducing the risk of acute kidney failure.

Why the Other Options Are Incorrect:

Instruct the client to take analgesics on a regular schedule:

Pain management is important for cancer patients but is not the priority in TLS. The main concern in TLS is preventing complications such as renal failure and life-threatening electrolyte imbalances.

Encourage the client to verbalize anxiety and grief:

Emotional support is essential, but in the context of TLS, stabilizing the client's physiological status takes precedence over psychosocial care.

Identify potential sources of infection:

Cancer patients, especially those undergoing chemotherapy, are at high risk for infection due to immunosuppression. However, infection is not the primary concern in TLS. The immediate focus should be on managing electrolyte imbalances and preserving kidney function.

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 and client-centered approach. Exploring the client’s readiness creates a safe, nonjudgmental space, respects autonomy, and builds trust. Many individuals facing IPV may not be ready to disclose or take action due to fear, emotional bonds, financial dependency, or shame. Acknowledging and respecting where the client is in their journey increases the likelihood of future engagement and support.

Why the other options are incorrect:

Report the findings to the police department

Mandatory reporting to police is typically limited to specific circumstances such as child abuse, elder abuse, or immediate threats to safety. Reporting without the client's consent in cases of IPV may violate confidentiality, damage trust, and place the client at greater risk. Unless legally required or life-threatening, the nurse should prioritize client autonomy and safety planning.

Determine the frequency and type of client abuse

Although this information is important for developing a care plan, asking for specific details before the client is emotionally ready can be retraumatizing or cause them to disengage. The nurse must first establish rapport and assess readiness before delving into sensitive questions.

Discuss treatment options for abusive partners

Focusing on the abuser’s treatment shifts attention away from the client's needs and safety. It may also imply that the client’s well-being depends on the abuser’s actions, which can be disempowering. The nurse's role is to support the client, not to manage or treat the abusive partner.

Correct Answer:Ask the client to describe her reaction to milk and eggs:

It is essential to understand the client’s specific reaction to milk and eggs, as this helps differentiate between a food allergy and an intolerance. An allergy involves an immune response, which can cause severe symptoms like anaphylaxis, while intolerance, such as lactose intolerance, results in digestive issues like bloating and diarrhea. By clarifying the symptoms, the nurse ensures the proper diagnosis and documentation, enabling appropriate dietary adjustments and preventing unnecessary restrictions.

Why the other options are incorrect:

Add egg allergy to the client’s identification armband:

An identification band is typically used to alert healthcare staff to severe allergies that may lead to anaphylactic reactions. A food intolerance, like egg intolerance, does not typically cause an immediate, life-threatening allergic reaction. Therefore, it is inappropriate to label it as a severe allergy on the identification band, which could lead to confusion and unnecessary precautions.

Eliminate the chicken selections from the client’s menu:

An egg intolerance does not necessitate the removal of chicken from the client’s diet. Eggs and chicken are distinct foods, and unless the client has a specific chicken allergy (which was not mentioned), there is no reason to eliminate chicken. The dietary focus should remain on avoiding egg-containing foods specifically.

Notify the dietary department of the client’s egg intolerance:

Notifying the dietary department is a necessary step for ensuring that meals provided to the client do not contain eggs, but it should not be the first priority. First, the nurse needs to gather more information about the client’s reactions to milk and eggs to ensure that an intolerance and not an allergy is present. Once confirmed, dietary restrictions can be communicated to the dietary team.

Enter new allergy information in the client’s electronic medical record:

Although updating the client’s electronic medical record is essential for proper documentation and communication with the healthcare team, it should only be done after clarifying the nature of the client’s reaction to milk and eggs. Once it is clear whether the client has a food allergy or intolerance, the relevant information can be recorded accurately.