NU 160 Exam 1

Correct Answer: D. Encouraging the client to drink 2 to 3 L of water daily

Explanation:

For a client with chronic obstructive pulmonary disease (COPD) who has thick, tenacious bronchial secretions, adequate hydration is the best intervention. Drinking 2 to 3 liters of water daily helps thin mucus, making it easier to cough up and clear the airways. Hydration also improves mucociliary clearance, reducing the risk of mucus plugging and infection.

Why the Other Options Are Incorrect:

A. Maintaining a semi-Fowler's position as often as possible

Incorrect. While a semi-Fowler’s or high-Fowler's position can help with breathing by promoting lung expansion, it does not directly address thick mucus secretions. Hydration is more effective for thinning secretions.

B. Administering oxygen via nasal cannula at 2 L/min

Incorrect. Oxygen therapy is helpful for hypoxia in COPD but does not loosen thick mucus. Additionally, excessive oxygen in COPD patients can suppress their drive to breathe, so it must be carefully monitored.

C. Helping the client select a low-salt diet

Incorrect. Although excessive sodium intake can contribute to fluid retention, it does not directly impact bronchial secretions. Hydration is the key factor in mucus mobilization.

Summary:

The correct answer is D (Encouraging the client to drink 2 to 3 L of water daily) because hydration helps thin bronchial secretions, making them easier to clear. The other options do not directly address the client's difficulty in bringing up mucus.

The correct answer is D: "I will not add ice cream to the amount of fluid intake."

Explanation:

When managing fluid intake in a client with acute kidney disease, it is important for the client to account for all sources of fluid, including food items that contain high water content. Ice cream, while solid, contains a significant amount of fluid, and it should be counted toward the total fluid intake. The statement "I will not add ice cream to the amount of fluid intake" shows that the client understands the need to limit fluids and is excluding ice cream from their fluid intake tally. This reflects an understanding of how to accurately track and limit fluid consumption.

Why The Other Options Are Incorrect

A: "I should consume most of the fluid during the evening." This is incorrect. Clients with fluid restrictions are typically advised to distribute fluid consumption throughout the day to prevent overloading the kidneys, especially in the evening when the body is less active. Drinking most of the fluid in the evening could lead to fluid retention and worsen the condition, making this statement an indication of misunderstanding.

B: "I will make a list of my favorite beverages." This is not a wrong answer, but it is less precise compared to option D. Making a list of favorite beverages shows some understanding of fluid management, but it does not directly address the issue of tracking all sources of fluid, including foods like ice cream, which is crucial in fluid restriction protocols.

C: "I will put beverages in large containers to give the appearance of drinking a lot." This is a problematic response. It suggests that the client may try to manipulate the appearance of their fluid intake to possibly consume more than what is allowed. The goal of fluid restriction is to accurately limit intake, and this statement demonstrates a misunderstanding of the need to adhere to the prescribed fluid limits.

Summary:

The best answer is D: "I will not add ice cream to the amount of fluid intake," as it correctly reflects an understanding that all sources of fluid, including foods with high water content like ice cream, need to be considered when managing fluid intake. The other answers indicate a misunderstanding of fluid management or involve strategies that could potentially lead to excess fluid consumption.

Correct Answer: D. Ask the client to demonstrate the skill.

Explanation:

The best way to ensure understanding, especially for a client with a low literacy level, is to use the teach-back method, which involves asking the client to demonstrate the skill. This allows the nurse to assess comprehension and correct any mistakes immediately. By having the client physically demonstrate how to self-administer the subcutaneous medication, the nurse can reinforce learning through hands-on practice, which is particularly effective for clients with limited literacy skills.

Why the Other Options Are Incorrect:

A. Provide the client with written material using large print.

While large print may be helpful for clients with visual impairments, it does not address low literacy. Clients with low literacy may struggle to understand written instructions, even if they are in large print. A more effective approach is to use visual aids, videos, and hands-on demonstrations rather than relying solely on written materials.

B. Simplify terms using acronyms.

Acronyms can be confusing, especially for clients with low literacy, as they require prior knowledge of medical terminology. Instead of acronyms, the nurse should use simple, everyday language and explain concepts clearly.

C. Provide a long teaching session.

Lengthy teaching sessions can be overwhelming and ineffective, especially for clients with low literacy. Instead, the nurse should use short, focused sessions with repetition and reinforcement to ensure understanding.

Summary:

The most effective strategy is D. Ask the client to demonstrate the skill, as it ensures that they have understood the instructions and can perform the task correctly. Hands-on demonstration allows for real-time feedback and correction, which is crucial for clients with low literacy.

Correct Answer: Prothrombin Time (PT)

Explanation:

Warfarin (Coumadin) is an oral anticoagulant that works by inhibiting vitamin K-dependent clotting factors to prevent thrombosis in conditions such as artificial heart valves, atrial fibrillation, and deep vein thrombosis. Prothrombin Time (PT) is the appropriate lab test to monitor warfarin therapy because it measures the time it takes for blood to clot and reflects the effectiveness of warfarin. The International Normalized Ratio (INR) is also used alongside PT to standardize the results and ensure therapeutic effectiveness. A therapeutic INR range for a client with an artificial heart valve is typically 2.5 to 3.5.

Why the Other Options Are Incorrect:

Hemoglobin (Hgb)

Incorrect. Hemoglobin measures the oxygen-carrying capacity of red blood cells and is used to assess anemia or blood loss. It does not directly monitor warfarin’s effectiveness.

Bleeding Time

Incorrect. Bleeding time assesses platelet function and is not a reliable measure of warfarin therapy, which affects clotting factors rather than platelets.

Activated Partial Thromboplastin Time (aPTT)

Incorrect. aPTT measures the function of the intrinsic clotting pathway and is used to monitor heparin therapy, not warfarin.

Summary:

The correct answer is Prothrombin Time (PT) because it measures the effectiveness of warfarin therapy. The International Normalized Ratio (INR) is also monitored to ensure therapeutic levels, particularly for clients with artificial heart valves.

Correct Answer: "Diuretics are the first type of medication to control hypertension."

Explanation of the Correct Answer:

Diuretics, particularly thiazide diuretics, are often the first-line pharmacological treatment for hypertension. They help reduce blood pressure by decreasing fluid volume and lowering peripheral vascular resistance. Common examples include hydrochlorothiazide (HCTZ) and chlorthalidone.

Explanation of Incorrect Answers:

"Limit your alcohol consumption to three drinks a day."

This is incorrect because the recommended alcohol limit for people with hypertension is no more than two drinks per day for men and one drink per day for women. Excessive alcohol intake can raise blood pressure and interfere with hypertension medications.

"Plan to lower saturated fats to 10 percent of your daily calorie intake."

This is incorrect because the Dietary Approaches to Stop Hypertension (DASH) diet recommends limiting saturated fats to less than 6% of total daily calories. A diet rich in fruits, vegetables, whole grains, and low-fat dairy is more effective in managing hypertension.

"Reaching your goal blood pressure will occur within 2 months."

This is incorrect because achieving optimal blood pressure control varies between individuals. It often requires several months of lifestyle modifications and medication adjustments, depending on the severity of hypertension and the individual's response to treatment.

Summary:

When educating middle-aged clients about hypertension, nurses should emphasize that diuretics are commonly the first-line medication, alcohol should be moderated, dietary fat should be limited to less than 6% saturated fat, and achieving target blood pressure takes time and varies per individual.

The correct answer is B. Administer subcutaneous Humalog.

Explanation 

Licensed Practical Nurses (LPNs) are permitted to administer subcutaneous insulin, including Humalog (insulin lispro), as it falls within their scope of practice. LPNs commonly provide routine medication administration, including subcutaneous injections, under the supervision of a registered nurse (RN) or healthcare provider.

Explanation of Incorrect Answers:

A. Hang a new bag of Total Parenteral Nutrition (TPN)

TPN is a highly specialized intravenous (IV) nutritional therapy that requires careful monitoring, sterile technique, and knowledge of fluid and electrolyte balance. It is considered high-risk because incorrect administration can lead to metabolic complications or infections. Only an RN or provider should initiate, adjust, or hang a new bag of TPN.

C. Start a blood transfusion 

Blood transfusions require initial assessment, verification of patient identity, and monitoring for transfusion reactions, which are responsibilities that must be performed by an RN. While LPNs may assist in monitoring a stable patient after the transfusion has begun, they cannot start the transfusion.

D. Administer IV morphine 

LPNs cannot administer IV push medications, including IV narcotics like morphine. IV medications require careful dosing, assessment of response, and monitoring for adverse reactions such as respiratory depression, which is within the RN’s scope of practice. Some state boards of nursing may allow LPNs to administer IV medications with additional certification, but this is not standard practice.

Summary:

The best task to delegate to an LPN is administering subcutaneous Humalog because it is within their scope of practice. The other options involve high-risk IV therapies (TPN, blood transfusions, and IV morphine) that require an RN’s expertise to ensure safe administration and monitoring. Proper delegation improves workflow efficiency while ensuring patient safety.

Correct Answers: 

B. "I will consume less caffeine and fewer spicy foods." 

C. "I will sleep with the head of my bed elevated." 

D. "I will try not to gain weight." 

Explanation

B. "I will consume less caffeine and fewer spicy foods." 

Caffeine, spicy foods, and acidic foods (e.g., citrus, tomatoes) can increase gastric acid production and worsen acid reflux symptoms associated with a hiatal hernia. Reducing intake of these foods helps minimize irritation and discomfort.

C. "I will sleep with the head of my bed elevated." 

Elevating the head of the bed by 6 to 8 inches reduces acid reflux by preventing stomach contents from flowing back into the esophagus. This is especially important at night when gravity no longer assists in keeping acid in the stomach.

D. "I will try not to gain weight." 

Obesity and weight gain increase intra-abdominal pressure, worsening reflux and symptoms of a hiatal hernia. Maintaining a healthy weight can reduce symptoms and improve digestive health.

Incorrect Answers & Explanations

A. "I will lie down for one half hour after meals." 

Lying down too soon after eating can cause stomach contents to reflux into the esophagus, worsening symptoms. Instead, clients should remain upright for at least 2 to 3 hours after meals to prevent reflux.

E. "I will drink less fluid." 

Drinking adequate fluids is important for digestion and preventing dehydration. However, clients should avoid drinking large amounts at once, especially with meals, as this can increase gastric pressure and contribute to reflux

Summary

Clients with a hiatal hernia should avoid caffeine and spicy foods, sleep with their head elevated, and maintain a healthy weight to reduce symptoms. They should stay upright after meals rather than lying down and should drink fluids in moderation but not excessively reduce intake.

Correct Answers:

✅ A. Wear sunglasses to filter ultraviolet (UV) light

✅ D. Wear eye protection when working with fluids

✅ E. Wash your hands before touching your eyelid

Explanation:

Health promotion for vision involves preventing eye damage, reducing infection risk, and promoting regular eye exams. The correct education includes:

A. Wear sunglasses to filter ultraviolet (UV) light 

UV exposure increases the risk of cataracts, macular degeneration, and other eye diseases. Sunglasses with 100% UV protection help prevent long-term damage.

D. Wear eye protection when working with fluids 

Safety goggles or protective eyewear should be used when working with chemicals, cleaning solutions, or other fluids that could splash into the eyes and cause irritation or injury.

E. Wash your hands before touching your eyelid 

Hand hygiene is essential in preventing eye infections, such as conjunctivitis (pink eye). Touching the eyes with unwashed hands can introduce bacteria, viruses, or irritants.

Why the Other Options Are Incorrect:

B. Avoid nonsteroidal anti-inflammatory drug (NSAID) use

NSAIDs (e.g., ibuprofen, aspirin) do not generally harm vision unless used excessively or in rare cases of side effects like bleeding disorders. Some NSAIDs are actually used to treat certain eye conditions, like postoperative inflammation.

C. Older adults should have an eye exam every 3-5 years 

The correct recommendation is:

Every 1-2 years for adults aged 65 and older (due to higher risk of cataracts, glaucoma, and macular degeneration).

Every 2-4 years for adults under 65, depending on risk factors.

Summary:

The best health promotion strategies for vision include wearing sunglasses (A), using protective eyewear (D), and maintaining hand hygiene (E). Avoiding NSAIDs (B) is not necessary, and older adults should have more frequent eye exams than every 3-5 years (C)

The correct answer is: D. Increased TSH

Explanation 

Thyroid-stimulating hormone (TSH) is increased in primary hypothyroidism because the pituitary gland is trying to stimulate an underactive thyroid gland to produce more thyroid hormones (T3 and T4). However, due to thyroid dysfunction, T3 and T4 levels remain low, and the pituitary compensates by releasing more TSH. This is the hallmark lab finding for primary hypothyroidism, such as in Hashimoto’s thyroiditis, which is an autoimmune cause of hypothyroidism.

Explanation of Incorrect Answers:

A. Elevated AST/ALT

Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are liver enzymes that indicate liver dysfunction. While hypothyroidism can lead to mild liver enzyme elevation due to metabolic changes, AST and ALT are not primary diagnostic markers for hypothyroidism.

B. Elevated ADH 

Antidiuretic hormone (ADH) is responsible for fluid balance and is secreted by the posterior pituitary. Inappropriate ADH secretion (SIADH) can cause hyponatremia, but it is not a defining characteristic of hypothyroidism.

C. Decreased TSH 

Decreased TSH is seen in hyperthyroidism (such as Graves' disease) or in secondary hypothyroidism, which results from a pituitary disorder. In primary hypothyroidism, the thyroid is not producing enough hormones, so the pituitary increases TSH secretion to compensate.

Summary:

The correct answer is D. Increased TSH because in primary hypothyroidism, the thyroid fails to produce adequate T3 and T4, leading to elevated TSH as the pituitary gland attempts to stimulate the thyroid.