Fundamentals of Nursing Practice Quiz 7

Answer: D – Bone marrow suppression

Explanation: The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status epilepticus.

Answer: D – Altered peripheral tissue perfusion related to venous congestion

Explanation: Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis,is incorrect because impaired gas exchange is related to decreased, not increased, blood flow, is inappropriate because no evidence suggest that this patient has a fluid volume excess, may be warranted but is secondary to altered tissue perfusion.

Answer: A – Superior vena cava

Explanation: When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are common insertion sites for central venous catheters.

Answer: D – Evaluation

Explanation: During the evaluation step of the nursing process the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions.

Answer: C – “With your history and the type of location of the injury, it’s hard to say.”

Explanation: Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.

Answer: B – Documenting drugs given

Explanation: Although documentation isn’t a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client’s reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are part of planning rather than implementation.

Answer: B – Recent pelvic surgery

Explanation: The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep vein is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client’s risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease.

Answer: D – Provide the client with normal sleep aids, such as pillows, back rubs, and snacks

Explanation: The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep medication should be avoided whenever possible. At some point, the nurse should do a thorough sleep assessment, especially if common sense interventions fail.

Answer: C – Moist, sterile saline gauze

Explanation: Moist, sterile saline dressings support would heal and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine can irritate epithelial cells, so it shouldn’t be left on an open wound.

Answer: C – Upcoding

Explanation: Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren’t the terms used for this illegal practice.