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Comprehensive Predictor Study
Guide for Nursing Students
Study Guide Comp - Comprehensive Predictor
Comprehensive Predictor Study Guide (Rasmussen
University)
Incision Dehiscence : If a client states "I feel like my incision ripped open" and the nurse notes dehiscence of the incision, the appropriate action is to apply a dry gauze dressing to the incision. Extending the client's legs above heart level or placing the client in low Fowler's position would not be appropriate in this situation.
Radiation Therapy with Sealed Implant : When caring for a client receiving radiation therapy through a sealed implant, the nurse should wear a lead apron when providing care for the client. This protects the nurse from exposure to radiation.
IV Catheter Insertion : When inserting an IV catheter for a client requiring fluid replacement, the nurse should:
Apply a tourniquet 15 cm (6 in) above the insertion site Check for pulsation at the site proximal to the tourniquet Anchor the vein by stretching the skin 2.5 cm (1 in) proximal to the insertion site
Wipe the skin dry before inserting the catheter
Femur Fracture with Buck's Extension Traction : When caring for a client with a femur fracture on bedrest with Buck's extension traction, the nurse should inspect the client's skin under the device every 8 hours.
Partial Laryngectomy with Continuous Enteral Feeding : If a client with a partial laryngectomy receiving continuous enteral feeding at 65 ml/hr through a gastrostomy tube is lying in a supine position, the nurse should intervene immediately. The client's position could compromise the airway.
Protective Isolation for Bone Marrow Transplant : When a client in protective isolation for a bone marrow transplant has a sibling with an upper respiratory infection, the appropriate nursing action is to allow the sibling to visit after donning a sterile gown, mask, and gloves, but prohibit physical contact.
Difficulty Falling Asleep : To help a client who reports difficulty falling asleep at night, the nurse should schedule routine care tasks during
hours when the client is awake. Encouraging ambulation, restricting fluids, or leaving the television on are not appropriate interventions.
Postpartum Breastfeeding Nutrition : When providing discharge teaching to a postpartum client planning to breastfeed, the nurse should recommend the client increase their intake of calcium during lactation.
Auscultation of Aortic Valve Closure : To best hear the closing of the aortic heart valve, the nurse should place the diaphragm of the stethoscope over the second right intercostal space, just to the right of the sternum.
Sterile Field for Wound Irrigation : When creating a sterile field for wound irrigation, the nurse should hold the bottle of sterile solution with the palm over the label while pouring. Setting up the field 7.6 cm below waist level or placing items within 1 cm of the edge are not appropriate actions.
Phototherapy for Newborn : When caring for a newborn receiving phototherapy, the nurse should assess the infant's eyes for corneal irritation every 4 hours.
Hemolytic Reaction during Blood Transfusion : If a client develops a hemolytic reaction during a blood transfusion, the nurse should decrease the infusion rate to 75 ml/hr and place the client in a left lateral position.
Referral for Client with Schizophrenia : For a client with schizophrenia who is having difficulty expressing their feelings, the nurse should make a referral to a mental health counselor or therapist.
Reportable Infections : The nurse should report Lyme disease to the Centers for Disease Control and Prevention, as it is a reportable infection.
Home Hospice Care Teaching : When teaching a client and their family about home hospice care, the nurse should include that hospice care improves quality of life through palliative care and encourages the family to coordinate health care services. Hospice care is not intended to postpone death, and 24-hour in-home care is not always provided.
Confirming NG Tube Placement : Prior to initiating an enteral feeding via an NG tube, the nurse should test the pH level of the client's gastric aspirate to confirm tube placement.
Prioritizing Client Assessments : Based on the shift report information, the nurse should plan to assess the client who had a hip arthroplasty and reports pain and erythema in their calf first, as this may indicate a potential complication.
potential shellfish allergy, as glucosamine is often derived from shellfish.
Chest Tube Management : If a client with a chest tube has continuous bubbling in the water-sealed chamber, the nurse should observe the system for an air leak.
Increased Intracranial Pressure in a Child : When caring for a child who is unresponsive and has increased intracranial pressure, the nurse should place the child in the Trendelenburg position.
Dietary Recommendations for Increased Cholesterol : To help a client with an increased cholesterol level, the nurse should recommend broiled lobster, as it is a low-cholesterol, high-protein food.
Digoxin Teaching : When teaching a client about digoxin, the nurse should include that the client should notify their provider if they experience muscle weakness, as this may indicate a side effect.
Acid-Base Imbalance in COPD with Pneumonia : The nurse should monitor the older client with COPD and pneumonia for respiratory acidosis, as the client's respiratory function is compromised.
Reportable Infections : The nurse should report syphilis to the Centers for Disease Control and Prevention, as it is a reportable infection.
Administering Eye Drops to a Preschooler : When administering eye drops to a preschooler with conjunctivitis, the nurse should apply pressure to the lacrimal punctum for 1 minute following administration to prevent drainage of the medication.
Speech Alterations in Schizophrenia : The client's statement "run cats soon the rain throwing procedure mechanical paper lake" demonstrates word salad, which is a speech alteration seen in schizophrenia.
Anthrax Exposure : If a client is suspected of exposure to anthrax, the nurse should begin prophylactic treatment with ciprofloxacin, as this is the appropriate antibiotic for anthrax exposure.
Anorexia Nervosa Interventions : When creating a plan of care for a client with anorexia nervosa, the nurse should include monitoring the client for 1 hour after meals and weighing the client once per week throughout hospitalization. Encouraging a 2.3 kg weight gain per week or allowing the client to choose mealtimes would not be appropriate interventions.
Gentamicin Toxicity : Lethargy is an indication that the client is developing toxicity from the gentamicin medication.
Referral for Atrial Septal Defect : When discharging a newborn with an atrial septal defect, the nurse should expect the provider to refer the client to a pediatric cardiologist.
Anorexia Nervosa Assessment Findings : When assessing an adolescent with anorexia nervosa, the nurse should expect to find hypokalemia, as this electrolyte imbalance is common in this condition.
Admitting a Client to the Med-Surg Unit : When admitting a client to the med-surg unit, the nurse should first observe the client's level of mobility to determine the appropriate level of care and assistance needed.
Mastitis and Breastfeeding : When a client with mastitis asks if they must stop nursing their baby, the nurse should respond that no, they do not need to stop nursing, but can continue to alternate between the affected and unaffected breast.
Referral for Family Therapy : When a community health nurse receives a request for a referral for family therapy, the appropriate action is to provide the client with a referral to a mental health counselor or therapist who specializes in family therapy.
Referral to Interdisciplinary Team Members
Occupational Therapist
The nurse should initiate a referral to an occupational therapist as part of the interdisciplinary team. Occupational therapists can assist clients with daily living activities and functional independence.
Social Worker
The nurse should initiate a referral to a social worker as part of the interdisciplinary team. Social workers can provide support, counseling, and connect clients with community resources.
Recreation Therapist
The nurse should initiate a referral to a recreation therapist as part of the interdisciplinary team. Recreation therapists can help clients engage in leisure and recreational activities to improve physical, cognitive, and psychosocial well-being.
Paramedical Technologist
The nurse should not initiate a referral to a paramedical technologist as part of the interdisciplinary team. Paramedical technologists are not typically part of the healthcare team for patient care.
Management of Diabetes Mellitus
3-Hour Oral Glucose Tolerance Test
The 3-hour oral glucose tolerance test is not the appropriate lab test to evaluate long-term management of blood glucose levels in clients with diabetes mellitus.
HbA1c
The HbA1c is the appropriate lab test to evaluate long-term management of blood glucose levels in clients with diabetes mellitus.
Urinalysis for Ketones
Urinalysis for ketones is not the appropriate lab test to evaluate long-term management of blood glucose levels in clients with diabetes mellitus.
Dietary Restrictions with Phenelzine
Cheddar Cheese
Cheddar cheese should be avoided while taking phenelzine, as it contains tyramine, which can interact with the medication.
Bananas
Bananas do not need to be avoided while taking phenelzine.
Chicken
Chicken does not need to be avoided while taking phenelzine.
Peanut Butter
Peanut butter does not need to be avoided while taking phenelzine.
Ethical Considerations in Nursing Practice
Battery
Administering an injection against the client's wishes would be considered battery, which is a violation of the client's right to refuse treatment.
Assault
Administering an injection against the client's wishes would not be considered assault, as assault involves the threat of physical harm.
Coercion
Administering an injection against the client's wishes would be considered coercion, which is a violation of the client's autonomy.
Break of Duty
Administering an injection against the client's wishes would be a breach of the nurse's duty to respect the client's right to refuse treatment.
Opioid Withdrawal Findings
Hyperflexia
Hyperflexia is not an expected finding in clients experiencing opioid withdrawal.
Miosis
Miosis (constricted pupils) is an expected finding in clients experiencing opioid withdrawal.
Euphoria
Euphoria is not an expected finding in clients experiencing opioid withdrawal.
Hypothermia
Hypothermia is not an expected finding in clients experiencing opioid withdrawal.
Vision Screening in Infants
The infant's eyes turn toward the light
This is an expected finding when shining a light source into the visual field of a 4-month-old infant during a vision screening.
The infant's head turns away from the light
The infant's head turning away from the light is not an expected finding during a vision screening.
The infant's eyes remain focused toward the floor
The infant's eyes remaining focused toward the floor is not an expected finding during a vision screening.
Place a pillow under the client's knees
Placing a pillow under the client's knees is not an appropriate intervention to reduce the risk of deep vein thrombosis.
Apply venous plexus foot pumps
Applying venous plexus foot pumps is an appropriate intervention to reduce the risk of deep vein thrombosis.
Encourage clients to dangle legs when sitting on the edge
of the bed
Encouraging clients to dangle their legs when sitting on the edge of the bed is an appropriate intervention to reduce the risk of deep vein thrombosis.
Vital Sign Findings Requiring Intervention
Blood pressure 72/45 mm Hg
A blood pressure of 72/45 mm Hg in a newborn would require intervention by the nurse, as it is below the normal range.
Management of Medication-Induced Dystonia
Hydromorphone
Hydromorphone is not the appropriate medication to administer for the management of uncontrolled contractions of the head and neck muscles (dystonia) induced by metoclopramide.
Diphenhydramine
Diphenhydramine is the appropriate medication to administer for the management of uncontrolled contractions of the head and neck muscles (dystonia) induced by metoclopramide.
Benztropine
Benztropine is not mentioned in the provided information.
Prioritizing Nursing Actions in Emergency
Situations
Stabilize the cervical spine
Stabilizing the cervical spine should be the first action the nurse takes when caring for a client following a motor vehicle crash, as this helps prevent further injury.
Findings Indicative of Opioid Intoxication
Constricted pupils, delayed reflexes, and decreased blood
pressure
These findings are potential manifestations of opioid intoxication and should be recognized by the nurse.
Introducing New Foods to Infants
Introduce a new food every 5 to 7 days
The nurse should instruct the guardian to introduce a new food every 3 to 5 days, not every 5 to 7 days, when introducing new foods to a 5-month-old infant.
Reporting Medications Prior to Colonoscopy
Metoprolol
Metoprolol is a priority medication to report to the provider prior to the client's colonoscopy, as it may need to be adjusted or held.
Clopidogrel (Plavix)
Clopidogrel (Plavix) is a priority medication to report to the provider prior to the client's colonoscopy, as it may need to be adjusted or held.
Metformin
Metformin is a priority medication to report to the provider prior to the client's colonoscopy, as it may need to be adjusted or held.
Digoxin
Digoxin is a priority medication to report to the provider prior to the client's colonoscopy, as it may need to be adjusted or held.
Require the client wear a dosimeter badge
Requiring the client to wear a dosimeter badge is an appropriate action for the nurse to take when caring for a client with a newly implanted sealed internal radiation device.
Adverse Effects of Loop Diuretics
Decreased reflexes
Decreased reflexes is not an expected finding indicating an adverse effect of loop diuretics.
Weight gain of 1.4 kg
Weight gain is not an expected finding indicating an adverse effect of loop diuretics, as they typically cause weight loss due to increased urinary output.
Increased urinary output
Increased urinary output is an expected finding indicating an adverse effect of loop diuretics.
Purpose of Z-Track Injection Technique
This technique prevents injury to the sciatic nerve
The purpose of the z-track injection technique is to prevent subcutaneous infiltration, not to prevent injury to the sciatic nerve.
This technique decreased the risk of subcutaneous
infiltration
This statement correctly indicates the purpose of the z-track injection technique, which is to decrease the risk of subcutaneous infiltration.
This technique allows a larger amount of medication to be
injected
The purpose of the z-track injection technique is not to allow a larger amount of medication to be injected.
This technique increases the absorption rate of the drug
The purpose of the z-track injection technique is not to increase the absorption rate of the drug.
Urinary Tract Infection Prevention in
Pregnancy
Decrease intake of citrus foods and beverages
Decreasing intake of citrus foods and beverages is not an appropriate recommendation for preventing urinary tract infections in pregnant women.
Wear nylon underwear
Wearing nylon underwear is not an appropriate recommendation for preventing urinary tract infections in pregnant women.
Increase fluid intake
Increasing fluid intake is an appropriate recommendation for preventing urinary tract infections in pregnant women.
Reporting Laboratory Values in Clients with
Breast Cancer
WBC 3,000/mm
A white blood cell count of 3,000/mm3 is a low value that the nurse should report to the provider, as it may indicate neutropenia, a common side effect of chemotherapy.
Hemoglobin 14 g/dL
A hemoglobin level of 14 g/dL is within the normal range and does not require reporting to the provider.
Proper Enoxaparin Administration Technique
Apply firm pressure to the injection site following
administration
Applying firm pressure to the injection site following administration of enoxaparin is an appropriate action for the nurse to take.
Expel the air bubble from the syringe prior to injection
Expelling the air bubble from the syringe prior to injection is an appropriate action for the nurse to take.
Verifying Prescriptions for Clients with Heart
Failure
Digoxin 0.125 mg PO daily
The nurse should obtain verification of the Digoxin 0.125 mg PO daily prescription from the provider, as it may need to be adjusted in clients with heart failure and low potassium levels.
Strict intake and output
The nurse does not need to obtain verification of the strict intake and output order, as this is a standard nursing intervention for clients with heart failure.
Furosemide 40 mg PO BID
The provided information does not mention a Furosemide prescription, so the nurse does not need to obtain verification of this order.
Correct Medication Documentation
Lorazepam 1.0 IV PRN every 6 hr
This prescription is correctly documented, including the medication name, route, dose, and frequency.
Sucralfate 1 g PO 1 hr ac
This prescription is correctly documented, including the medication name, route, dose, and timing in relation to meals.
Enoxaparin 30 mg SC every 12 hr
This prescription is correctly documented, including the medication name, route, dose, and frequency.
Morphine 4 mg IV stat
This prescription is not correctly documented, as the dose is missing the unit of measurement (mg).
Findings Requiring Intervention for Chest
Tubes
Tidaling with spontaneous respirations
Tidaling (movement of the water seal chamber with respirations) with spontaneous respirations is an expected finding and does not require intervention by the nurse.
Drainage collection chamber is 1/3 full
The drainage collection chamber being 1/3 full does not require intervention by the nurse.
1 cm of water present in the water seal chamber
1 cm of water present in the water seal chamber is an expected finding and does not require intervention by the nurse.
Suction chamber pressure of -20 cm H2O
A suction chamber pressure of -20 cm H2O is an expected finding and does not require intervention by the nurse.
Nursing Actions for Postpartum Uterine Atony
Take vital signs
Taking the client's vital signs is an appropriate first action the nurse should take when assessing a postpartum client with a boggy, high-positioned uterus.
Massage the uterus
Massaging the uterus is the appropriate first action the nurse should take when assessing a postpartum client with a boggy, high-positioned uterus, as this can help promote uterine contraction.
Indicators of Hypervolemia
Serum sodium 138 mEq/L
A serum sodium of 138 mEq/L is within the normal range and does not indicate hypervolemia.
Urine specific gravity 1.
A urine specific gravity of 1.001 is low
Ophthalmoscopic Examination
When performing an ophthalmoscopic examination, the nurse should:
Darken the room and use the right eye to examine the client's right eye, and vice versa.
Radiation Therapy Teaching
When providing teaching to a client with esophageal cancer who is scheduled to start radiation therapy, the nurse should include the following:
Apply a warm compress to the radiated area. Use a washcloth to bathe the treatment area. Wear clothing over the area of radiation.
Advance Directives Understanding
A client demonstrates an understanding of advance directives when they state:
"My health care proxy can make medical decisions for me." "I have the right to refuse treatment."
Ileostomy Discharge Teaching
The nurse can recognize effective teaching when the client states:
"My stoma will drain liquid fluid continuously." "I will change my pouch system every 2 weeks."
Oral Contraceptive Contraindications
A contraindication to the use of combination oral contraceptives is:
Impaired liver function.
Intramuscular Injection Site
The safest site for an intramuscular injection in an adult client is the ventrogluteal.
Biohazardous Medication Spill
If a nurse accidentally punctures an IV bag containing doxorubicin hydrochloride, causing the medication to leak, the nurse must follow the facility's procedures for the safe handling of a biohazardous material spill.
Acetaminophen Lab Values
The lab values that would be monitored for a client taking acetaminophen are AST and ALT.
Atrial Fibrillation
Atrial fibrillation is a condition that can be managed by nurses.
Septic Shock Treatment
The medications used to treat septic shock are crystalloid solution or dobutamine.
Hyperosmolar State
In a hyperosmolar state, the client would not have ketones present.
