108 EXAM 3

The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning's blood work, the nurse notices that the client's potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance?

Metabolic alkalosis

A school nurse is providing health promotion teaching to a group of high school seniors. The nurse should prioritize prevention of what risk factor for traumatic brain injury?

Substance Abuse

The nurse is caring for an 85-year-old client who has been hospitalized for a fractured radius. The client's daughter has accompanied the client to the hospital and asks the nurse what her father can do for his very dry skin, which has become susceptible to cracking and shearing. What is the nurse's best response?

"He should likely take showers rather than baths, if possible."

The community health nurse is performing a home visit to an older client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response?

"Limiting your fluids can create imbalances that can result in confusion. Maybe we need to adjust the timing of your fluids."

The nurse is caring for a client with metastatic bone cancer. The client asks the nurse why he has had to keep getting larger doses of his pain medication, although they do not seem to affect him. What is the nurse's best response?

"Over time you become more tolerant of the drug."

A nurse is caring for an older adult client who has become increasingly frail and unsteady on her feet. During the assessment, the client indicates that she has fallen three times in the month, though she has not yet suffered an injury. The nurse should take action in the knowledge that this client is at a high risk for what health problem?

A hip fracture

The ICU nurse is caring for a client in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the client?

Abdominal compartment syndrome

An occupational health nurse overhears an employee talking to his manager about a 65-year-old coworker. What phenomenon should the nurse identify when hearing the employee state, "He should just retire and make way for some new blood."?

Ageism

An oncology nurse is contributing to the care of a client who has failed to respond appreciably to conventional cancer treatments. As a result, the care team is considering the possible use of biologic response modifiers (BRMs). The nurse should know that these achieve a therapeutic effect by what means?

Altering the immunologic relationship between the tumor and the client

An oncology client has just returned from the postanesthesia care unit after an open hemicolectomy. This client's plan of nursing care should prioritize which of the following?

Assess the client's wound for dehiscence every 4 hours.

An oncology client has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis?

Avoid rubbing or scratching the affected area

A client is receiving care on the oncology unit for breast cancer that has metastasized to her lungs and liver. When addressing the client's pain in the plan of nursing care, the nurse should consider what characteristic of cancer pain?

Cancer pain can be acute or chronic and it typically requires comparatively high doses of pain medications.

The hospice nurse has just admitted a new client to the program. What principle guides hospice care?

Care addresses the needs of the client as well as the needs of the family.

The nurse has just received report on a client who is coming to the unit from the emergency department with a torn meniscus. The nurse reviews the PRN medications and sees that an NSAID (ibuprofen) is prescribed every 6 hours. How should the nurse best implement preventive pain measures?

Check for allergies, use a pain scale to assess the client's pain, and offer the ibuprofen every 6 hours until the client is discharged.

An interdisciplinary team has been working collaboratively to improve the health outcomes of a young adult who suffered a spinal cord injury in a workplace accident. Which member of the rehabilitation team should determine the final outcome of the process?

Client

A client is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the client's care?

Communicate clearly and frequently with the client's family.

The physician has prescribed a peripheral IV to be inserted before the client goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

Consider potential effects on the client's mobility when selecting a site.

An 84-year-old client has returned from the post-anesthetic care unit (PACU) following hip arthroplasty. The client is oriented to name only. The client's family is very upset because, before having surgery, the client had no cognitive deficits. The client is subsequently diagnosed with postoperative delirium. What should the nurse explain to the client's family?

Delirium of this type is treatable and her cognition will return to previous levels.

An 11-year-old boy has been brought to the ED by his teacher, who reports that the boy may be having a "really bad allergic reaction to peanuts" after trading lunches with a peer. The triage nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. What interventions should the nurse prioritize?

Establishing a patent airway and beginning cardiopulmonary resuscitation

The ICU nurse is caring for a client with sepsis whose tissue perfusion is declining. What sign would indicate to the nurse that end-organ damage may be occurring?

Heart and respiratory rates are elevated

A gerontologic nurse practitioner provides primary care for older adults who are living with various forms of cardiovascular disease. This nurse is well aware that heart disease is the leading cause of death in the aged. What is an age-related physiologic change that contributes to this trend?

Heart muscle and arteries lose their elasticity.

One day after a client is admitted to the medical unit, the nurse determines that the client is oliguric. The nurse notifies the acute-care nurse practitioner who prescribes a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve what goal?

Help distinguish reduced renal blood flow from decreased renal function

The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in her lips and fingers. She states that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should the nurse first suspect?

Hypocalcemia

An elderly female client who is bedridden is admitted to the unit because of a pressure ulcer that can no longer be treated in a community setting. During assessment, the nurse finds that the ulcer extends into the muscle and bone. At what stage should the nurse document this ulcer?

IV

The nurse is admitting an oncology client to the unit prior to surgery. The nurse reads in the electronic health record that the client has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem?

Impaired wound healing

An elderly client has come in to the clinic for her twice-yearly physical. The client tells the nurse that she is generally enjoying good health, but that she has been having occasional episodes of constipation over the past 6 months. What intervention should the nurse first suggest?

Increase daily intake of water.

The nurse is providing care for an older adult client whose diagnosis of dementia has recently led to urinary incontinence. When planning this client's care, what intervention should the nurse avoid?

Indwelling catheter

The nurse is performing an admission assessment on an older adult client newly admitted for end-stage liver disease. What principle should guide the nurse's assessment of the client's skin turgor?

Inelastic skin turgor is a normal part of aging.

While assessing a client's peripheral IV site, the nurse observes edema around the insertion site. How should you document this complication related to IV therapy?

Infiltration

An older adult experienced a cerebrovascular disease 6 weeks ago and is currently receiving inpatient rehabilitation. The nurse is coaching the client to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the client performing?

Isometric

The nurse is providing client teaching to a client with early stage Alzheimer disease (AD) and her family. The client has been prescribed donepezil hydrochloride. What should the nurse explain to the client and family about this drug?

It slows the progression of AD.

A client with a diagnosis of prostate cancer is scheduled to have an interstitial implant for high-dose radiation (HDR). What safety measure should the nurse include in this client's plan of care?

Limit the time that visitors spend at the client's bedside.

The nurse is providing care for an 82-year-old man whose signs and symptoms of Parkinson disease have worsened over the past several months. The man states that he can no longer do as many things for himself as he used to be able to. What factor should the nurse recognize as impacting the client's life most significantly?

Loss of independence

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. What goal of this treatment should the nurse identify?

Maintenance of adequate mean arterial pressure

The nurse is caring for a client who has a peripheral IV in place for fluid replacement. When caring for the client's IV site, the nurse should

ensure that the tubing is firmly anchored to the client's skin.

A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following?

Osmosis and osmolality

A client with a diagnosis of gastric cancer has been unable to tolerate oral food and fluid intake and her tumor location rules out the use of enteral feeding. What intervention will best meet this client's nutritional needs?

Parenteral nutrition given via a peripherally inserted central catheter

A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in clients who are being treated for shock. What intervention should be specified in the client's plan of care while the client is ventilated?

Performing frequent oral care

The home health nurse is caring for a homebound client who is terminally ill. You are delivering a patient-controlled analgesia (PCA) pump to the client at your visit today. The family members will be taking care of the client. What would your priority nursing interventions be for this visit?

Provide client and family teaching regarding the operation of the pump, monitoring the IV site, and knowing the side effects of the medication.

An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the client's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the client's risk of septic shock?

Remove invasive devices as soon as they are no longer needed

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?

Respiratory acidosis

A 60-year-old client who has diabetes had a below-knee amputation 1 week ago. The client asks, "Why does it still feel like my leg is attached, and why does it still hurt?" The nurse explains neuropathic pain in terms that are accessible to the client. The nurse should describe what pathophysiologic process?

The abnormal reorganization of the nervous system

The nurse in a pain clinic caring for a client who is suffering from long-term, intractable pain. The pain team feels that first-line pharmacologic and nonpharmacologic methods of pain relief have been ineffective. What recommendation should guide this client's subsequent care?

The client may benefit from referral to a neurologist or neurosurgeon to discuss pain-management options.

The nurse is receiving an older adult client from the PACU. Part of the report had been passed on from the preoperative assessment where it was noted that the client has been agitated in the past following opioid administration. What principle should guide the nurse's management of the client's pain?

The elderly may require lower doses of medication and are easily confused with new medications.

A nurse is planning care for a nephrology client with a new nursing graduate. The nurse states, "A client in kidney disease partially loses the ability to regulate changes in pH." What is the cause of this partial inability?

The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.

A client comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The client fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurse's most likely explanation for the low urine output?

The man is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.

The mother of a client with cancer comes to the nurse concerned with her daughter's safety. She states that the dose of morphine that her daughter requires to control her pain is getting "higher and higher." As a result, the mother is afraid that her daughter will overdose. The nurse should educate the mother about what aspect of her pain management?

There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.

The ICU nurse caring for a client in shock is administering vasoactive medications as per orders. The nurse should administer this medication in what way?

Through a central venous line

The home health nurse is performing a home visit for an oncology client discharged 3 days ago after completing treatment for non-Hodgkin lymphoma. The nurse's assessment should include examination for the signs and symptoms of what complication?

Tumor lysis syndrome (TLS)

The nurse is caring for a female client who developed a pressure ulcer as a result of decreased mobility. The nurse on the previous shift has provided client teaching about pressure ulcers and healing promotion. The nurse determines that the client has understood the teaching by observing the client:

avoid placing her body weight on the healing site.