204 exam 3 review

1 tsp = ? mL

5 mLs

WBC (adult)

5000-10,000cells/mm3

How does the healthcare team know that a patient has an infection with a particular bacteria?

A culture is performed and when a culture and sensitivity is performed, the correct antibiotic can be prescribed

What is the only way that a patient can be told that 100 they have cancer?

A tissue biopsy has been performed and confirmed cancerous lesions

What are items allowed in a full liquid diet?

All types of fruit juices and vegetable juice, milk, sorbet or frozen yogurt, soups without chunks, yogurt, pudding/custard, honey

What are important facts about an NG tube and parenteral nutrition?

Aspiration as possible so be careful! Check for placement with an x-ray initially and whenever in question... If during a feeding the patient shows signs of aspiration... Stop the feed and verify placement (signs are gagging, coughing, anxiety, setting up etc.)

Urinalysis - expected findings

Color: Light yellow to amber Clarity: Clear to slightly hazy Specific gravity: 1.005-1.030 Potential hydrogen (pH): 4.6-8.0 Glucose: Negative Ketones: Negative Red blood cells: ≤2 Protein: 0-8mg/dL Bilirubin: Negative Bacteria: Negative

Creatinine

Creatinine (Female): 0.5-1.1 mg/dL Creatinine (Male): 0.6-1.3 mg/dL

How does the registered nurse plan on caring for a patient who is hearing impaired? Visually impaired?

For hearing impairment make sure patient has hearing aids, the RN faces the patient and speaks in a regular speed, make sure the surrounding area is not too loud with distractions, avoid yelling, and avoid over pronunciation. For visually impaired, make sure glasses are worn if needed, walkways are clear, food is described to the patient like a clock.

What does a nurse do to help a patient who is overstimulated and a patient who is understimulated.

For overstimulated patients decrease stimulation by dimming the lights and the television volume, closing the door of the room, clustering activities so the client has time to rest. For understimulation, turn on the television/music, open the window shades, place the client near the nurses station, provide touch via massage and talk to the patient

HgA1C

G4-5.7% non diabetic: 4-5.6% pre-diabetic: 5.7-6.4% diabetic: >6.5% (goal for diabetics: <7%)

What is the importance of the gag reflex?

It prevents aspiration

What does the nurse note when a patient is showing signs of infection on the road?

Local symptoms include erythema, warm to touch, possible drainage... And systemically chills, fever, general malaise.

Describe what an albumin level tells the healthcare team.

Pre-albumin and albumin help alert the healthcare team of potential undernourishment.

If a patient is paralyzed and has decreased sensation, when moving the patient what does the RN utilize to safely move the patient?

Proper body mechanics, mechanical lift if necessary, blankets and sheets to lift and raise the patient to avoid friction & shear

What will the plan of care be if a patient has sensory deficits in taste and smell?

Recognize that deficit in nutrition is common, provide foods that smell good and that are seasoned nicely. Ensure that the patient has good oral hygiene and frequent dental cleanings

Describe what a CBC provides the healthcare team.

The CBC and essence tells you if there's infection, anemia, and risk for hemorrhage.

What is important to know about a wound drain collection device?

The drainage needs to be measured, it is usually not sutured in place to allow for easy removal, it works off of negative pressure/suction, it should drain gradually

What does it mean when a patient has impaired equilibrium?

The inner ear may have issues causing dizziness, spinning of the room, and loss of balance= fall risk -----> vertigo

What are the components of a food label?

The nutritional facts including the calories, distribution of fats, cholesterol, sodium, carbohydrates, sugars, proteins ,vitamins etc., along with a serving size and the recommended daily allowances.

The nurse is caring for a patient who is sedated following a colonoscopy. Which is the priority action of the nurse? a. Provide a quiet, dark environment so that the patient can rest comfortably. b. Monitor the patient's pulse oximetry and respirations closely. c. Inform the patient that the procedure has been completed. d. Assess the patient's bowel sounds and passage of flatus.

The priority intervention for sedated patients is to monitor pulse oximetry and respirations closely because sedation may suppress the respiratory drive. The nurse should monitor vital signs until the patient is fully awake and observe stools for visible blood. The nurse should also instruct the patient to report any abdominal pain as these assessment findings are alerts for possible perforation of bowel, hypotension, and hemorrhage. Providing a quiet environment is nice for the patient, but dim lighting may impair the nurse's ability to assess the patient. Informing the patient that the procedure has been completed is not a priority. Assessing the patient's bowel sounds and passage of flatus is not as important as careful respiratory monitoring.

What are items allowed in a clear liquid diet?

Water, black coffee, broth/clear soup, apple juice, tea, Pedialyte, sports drinks, cola/sprite

The clinic nurse has provided instructions to a client who will be reporting to the laboratory the next morning to have blood drawn for a complete blood cell count. Which statement made by the client indicates an understanding of the preparation for this laboratory test? a. "There is no special preparation for this test." b. "I cannot eat or drink anything after midnight." c. "I need to avoid any cold cuts and luncheon meats for the rest of the day." d. "I can drink coffee or tea in the morning before the test but cannot eat anything."

a. "There is no special preparation for this test." For most hematological laboratory studies, including complete blood cell count, no special care is needed either before or after the test. There is no reason to fast after midnight or avoid luncheon meats or cold cuts before the laboratory test being drawn.

. The nurse is explaining to a client what electroencephalography (EEG) involves. What response by the client indicates that further teaching is needed? a. "This test is minimally invasive." b. "There is no risk of electric shock." c. "It can help diagnose and treat my seizures." d. "Electrodes are placed on specific areas of my scalp."

a. "This test is minimally invasive." An EEG is noninvasive, not minimally invasive. All of the other options are correct.

The nurse is caring for a patient who has just undergone paracentesis. For which complication will the nurse carefully monitor? a. Collapse of the lung with shortness of breath b. Fecal impaction from retained barium in the colon c. Cerebrospinal fluid leak resulting in severe headache d. Perforation of the bowel resulting in abdominal infection

d. Perforation of the bowel resulting in abdominal infection Paracentesis is drainage of fluid from the abdominal cavity. Since the needle is near the intestines, bowel perforation can occur, manifested by abdominal pain and fever as infection (peritonitis) sets in. Possible complications do not include lung collapse, CSF leak, or impaction.

Hemoglobin (adult)

female: 12-16 gm/dL male: 14-18 gm/dL

Hematocrit (adult)

female: 37-47% male: 42-52%

RBC (adult)

female: 4.2-5.4 x106/μL male: 4.7-6.1 x106/μL

What does the biochemical profile provide the healthcare team?

his lab helps to determine if the kidneys and the liver are functioning properly and if the patient is well nourished

Mobility is...

mobility is the best way to prevent constipation post surgery. anesthesia stops peristalsis. auscultate bowel sounds.

BUN

10-20 mg/dL >>>> Dehydration <<<< Fluid overload

How many mls are there in 200 teapoons

1000 mLs

1 tbs = ? mL

15 mLs

Prealbumin

15-36 mg/dL

Platelets

150,000-400,000 cells/ mm3

What is 9 PM in military time?

2100

1 oz = ? mL

29. 5735 mL.

Albumin

3.5-5 g/dL

Glucose

74-106 mg/dL

A client returns to the nursing unit after undergoing an esophagogastroduodenoscopy (EGD). Which is the appropriate nursing intervention? a. Allow the client to have bathroom privileges. b. Keep the client lying flat in bed in the supine position. C. Withhold oral fluids until the client's gag reflex has returned. d. Tell the client to report a sore throat immediately because it is a serious complication.

C. Withhold oral fluids until the client's gag reflex has returned. In preparation for the passage of the endoscope, an anesthetic is sprayed to inactivate the gag reflex and thus facilitate passage of the tube. It may take 1 to 2 hours for the anesthetic spray to wear off and for the gag reflex to return. The client would remain on bed rest in a semi-Fowler's position until fully alert. A sore throat is expected because of the endoscopic tube.

The nurse is explaining to an older client about a creatinine clearance test that has been prescribed. What response by the client indicates that there is a need for further teaching? a. "This test measures the levels of all of the medications that I take." b. "The doctor has to do tests on my kidneys to see how they are filtering." c. "In older clients, changes in the kidneys lead to less blood flow to the kidneys." d. "With aging, the kidneys don't clear all of my medications, so I can get very ill."

a. "This test measures the levels of all of the medications that I take." A creatinine clearance test does not measure levels of a client's medications but measures the glomerular filtration rate of the kidneys and how effectively the kidneys can eliminate substances. The other options are accurate statements.

The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse reports to the client that the total cholesterol level is within the recommended guidelines if which value is noted on the laboratory report? a. 146 mg/dL (4 mmol/L) b. 224 mg/dL (6 mmol/L) c. 256 mg/dL (7 mmol/L) d. 301 mg/dL (8 mmol/L)

a. 146 mg/dL (4 mmol/L) The client needs to be counseled to keep the total cholesterol level under 200 mg/dL (under 5 cholesterol levels will aid in prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life.

A client with diabetes mellitus reports to the clinic for determination of the glycosylated hemoglobin (HbA1c) level. Which value on this laboratory test indicates client compliance with the prescribed diabetic regimen? a. 6% b. 8% c. 10% d. 15%

a. 6% The HbA1c measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Depending on the primary health care provider preference, the level should be <6% for an adult without diabetes. Elevations in blood glucose will cause elevations in the amount of glycosylation. Elevations indicate a continued need for teaching related to prevention of hyperglycemic episodes.

The nurse instructs a client with diabetes mellitus who takes insulin about blood glucose monitoring and monitoring for signs of hypoglycemia. The nurse would inform the client that a blood glucose level of which value indicates hypoglycemia? a. 60 mg/dL (3.3 mmol/L) b. 90 mg/dL (5.0 mmol/L) c. 110 mg/dL (6.1 mmol/L) d. 120 mg/dL (6.7 mmol/L)

a. 60 mg/dL (3.3 mmol/L) The principal adverse effect of insulin therapy is hypoglycemia, a blood glucose level of 60 mg/dL (3.3 mmol/L) or lower. The remaining options identify values that are in the normal blood glucose range.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's fasting serum glucose level is normal if which value is noted? a. 99 mg/dL (5.5 mmol/L) b. 120 mg/dL (6.9 mmol/L) c. 130 mg/dL (7.4 mmol/L) d. 140 mg/dL (8 mmol/L)

a. 99 mg/dL (5.5 mmol/L) The normal fasting blood glucose is 70 to 99 mg/dL (4 to 5.65 mmol/L) in the adult client. The results in the remaining options indicate elevated fasting serum glucose levels.

The nurse is planning dietary education for the patient. What food labeling considerations should the nurse be aware of when planning that education? (Select all that apply.) a. Ask patient if food labels are read routinely. b. Assess patient's level of understanding of food labels. c. Encourage patient to read the food labels. d. Explain to patient all food labels are different. e. Assess patient's understanding of recommended daily allowance.

a. Ask patient if food labels are read routinely. b. Assess patient's level of understanding of food labels. c. Encourage patient to read the food labels. e. Assess patient's understanding of recommended daily allowance. Evidence indicates a consistent link between eating healthier foods and reading nutrition labels. Patients should be asked if they read food labels when shopping for groceries or food products. Evaluate their understanding of the main elements of a nutrient label (i.e., calories, fats, carbohydrates, sugar, and serving size). Assess patient understanding of the percentages of recommended daily allowances of fats, proteins, and carbohydrates listed on food labels. Uniform nutrition labeling for packaged food was introduced in the United States in 1994, as part of the Nutrition Labeling and Education Act (NLEA), to increase consumer awareness about the nutritional content of food and improve dietary practices; therefore, all labels are the same.

. A clinic nurse is providing instructions to a client regarding the procedure for collecting a midstream (clean-catch) urine specimen. What would the nurse instruct the client to do? a. Begin the flow of urine and then collect the specimen. b. Cleanse the perineum from back to front before collecting the specimen. c. Collect the specimen in the evening before going to bed, and deliver it to the laboratory immediately the next morning. d. Scrub the perineum with povidone-iodine solution in the evening and again in the morning before collecting the specimen.

a. Begin the flow of urine and then collect the specimen. The client would briefly delay collecting the sample until after starting the flow of urine. As part of the correct procedure, the client would cleanse the perineum from front to back with the antiseptic swabs that are packaged with the specimen kit to prevent contamination of the specimen. The specimen needs to be sent to the laboratory as soon as possible and not allowed to stand. Improper specimen handling can yield inaccurate test results. The client is not instructed to scrub the perineum with povidone-iodine solution in the evening and again in the morning before collecting the specimen. This action is unnecessary and can cause irritation.

A postoperative client has been placed on a clear liquid diet. The nurse would provide the client with which items that are allowed to be consumed on this diet? Select all that apply. a. Broth b. Coffee c. Gelatin d. Pudding e. Vegetable juice f. Pureed vegetables

a. Broth b. Coffee c. Gelatin A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet.

A nursing student is caring for a client who has been admitted to the hospital with malnutrition. The nursing instructor determines that the student has made a correct assessment of malnutrition consequences if the student documents which noted findings? Select all that apply. a. Cachexic b. Lethargic c. Lean extremities d. Intolerant to heat e. Dry, flaking skin f. Poor wound healing

a. Cachexic b. Lethargic e. Dry, flaking skin f. Poor wound healing Some common findings of severe malnutrition in adults include the following: lethargy; cachexia; dry, flaking skin; and poor wound healing. Edema, not lean extremities, and intolerance to cold, not heat, are also present.

A child with leukemia is complaining of nausea. The nurse suspects that the nausea is related to the chemotherapy regimen. The nurse, concerned about the child's nutritional status, would offer which item during this episode of nausea? a. Cool, clear liquids b. Low-protein foods c. Low-calorie foods d. The child's favorite foods

a. Cool, clear liquids When the child is nauseated, offering cool, clear liquids is best because they are soothing and better tolerated. Supportive nutritional measures would include oral supplements with high-protein and high-calorie foods. The nurse would not offer favorite foods when the child is nauseated because foods eaten during times of nausea will be associated with being sick.

The nurse is caring for a patient who has a deep leg wound that is badly infected. Which laboratory test results will the nurse expect to find in the patient's chart? a. Elevated C-reactive protein (CRP) 6.5 mg/dL b. Decreased serum creatinine 0.8 mg/dL c. Elevated serum bilirubin 0.5 mg/dL d. Prothrombin time (PT) 11.5 sec

a. Elevated C-reactive protein (CRP) 6.5 mg/dL C-reactive protein (CRP) is produced by the liver in response to inflammation, tissue damage, and infection. Blood levels of CRP have been used as a marker for inflammatory and autoimmune disorders. The nurse would expect to see an elevated CRP in a patient with an infected wound. Creatinine is an indicator of kidney function, and bilirubin is an indicator of liver function. Prothrombin time indicates clotting ability of the blood, particularly when the patient is taking warfarin (Coumadin).

The nurse is educating the patient about the risk of heart disease from metabolic syndrome and describes a cluster of which symptoms? (Select all that apply.) a. Elevated blood glucose b. High waist circumference c. History of smoking d. Hypertension e. Elevation serum cholesterol

a. Elevated blood glucose b. High waist circumference d. Hypertension e. Elevation serum cholesterol Metabolic syndrome is a cluster of medical conditions characterized by insulin resistance and the presence of obesity, abdominal fat, elevated blood glucose, triglycerides, serum cholesterol, and hypertension. Smoking is not part of the syndrome.

The nurse is completing documentation after feeding a patient with aspiration precautions. Which items should the nurse document? (Select all that apply.) a. Episodes of coughing or gagging b. Hesitation or fear of eating c. Amount eaten d. Aspiration protocol used e. Respiratory status

a. Episodes of coughing or gagging b. Hesitation or fear of eating c. Amount eaten d. Aspiration protocol used e. Respiratory status It is important to document thoroughly the patient's experience during the feeding so the other nursing staff will be aware of patient's needs including any episodes of coughing, gagging, or choking; respiratory status; hesitancy or fear of eating; and occurrences of nausea, vomiting, regurgitation, and amount of food eaten.

The nurse has a prescription to obtain a urinalysis specimen from a client with an indwelling urinary catheter. Which actions would the nurse plan to include in performing this procedure? Select all that apply. a. Explaining the procedure to the client b. Clamping the tubing of the drainage bag c. Obtaining the specimen from the urinary drainage bag d. Aspirating a sample from the port on the drainage tubing e. Wiping the port with an alcohol swab before inserting the syringe

a. Explaining the procedure to the client b. Clamping the tubing of the drainage bag d. Aspirating a sample from the port on the drainage tubing e. Wiping the port with an alcohol swab before inserting the syringe A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag, so its properties do not necessarily reflect current client status. In addition, it may become contaminated with bacteria from opening the system. The remaining options are correct interventions for obtaining the specimen.

The nurse is providing dietary education to the patient to assist with inclusion of more complex carbohydrates in the diet. The nurse knows which foods would be beneficial to include? (Select all that apply.) a. Green peas b. Bananas c. Beans d. Potatoes e. Apples

a. Green peas c. Beans d. Potatoes Complex carbohydrates provide the body with vitamins and minerals. Food sources include bread; rice; pasta; legumes such as dried beans, peas, and lentils; and starchy vegetables such as corn, pumpkin, green peas, and potatoes. Bananas and apples are fruits, which are simple carbohydrates.

The nurse is preparing to test a client's blood glucose level with a glucometer. Which steps would facilitate obtaining an accurate result? Select all that apply. a. Hold the finger in a dependent position during the test. b. Use gentle pressure to obtain an adequate amount of blood. c. Obtain the blood specimen by puncturing the central tip of the finger. d. Obtain the blood specimen by puncturing the lateral side of the finger. e. Allow the drop of blood to form without squeezing near the puncture site. f. Clean the site with an antiseptic swab, and then puncture the site immediately.

a. Hold the finger in a dependent position during the test. b. Use gentle pressure to obtain an adequate amount of blood. d. Obtain the blood specimen by puncturing the lateral side of the finger. When obtaining a droplet of blood for a blood glucose monitor, the site needs to be cleaned with an antiseptic swab and then allowed to dry completely. The puncture site would be the lateral side of the finger because the central tip contains more nerves and may be more painful. Holding the finger in a dependent position improves blood flow to the puncture site. Gentle pressure may be needed to obtain an adequate amount of blood for the test strip.

The nurse is teaching a patient about the impact of obesity and a high body mass index (BMI). The nurse identifies that as the BMI increases, so does the risk for which conditions? (Select all that apply.) a. Increase in blood pressure b. Increase in HDL c. Increase in total cholesterol d. Development of atherosclerosis e. Decrease in triglycerides

a. Increase in blood pressure c. Increase in total cholesterol d. Development of atherosclerosis As BMI levels rise, blood pressure and cholesterol levels also rise and the average high-density lipoprotein (HDL), or good, cholesterol levels decrease. Hyperlipidemia (elevation of plasma cholesterol, triglycerides, or both) or low HDL levels contribute to the development of atherosclerosis (the buildup of fat deposits on arterial vessel walls). Obesity contributes to higher triglycerides.

The nurse is caring for a patient who needs to collect a 24-hour urine specimen at home. Which steps of specimen collection may be delegated to the assistant? (Select all that apply.) a. Label the urine container and lab slips with the patient's name and information. b. Assess the patient's ability to collect the specimen as required. c. Explain the procedure to the patient. d. Obtain the urine container from the utility room or laboratory. e. Transport the specimen to the laboratory once it is collected. f. Ensure that the correct test is ordered and collected.

a. Label the urine container and lab slips with the patient's name and information. d. Obtain the urine container from the utility room or laboratory. e. Transport the specimen to the laboratory once it is collected. The assistant may label the container and lab slips, obtain the urine container from the utility room, and transport the specimen to the lab. These are tasks that do not require nursing judgment. Assessment of the patient is always done by the nurse, as well as explaining the procedure to the patient and ensuring that the correct test is performed.

The nurse is caring for a postoperative general surgery foreign-speaking client with a history of poor nutrition. What are some reasonable issues that can impact this client? Select all that apply. a. Longer hospital stays and increased medical costs b. Reduced quality of life and increased mortality rate c. Lack of culturally specific foods related to the client's needs d. Shortage of qualified nutritional staff in the dietary department e. Impaired wound healing and increased risk of postoperative infection f. Impaired functioning of the gastrointestinal (GI) tract, cardiovascular system, respiratory system, and immune system

a. Longer hospital stays and increased medical costs b. Reduced quality of life and increased mortality rate e. Impaired wound healing and increased risk of postoperative infection f. Impaired functioning of the gastrointestinal (GI) tract, cardiovascular system, respiratory system, and immune system Issues that can impact postoperative general surgery clients with a history of poor nutrition are well documented and include the following: impaired wound healing and increased risk of postoperative infection; impaired functioning of the GI tract, cardiovascular system, respiratory system, and immune system; reduced quality of life and increased mortality rate; and longer hospital stay and increased medical costs. Lack of culturally specific foods related to the client's operative needs and shortage of qualified nutritional staff in the dietary department are not reasonable options and not likely to be an issue in the hospital.

The nurse is caring for a patient who is undergoing a liver biopsy. Which interventions will be included in the patient's care plan for the diagnosis of risk for infection: r/t invasive diagnostic procedure? (Select all that apply.) a. Monitor for and report redness, warmth, discharge, or fever promptly to the physician. b. Carefully maintain the sterile field during the biopsy procedure. c. Teach patient how to care for the biopsy site when procedure is completed. d. Provide a supportive, caring presence to minimize patient anxiety. e. Provide information about the pathophysiology and treatment options for liver cancer. f. Consider using healing touch and other mind-body-spirit interventions.

a. Monitor for and report redness, warmth, discharge, or fever promptly to the physician. b. Carefully maintain the sterile field during the biopsy procedure. c. Teach patient how to care for the biopsy site when procedure is completed. Interventions for the Nursing diagnosis of risk for infection involve monitoring for signs and symptoms of infection, preventing contamination of supplies by maintaining a sterile field during the procedure, and teaching the patient how to care for the site afterward. Providing a caring presence, providing information about liver cancer, and using healing touch may be helpful for the patient but will not minimize the risk of infection.

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the primary health care provider (PHCP), and the PHCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. a. Peas b. Nuts c. Cheese d. Cauliflower

a. Peas b. Nuts d. Cauliflower The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the primary health care provider (PHCP), and the PHCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. a. Peas b. Nuts c. Cheese d. Cauliflower e. Processed oat cereals

a. Peas b. Nuts d. Cauliflower The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or labeled as salted). Peas and cauliflower are also a good source of magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content.

The nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30% (0.30). Which action would the nurse take? a. Report the abnormally low level. b. Report the abnormally high level. c. Inform the client that the laboratory result is normal. d. Place the normal report in the client's medical record.

a. Report the abnormally low level. The normal hematocrit level ranges from 37% to 52% (0.37 to 0.52), depending on age. A hematocrit level of 30% (0.30) is a low level and would be reported to the primary health care provider because it indicates blood loss.Therefore, the remaining options are incorrect.

A client with trigeminal neuralgia who is receiving carbamazepine 400 mg orally daily has a white blood cell (WBC) count of 2800 mm3 (2.8 × 109/L), blood urea nitrogen (BUN) of 17 mg/dL (6.12 mmol/L), sodium of 141 mEq/L (141 mmol/L), and uric acid of 5 mg/dL (0.3 mmol/L). On the basis of these laboratory values, the nurse would make which interpretation? a. The WBC count is low, indicating a blood dyscrasia. b. The BUN level is elevated, indicating nephrotoxicity. c. The sodium level is low, indicating an electrolyte imbalance. d. The uric acid level is elevated, indicating the risk for renal calculi.

a. The WBC count is low, indicating a blood dyscrasia. Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia; cardiovascular disturbances; thrombophlebitis; dysrhythmias; and dermatological effects. The normal WBC count is 5000-10,000/mm3 (5-10 × 109/L). Normal sodium is 135-145 mEq/L (135-145 mmol/L), and normal BUN is 10-20 mg/dL (3.6-7.1 mmol/L), Normal uric acid for males is 4.0-8.5 mg/dL (240-501 mcmol/L) and for females is 2.7-7.3 mg/dL (160-430 mcmol/L). Therefore, options 2, 3, and 4 are incorrect.

The nurse is completing a nutrition assessment on a patient. What are some important considerations? (Select all that apply.) a. The nurse should include the patient's cultural influences in the assessment. b. The food diary accuracy is better for a 24-hour recall than a 3 to 5 day food journal. c. The nurse should be nonjudgmental in the nutritional review. d. A consultation with a registered dietitian may be indicated. e. A gathering of anthropometric measurements may be necessary.

a. The nurse should include the patient's cultural influences in the assessment. c. The nurse should be nonjudgmental in the nutritional review. d. A consultation with a registered dietitian may be indicated. e. A gathering of anthropometric measurements may be necessary. When collecting data, the nurse should take into consideration the patient's culture and ethnicity. Recognizing these influences on the patient's nutritional intake allows the nurse to make informed decisions. The data analysis may reveal the need to refer the patient to a registered dietitian for further evaluation of nutritional status. The 24-hour recall is dependent on the ability of the patient to remember consumption of foods and their quantities from the previous day. It is vital to remember that the patient's recall may not be factual and the intake may not be that of a typical day. The other means of assessing a patient's usual dietary pattern is to have the patient keep a written journal of food intake for a certain amount of time. The food diary should encompass entries for 3 to 5 days and includes dietary intake for a typical weekend. Anthropometric measurements may be needed for a full assessment.

The nurse is caring for a patient who is to have a noncontrast MRI scan performed. Which assessment finding leads the nurse to report that the patient may not be able to have the test? a. The patient has an implanted insulin pump. b. The patient is breastfeeding her newborn infant. c. The patient is severely allergic to iodine and latex. d. The patient has profound hearing loss.

a. The patient has an implanted insulin pump. Any metal implants are a contraindication for an MRI scan because the scan uses powerful magnets. Insulin pumps often contain metal that can react with the strong magnets in the MRI machine. Breastfeeding is not a contraindication to MRI because there is no radiation exposure. No latex or iodine is used during MRI testing. Profound hearing loss will not be a problem, although MRI scanning is very loud.

Based on research on aging, the nurse knows that improper nutrition may result in the onset of which specific diseases? (Select all that apply.) a. Type 2 diabetes b. Atherosclerosis c. Osteoporosis d. Rheumatoid arthritis e. Chronic asthma

a. Type 2 diabetes b. Atherosclerosis c. Osteoporosis Improper nutrition may result in the onset of specific diseases of the endocrine, cardiovascular, gastrointestinal, and musculoskeletal systems, such as diabetes type 2, atherosclerosis, diverticulosis, osteoporosis, and some cancers. Rheumatoid arthritis is an inflammatory autoimmune disorder. Asthma is a respiratory disorder not related to poor nutrition.

A stool for culture needs to be obtained from a client suspected of having Clostridium difficile infection. What steps would the nurse plan to implement when obtaining the specimen? Select all that apply. a. Wearing sterile gloves b. Using a sterile container c. Refrigerating the specimen d. Sending the specimen directly to the laboratory e. Positioning the client in a dorsal recumbent position

a. Wearing sterile gloves d. Sending the specimen directly to the laboratory A stool smear specimen is obtained using sterile gloves and a sterile container. After obtaining the specimen, the stool is sent immediately to the laboratory. Storing a stool specimen for culture in a refrigerator is contraindicated because it can retard the growth of organisms. The client needs to be positioned in a lateral recumbent position to obtain the sample.

The nurse preceptor and the orientee note that the reticulocyte count for a client is increased. The preceptor determines that the orientee understands the significance of reticulocytes if the orientee makes which statement with regard to red blood cells (RBCs)? a. "A reticulocyte is a mature RBC." b. "A reticulocyte is an immature RBC." c. "A reticulocyte is decreased whenever there is accelerated production of RBCs." d. "A reticulocyte is increased when the bone marrow has slowed production of RBCs."

b. "A reticulocyte is an immature RBC." The reticulocyte is an immature RBC. The reticulocyte count is increased any time there is an accelerated production of RBCs. It is decreased when the bone marrow has slowed production of RBCs.

The nurse is teaching a client who is preparing for discharge from the hospital after having a stroke about the prevention of pressure injuries while the client has limited mobility. Which statement by the client indicates the need for further teaching? a. "I will inspect my skin daily." b. "I can sit in my favorite chair all day." c. "I need to drink at least 2 liters of fluid daily." d. "I will make sure that my skin is clean and well moisturized."

b. "I can sit in my favorite chair all day." Sitting in one position all day can be a risk factor for pressure injury development. Options 1, 3, and 4 are preventative measures for pressure injury development.

The nurse is caring for a client with a diagnosis of celiac disease. The nurse recognizes that client teaching has been effective when the client makes which statement? a. "I can eat whatever I want." b. "I will eat rice cereal for breakfast." c. "I will eat beef barley soup for lunch." d. "I will eat only wheat bread for a snack."

b. "I will eat rice cereal for breakfast." A client with celiac disease would be instructed to avoid gluten-containing products such as wheat, barley, oats, and rye.

The primary health care provider (PHCP) tells a client that a blood transfusion is needed and that a blood sample must be drawn first for blood typing and crossmatching. The nurse explains to the client what a typing and crossmatch test is for and why it is done. What response by the client about blood typing implies to the nurse that further teaching is needed? a. "It is an antigen found on the surface of the red blood cell." b. "It is an antibody found on the surface of the red blood cell." c. "An acute transfusion reaction can happen if I get blood incompatible with mine." d. "If I have group AB blood, I'm a universal recipient because I have no antibodies to react to the transfused blood."

b. "It is an antibody found on the surface of the red blood cell." The major blood types are A, B, AB, and O. The blood type indicates an antigen, not an antibody, found on the surface of the red blood cell. The other responses are accurate statements.

The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education? a. "The wound will be red." b. "The wound will have pus." c. "The wound will be warm." d. "The wound will need to be treated

b. "The wound will have pus." An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of at least 105/g of tissue sampled when cultured. The wound will need to be treated for the infection.

The nurse just completed an assessment and reviewed the laboratory test results for an adult adult client client seen in the clinic. The client complains of being tired. The nurse determines that the hemoglobin level is normal if which value is noted on the laboratory report? a. 8 g/dL (80 mmol/L) b. 14 g/dL (140 mmol/L) c. 22 g/dL (220 mmol/L) d. 32 g/dL (320 mmol/L)

b. 14 g/dL (140 mmol/L) The normal hemoglobin level for an adult ranges from 12 to 16 g/dL (120 to 160 mmol/L). A hemoglobin level of 8 g/dL (80 mmol/L) is low, while 22 and 32 g/dL (220 and 320 mmol/L) are extremely elevated.

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? a. 3 mg/dL (1.05 mmol/L) b. 15 mg/dL (5.25 mmol/L) c. 29 mg/dL (10.15 mmol/L) d. 35 mg/dL (12.25 mmol/L)

b. 15 mg/dL (5.25 mmol/L) The normal BUN level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Values of 29 mg/dL (10.15 mmol/L) and 35 mg/dL (12.25 mmol/L) reflect continued dehydration. A value of 3 mg/dL (1.05 mmol/L) reflects a lower than normal value, which may occur with fluid volume overload, among other conditions.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the blood urea nitrogen (BUN) level is normal if which value is noted on the laboratory report? a. 4 mg/dL (1.4 mmol/L) b. 20 mg/dL (7.1 mmol/L) c. 30 mg/dL (10.7 mmol/L) d. 39 mg/dL (14.0 mmol/L)

b. 20 mg/dL (7.1 mmol/L) The normal BUN level ranges from 10 to 20 mg/dL (3.6 to 7.1 mmol/L). A BUN of 30 or 39 mg/dL (10.7 or 14.0 mmol/L) reflects an elevated value, while 4 mg/dL (1.4 mmol/L) reflects a lower than normal value.

The nurse is reviewing the laboratory test results for an adult client who is being treated for anemia. The nurse determines that the hematocrit level is normal if which value is noted on the laboratory report? a. 58% (0.58) b. 50% (0.50) c. 40% (0.40) d. 32% (0.32)

b. 50% (0.50) The normal hematocrit level for an adult ranges from 37% to 52% (0.37 to 0.52 volume fraction). A hematocrit of 58% (0.58) is a high level, whereas 40% and 32% are low hematocrit levels.

The ambulatory care nurse is providing instructions to a client who is scheduled for a colonoscopy and possible removal of a polyp. Which instructions are appropriate for client preparation for this procedure? a. Clear liquids may be consumed starting 24 hours after the procedure. b. A bowel preparation will be needed in preparation for the procedure. c. Clear liquids only are allowed on the day of the scheduled procedure. d. If blood-tinged stools are noted after the procedure, the primary health care provider needs to be notified.

b. A bowel preparation will be needed in preparation for the procedure. The client needs to be instructed that bowel preparation with a laxative is prescribed before the procedure to cleanse the bowel. Oral intake is allowed after the procedure once the client is stable. A clear liquid diet is permitted on the day before the procedure (per primary health care provider preference), and then oral intake is avoided for 8 hours immediately before the procedure. If a polyp has been removed, the client is instructed that the stool may be tinged with blood. However, any signs of tenderness, abdominal pain, or bloody stools need to be reported to the primary health care provider.

The nurse is creating a plan of care for a client receiving enteral feedings via a gastrostomy tube (G-tube). The nurse would plan to include which intervention in the plan of care? a. Provide oral fluids 3 times per day. b. Check around the stoma site for skin irritation. c. Medicate with antidiarrheal medications every day. d. Use sterile technique when administering the tube feedings.

b. Check around the stoma site for skin irritation. A G-tube is a tube inserted directly into the stomach for the purpose of providing direct enteral nutrition. Generally, G-tubes are well tolerated and beneficial to clients on long-term enteral nutrition. Aspiration of stomach contents into the lungs can occur, and the client's head of the bed must be kept elevated. Because of the surgical incision, occasionally gastric contents leak out onto the client's skin. Gastric contents are highly acidic and can cause skin irritation. The skin irritation may lead to infection. The nurse must monitor the insertion site for skin irritation. Oral fluids are not generally a component of the plan of care because the client with a G-tube normally does not have the capability of swallowing. Although diarrhea may be a complication of the feedings, antidiarrheals are not administered daily. Aseptic, not sterile, technique is necessary when administering feedings.

The nurse is assessing a client with chronic obstructive pulmonary disease. With a finger sensor, the nurse measures the client's oxygen saturation with a pulse oximeter machine and obtains a reading of 78% while the client is on oxygen via nasal cannula at 2 L/min. The client is showing no signs of restlessness or dyspnea. What is the first nursing action? a. Increase the client's oxygen to 4 L/min. b. Check the finger sensor's position and repeat the test. c. Notify the client's primary health care provider (PHCP) about the low reading. d. Check the client's chart to find out what the previous readings have been.

b. Check the finger sensor's position and repeat the test. Note that the low reading does not match the client's signs and symptoms. The first action by the nurse is to ensure that the test was done properly and the reading is accurate. The nurse would not increase the oxygen without a PHCP's prescription. The results of the test would be verified before any other actions are taken, and this can be done quickly.

. The nurse working in a same-day procedure unit is admitting a client scheduled for an arthrogram using a contrast medium. Which is the priority nursing assessment for this client? a. Determine if the client understands the procedure. b. Determine if the client has an allergy to iodine or shellfish. c. Determine if the client wishes to void before the procedure. d. Determine if the client is able to remain still during the procedure.

b. Determine if the client has an allergy to iodine or shellfish. Because of the risk of allergy to contrast medium, the nurse places highest priority on identifying an allergy to iodine or shellfish because allergic reaction as severe as anaphylaxis could occur. The nurse also would assess knowledge of the procedure, whether the client needs to void beforehand, and the ability to remain still during the procedure. Although all of these assessments may be made, the one with the highest priority is prevention of an allergic reaction through complete assessment.

The nurse has a prescription to get a client who is paraplegic out of bed and into a chair. The nurse determines which item would be best to put in the chair under the client? a. Pillow b. Foam pad c. Folded blankets d. Plastic-lined absorbent pad

b. Foam pad The client who cannot shift weight unassisted would have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for this purpose are those that have a tendency to equalize the client's weight on the pad. These include foam, water, gel, and alternating air products. A pillow provides cushion but does not distribute weight equally. A plastic-lined pad and folded blankets provide no pressure relief.

A client with exacerbation of heart failure is being prepared for a thoracentesis. The nurse would assist the client to which position for the procedure? a. Lying in bed on the affected side b. Lying in bed on the unaffected side c. Left lateral recumbent position with the head of the bed flat d. Prone with the head turned to the side and supported by a pillow

b. Lying in bed on the unaffected side To facilitate removal of fluid from the chest, the client is positioned sitting at the edge of the bed leaning over the bedside table, with the feet supported on a stool; or lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. The prone and left lateral recumbent positions are inappropriate positions for this procedure.

The evening shift nurse is reviewing the laboratory results of a client's urine culture showing 100,000 bacterial units/mL of urine. What would be the nurse's action? a. No action is needed because this is a normal value. b. Page the primary health care provider (PHCP) with the results. c. Collect another urine specimen to confirm the results. d. Notify the PHCP during rounds in the morning.

b. Page the primary health care provider (PHCP) with the results. The PHCP needs to be notified. A colony count of 100,000 is considered a positive culture and could be indicative of pyelonephritis if accompanied by fever and flank pain. A positive culture that is accompanied by dysuria, frequency, and urgency is indicative of cystitis. The other options are incorrect and delay necessary intervention.

When the nurse is caring for a patient receiving enteral feedings, which tasks can that nurse delegate to the UAP? (Select all that apply.) a. Verify tube placement b. Perform oral care c. Administer tube feeding d. Obtain vital signs and report results e. Measure oxygen saturation

b. Perform oral care c. Administer tube feeding d. Obtain vital signs and report results e. Measure oxygen saturation Administering an enteral feeding may be delegated, at the nurse's discretion, to UAP in accordance with state regulations and facility policies and procedures. The nurse should verify tube placement and assess the patient prior to delegating this procedure. The UAP can perform oral care and obtain vital signs, including oxygen saturation, and report results.

The nurse is reviewing the laboratory test results for a client who takes 325 mg of acetylsalicylic acid, or aspirin, daily and has been having frequent nosebleed episodes. What blood level would the nurse review? a. Hemoglobin (Hgb) b. Prothrombin time (PT) c. Red blood cell (RBC) level d. Partial thromboplastin time (PTT)

b. Prothrombin time (PT) PT is used to evaluate the adequacy of the extrinsic system and common pathway in the clotting mechanism. When clotting factors exist in deficient quantities, the PT is prolonged. Many diseases and medications such as salicylates are associated with decreased PTs. PT is also used to monitor the adequacy of warfarin therapy. The Hgb level is related to oxygen and carbon dioxide transport. Hgb concentration serves as the oxygen-carrying capacity of the blood and also acts as an important acid-base buffer system. The RBC level is helpful in identifying the cause of anemia and the presence of other diseases. The PTT is used to evaluate the intrinsic system and the common pathway of clot formation and is most commonly used to monitor heparin therapy.

The nurse has delegated the feeding of a patient who has recently had a stroke to the UAP. Which procedure that the UAP performs would demonstrate a need for further education? a. Uses thickened liquids. b. Puts the bed at 25 degrees. c. Encourages slow eating. d. Has the patient alternate between food and sips of fluid.

b. Puts the bed at 25 degrees. During feeding, the head of the bed needs to be elevated at 30 to 45 degrees or higher. Liquids are thickened, and patients are encouraged to use slow-eating habits and to alternate between bites of food and sips of fluids to facilitate swallowing.

The nurse prepares to provide instructions to a client with a low potassium level about the foods that are high in potassium and plans to tell the client to consume which foods? Select all that apply. a. Peas b. Raisins c. Potatoes d. Cantaloupe e. Cauliflower f. Strawberries

b. Raisins c. Potatoes d. Cantaloupe f. Strawberries The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.

A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. Which priority action would the nurse include in the client's plan of care to ensure safety? a. Shave the groin for insertion of a femoral catheter. b. Remove all metal-containing objects from the client. c. Inform the client to remain motionless throughout the procedure. D. Instruct the client in inhalation techniques for the administration of the radioisotope.

b. Remove all metal-containing objects from the client. In MRI, radiofrequency pulses in a magnetic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, and watches, need to be removed. In addition, a history needs be taken to ascertain whether the client has any internal metallic devices such as orthopedic hardware, pacemakers, or shrapnel. Insertion of a femoral catheter is not part of the procedure. The client needs to be motionless throughout the procedure for quality of the scan, but this action is not related to a safety issue and therefore is not the priority. A radioisotope may be prescribed with positron emission tomography.

The nurse is caring for a client with a peptic ulcer who has just undergone an esophagogastroduodenoscopy (EGD). Which client problem would be the priority? a. Risk for dehydration caused by bleeding in the gastrointestinal tract b. Risk for choking and aspiration related to a poor gag reflex postprocedure c. Lack of knowledge of postprocedure care related to not having had an EGD before d. Sore throat related to passage of the endoscope through the pharyngeal region during EGD

b. Risk for choking and aspiration related to a poor gag reflex postprocedure EGD is a visual inspection of the esophagus, stomach, and duodenum using a fiber-optic endoscope. All the client problems listed as options are potentially appropriate for a client who just had an EGD. After the procedure, the client is recovering from the use of conscious sedation and the administration of a local anesthetic to the throat. Therefore, the client problem in option 2 is most important at this point because of the potential for airway problems.

The nurse is preparing to insert a nasogastric (NG) tube in a patient. Which step in the process indicates a need for further education? a. The nurse lubricates 4 inches of the tube prior to insertion. b. The nurse marks the length of the tube with a marker for insertion. c. The nurse measures the length of tube needed using the nose-earlobe-xiphoid process. d. The nurse applies clean gloves for the procedure.

b. The nurse marks the length of the tube with a marker for insertion. Document the length of the tube to be used if the tube has a preprinted measurement scale. For any tube (with or without a preprinted scale), mark the measurement on the tube using a small piece of tape to ensure proper placement of the tube; fold the ends of the tape for easy removal. Do not use a permanent marker to mark the tube at this point of the procedure. When placement of the tube is confirmed as correct, then remove the measurement marking tape, mark the exit location on the tube with permanent marker, and proceed with the ordered treatment. Lubricate 4 inches of the tube tip with a water-soluble lubricant. For an NG tube, measure the length of tube needed for the patient by placing the tip of the tube at the tip of the patient's nose and extending it to the patient's earlobe and then to the patient's xiphoid process. Clean gloves are used.

The nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. The nurse plans to implement which intervention to obtain the specimen? a. Ask the client to obtain the specimen after breakfast. b. Use a sterile plastic container for obtaining the specimen. c. Provide tissues for expectoration and obtaining the specimen. d. Ask the client to expectorate a small amount of sputum into the emesis basin.

b. Use a sterile plastic container for obtaining the specimen. Sputum specimens for culture and sensitivity testing need to be obtained using sterile technique because the test is done to determine the presence of organisms. If the procedure for obtaining the specimen is not sterile, the specimen will be contaminated, and the results of the test will be invalid. A first-morning specimen is preferred because it contains overnight secretions from the tracheobronchial tree.

The nurse is providing information to a client about a computed tomography (CT) scan of the head. Which statement would the nurse include when reviewing preparation for the CT with the client? a. "You will need to stand up straight for the entire procedure." b. "All scans require the injection of dye before the procedure." c. "Each set of head scans takes less than 5 minutes to perform." d. "You will need to remain on bed rest for 12 hours after the scan."

c. "Each set of head scans takes less than 5 minutes to perform." For a CT scan of the head, the client lies on a movable table in a head-holding device. Each set of head scans takes less than 5 minutes to perform. An iodinated contrast medium may or may not be used. No special aftercare is indicated, so the client may resume the usual diet and activity afterward.

The nurse is educating a patient about a renal diet. Which statement by the patient indicates a need for further education? a. "I need to eat a low-sodium diet." b. "I can have limited amounts of meat." c. "I can drink unlimited cola if it is diet." d. "I should avoid or limit bananas."

c. "I can drink unlimited cola if it is diet." Renal diets restrict potassium, sodium, protein, and phosphorous intake. Fresh fruits (except bananas) and vegetables are excellent dietary choices for individuals on a renal diet. Meats, processed foods, peanut butter, cheese, nuts, caramels, ice cream, and colas are typically allowed in limited quantities or contraindicated.

The nurse is explaining to the UAP that the patient is on a full-liquid diet. Which statement by the UAP indicates a need for reorientation? a. "I can give the patient orange juice." b. "I can give the patient yogurt." c. "I can give the patient oatmeal." d. "I can give the patient milk."

c. "I can give the patient oatmeal." Full-liquid diets consist of foods that are or may become liquid at room or body temperature. Full-liquid diets include juices with and without pulp, milk and milk products, yogurt, strained cream soups, and liquid dietary supplements. Oatmeal is not considered part of a full-liquid diet.

The nurse is providing education to an older adult around a healthy diet to support the challenges related to aging. Which statement indicates a need for further education? a. "I should choose foods that are nutrient dense." b. "High-fiber foods minimize the risk of constipation." c. "I should eat more calories to avoid malnutrition." d. "I can add spices to enhance the taste of food."

c. "I should eat more calories to avoid malnutrition." Calorie needs change with aging because of more body fat and less lean muscle. Less activity further decreases calorie requirements. Eating whole-grain foods and a variety of fruits and vegetables and drinking water may minimize the risk of constipation. The challenge for older adults is to choose foods that are nutrient dense; these foods are high in nutrients in relation to their calories. Older adults may experience a decreased sense of smell or taste, so the addition of spices and herbs may enhance the taste of foods.

A client is being scheduled for a positron emission tomography (PET) scan of the brain. The nurse would provide which explanation to the client? A. "The test uses magnetic fields to produce images." b. "The test provides cross-sectional views of the brain." c. "The test detects abnormal glucose metabolism in the brain." d. "The test views bones of the skull, nasal sinuses, and vertebrae."

c. "The test detects abnormal glucose metabolism in the brain." The PET scan can detect abnormal brain tissue metabolism. A radionuclide is attached to a glucose component and is injected as an intravenous bolus. The computer records the chemical activity in the brain following injection. Options 1, 2, and 4 describe magnetic resonance imaging (MRI), computed tomography (CT), and radiography, respectively.

The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse determines that the urine specific gravity is normal if which value is noted on the laboratory results? a. 1.001 b. 1.003 c. 1.019 d. 1.036

c. 1.019 The normal range for urine specific gravity is between 1.005 and 1.030. Values of 1.001 and 1.003 represent low values, and 1.036 reflects an elevated value.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's platelet level is normal if which value is noted? a. 70,000 mm3 (70 × 109/L) b. 110,000 mm3 (110 × 109/L) c. 160,000 mm3 (160 × 109/L) d. 500,000 mm3 (500 × 109/L)

c. 160,000 mm3 (160 × 109/L) A normal platelet count ranges from 150,000 to 400,000 mm3 (150 to 400 × 109/L). Values of 70,000 and 110,000 mm3 (70 and 110 × 109/L) identify decreased values. A value of 500,000 mm3 (500 × 109/L) is an elevated value.

The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse determines that the white blood cell (WBC) count is normal if which value is noted on the laboratory report? a. 2000 mm3 (2 × 109/L) b. 3600 mm3 (3.6 × 109/L) c. 8600 mm3 (8.6 × 109/L) d. 13,500 mm3 (13.5 × 109/L)

c. 8600 mm3 (8.6 × 109/L) The normal WBC count ranges from 5000 to 10,000 mm3 (5 to 10 × 109/L). Values of 2000 mm3 (2 × 109/L) and 3600 mm3 (3.6 × 109/L) indicate low values, while 13,500 mm3 (13.5 × 109/L) indicates an elevated value.

The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions the client that which could cause a false-negative result? a. Iodine b. Colchicine c. Ascorbic acid d. Acetylsalicylic acid

c. Ascorbic acid Ascorbic acid can interfere with results of occult blood testing, yielding a false-negative result. Colchicine and iodine can cause false-positive results. Acetylsalicylic acid would have no effect or could cause a positive result by inducing bleeding from the gastrointestinal tract.

A computed tomography scan of the chest with contrast is scheduled to be performed in a client suspected of having a pulmonary embolism. In planning the preprocedure care for this client, which nursing action is necessary? a. Encourage intake of fluids. b. Shave the anticipated entry site. c. Ask the client about allergies and previous reactions. d. Contact the operating room regarding the need for the procedure.

c. Ask the client about allergies and previous reactions. A computed tomography scan is not performed in the operating room; therefore, it is not necessary that the nurse contact this department. There is no surgical entry site; therefore, shaving is unnecessary. The procedure is explained to the client, who also is asked about allergies to shellfish or contrast media. Oral ingestion except for sips of water is avoided for 4 to 6 hours before the test.

The nurse has a prescription to collect a 24-hour urine specimen from a client. The nurse is demonstrating correct procedure when which technique is performed? a. Ask the client to void, save the specimen, and note the start time. b. Place the specimen in various containers as necessary for the test. c. Ask the client to save a sample voided at the end of the collection time. D. Remove urine from the collection container for other prescribed specimens.

c. Ask the client to save a sample voided at the end of the collection time. Because the 24-hour urine test is a timed quantitative determination, the test must be started with an empty bladder; therefore, the first urine is discarded. Fifteen minutes before the end of the collection time, the client would be asked to void, and this specimen is added to the collection. The urine sample needs to be placed in the appropriate container and may be refrigerated or placed on ice to prevent changes in the urine. Because this is a quantitative determination of constituents in the urine, no urine would be removed from the container.

The nurse is creating a plan of care for a client receiving enteral feedings. Which client problem is the highest priority? a. Diarrhea b. Nutrition c. Aspiration d. Deficient fluid volume

c. Aspiration Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places the client at risk for aspiration. Diarrhea and nutrition may be appropriate problems, but they are not of highest priority. Deficient fluid volume is not likely to occur in this client.

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because they have been "bored" with the clear liquid diet. The nurse would prepare to offer which full liquid item to the client? a. Tea b. Gelatin c. Custard d. Ice pop

c. Custard Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, refined cooked cereals, and strained vegetable juices. A clear liquid diet consists of foods that are relatively transparent. The food items in the incorrect options are clear liquids.

The nurse is developing a plan of care for a client who has undergone an esophagogastroduodenoscopy procedure. The nurse would include which intervention in the nursing care plan? a. Monitor the client's vital signs every hour for 4 hours. b. Place the client in a prone position to provide comfort. c. Ensure that a gag reflex is present before allowing the client any oral intake. d. Provide saline gargles immediately on the client's return to the nursing unit to aid in comfort.

c. Ensure that a gag reflex is present before allowing the client any oral intake. After esophagogastroduodenoscopy (EGD), the vital signs are checked frequently, usually every 30 minutes, until sedation wears off. The nurse places the client in a semi-Fowler's to Fowler's position to aid in comfort and prevent aspiration. The client remains on NPO (nothing by mouth) status until the gag reflex returns (usually in 2 to 4 hours). The nurse can check the gag reflex by using a tongue depressor to stroke the back of client's throat. Saline gargles would not be allowed until the gag reflex returns.

When the nurse is caring for a patient who is receiving total parenteral nutrition (TPN), the nurse will change the tubing at which interval? a. Every 72 hours b. Every 48 hours c. Every 24 hours d. Every 12 hours

c. Every 24 hours Tubing should be changed every 24 hours, with aseptic technique used to minimize the risk of contamination, and the dressing over the site should be changed every 48 hours, with assessment for signs and symptoms of infection (redness, swelling, or drainage).

When caring for an adolescent patient with anorexia nervosa, the nurse knows what would be the best treatment option for this patient? a. Hospitalization with skill nursing care b. Compulsory tube feedings c. Individually determined by a collaborative team d. Outpatient treatment

c. Individually determined by a collaborative team Ultimately, the decision on how best to ethically treat an adolescent suffering from an eating disorder needs to be one of collaboration among the child's physician, nurse, counselor, spiritual adviser, parents, and other concerned adults. Highly skilled nursing care with hospitalization is preferred prior to a drop in BMI levels below 13 kg/m2. Compulsory tube feedings are not always the best option. Although most adolescents with eating disorders can be treated on an outpatient basis, those who exhibit severe depression, extreme physical complications resulting from electrolyte imbalances, or suicidal tendencies may require extensive inpatient treatment.

The client with lung cancer and a right-sided pleural effusion seen on chest x-ray is being prepared for a thoracentesis. The nurse would assist the client to which position for the procedure? a. Supine position, with the head of the bed flat b. Prone, with the head turned to the side supported by a pillow c. Left side-lying position, with the head of the bed elevated 45 degrees d. Right side-lying position, with the head of the bed elevated 45 degrees

c. Left side-lying position, with the head of the bed elevated 45 degrees To facilitate removal of fluid from the pleural space, two positions may be used. The client may be positioned sitting on the edge of the bed, leaning over the bedside table, with the feet supported on a stool. The other position is lying in bed on the unaffected side, with the head of the bed elevated 45 degrees (Fowler's position). The other options are incorrect because they do not facilitate drainage of fluid to an area easily removed with thoracentesis.

The nurse is providing instructions to the client with lung cancer scheduled for magnetic resonance imaging who is suspected of brain metastasis. Which instruction would the nurse provide to the client? a. Injection of a dye is necessary. b. Food and fluids are restricted for 12 to 24 hours before the test. c. Lying still in a flat position for 45 to 60 minutes may be necessary. d. The test may cause some pain, and pain medication will be prescribed if pain occurs.

c. Lying still in a flat position for 45 to 60 minutes may be necessary. The client will need to lie in a flat position for 45 to 60 minutes. The client is informed that magnetic resonance imaging (MRI) is a painless test and that a contrast dye may or may not be used. Additionally, no dietary restrictions are necessary with MRI. The nurse informs the client that the MRI may damage items such as credit cards and watches and that jewelry and hair clips cause artifacts. These objects need to be removed from the client before the test.

The nurse receives a telephone laboratory report indicating that a client with diabetes mellitus has a glycosylated hemoglobin (HgbA1c) level of 7.6%. In which priority area would the nurse plan to provide diabetic teaching? a. Avoidance of infection b. Rotation of insulin injection sites c. Measures to prevent hyperglycemia d. Avoidance of hypoglycemic episodes

c. Measures to prevent hyperglycemia The normal level for HgbA1c is <6% in an adult without diabetes. Regardless, a level of 7.6% is elevated. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation, helping to detect otherwise unknown episodes of hyperglycemia. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes because the results are reflective of the blood glucose levels over the preceding 2- to 3-month period.

The nurse is assisting the primary health care provider during a colonoscopy procedure. The nurse helps the client to assume which best position for the procedure? a. Supine b. Lithotomy c. Modified left lateral d. Modified right lateral

c. Modified left lateral The client is placed in the modified left lateral position for the procedure. This position uses the client's anatomy to the best advantage for introducing the colonoscope. The modified left lateral position would also be used for giving the client an enema while lying down. Therefore, options 1, 2, and 4 are incorrect.

The nurse recognizes which outcome statement to be appropriate for the nursing diagnosis Impaired swallowing? a. Patient will consume 50% of each meal. b. Patient will gain 2 lb a week. c. Patient will not show any signs of aspiration during meals. d. Patient will demonstrate using an assistive device to feed self.

c. Patient will not show any signs of aspiration during meals. An appropriate goal statement for impaired swallowing is that the patient will not exhibit any signs or symptoms of aspiration during this hospitalization (e.g., lungs clear, respiratory rate within normal range for patient). Consuming 50% of meals and gaining weight are appropriate goals for Impaired nutritional intake. Using assistive devices is an appropriate goal for Impaired self-feeding.

The nurse knows that initial verification of a nasogastric placement is important. Which method is considered the only reliable method to determine enteral tube placement? a. Auscultation of air bolus b. Measurement of pH of the aspirate c. Radiographic image d. Aspirate contents to visually inspect appearance

c. Radiographic image Studies support the use of radiographic confirmation as the only reliable method to date of confirming enteral tube placement. Using only pH and the appearance of aspirate from the newly inserted tube is not a safe method of verifying proper gastric tube placement, especially in patients receiving antacid medications. Auscultation of an air bolus to assess tube placement is no longer recognized as a reliable source in determining gastric tube placement.

The nurse is attempting to open an occluded PEG tube. Which intervention by the nurse requires re-education? a. Flushes the tube with a small amount of air. b. Flushes the tube using a 50- to 60-mL syringe and warm water. c. Reinserts the stylet to break up the clot. d. Flushes the tube with a special enzyme solution.

c. Reinserts the stylet to break up the clot. Once the stylet is removed, it is never reinserted because it can puncture the intestine. If the tube becomes occluded, flush it with a small amount of air. If this is unsuccessful in removing the occlusion, flush the tube using a 30 to 60 mL syringe and warm water. If flushing the tube with water is ineffective, research now suggests using special enzyme solutions or declogging devices rather than carbonated beverages or juices.

The nurse is preparing to instruct a client with hypertension on the importance of choosing foods low in sodium. The nurse would plan to teach the client to limit intake of which food? a. Apples b. Bananas c. Smoked salami d. Steamed vegetables

c. Smoked salami Smoked foods are high in sodium, which is noted in the correct option. The remaining options are fruits and vegetables, which are low in sodium.

The nurse is consulting with a dietitian to plan a menu for a client who is on a regular diet and is a vegan. Which food item would the nurse and the dietitian select for the client's meal? a. Scrambled eggs b. Buttered wheat toast c. Stir-fried vegetables d. Chocolate milkshake

c. Stir-fried vegetables Vegans exclude animal products from the diet. Stir-fried vegetables are eaten by vegans (as long as they are not fried in butter). Vegans do not eat eggs. Buttered wheat toast also is not acceptable because butter is a dairy product. Milkshakes are not an appropriate choice because dairy products, such as milk, are not eaten on this diet. Foods eaten by a client who is a vegan include grains, fruits, and vegetables.

The nurse has received an order from the health care provider to discontinue the nasogastric tube. Which action by the nurse indicates a need for further education? a. The nurse clears the tube with air prior to discontinuing. b. The nurse stops the tube feeding. c. The nurse instructs the patient to cough while pulling out the tube. d. The nurse clamps the tube while pulling it out.

c. The nurse instructs the patient to cough while pulling out the tube. To remove the tube, instruct the patient to take a deep breath and hold it; pinch the tube, and pull it out smoothly and quickly. The nurse should stop any feedings, and suction and flush the tube with water and/or air as appropriate. The nurse should not ask the patient to cough while pulling out the tube. Coughing during tube insertion may indicate the tube is entering the patient's lungs.

The nurse has determined that an unconscious client is at risk for nutritional problems. Which outcome indicates to the nurse that the goals have not yet been fully met? a. Stable weight b. Intake equaling output c. Total protein concentration of 4.5 g/dL (45 g/L) d. Blood urea nitrogen (BUN) level of 20 mg/dL (7.1 mmol/L)

c. Total protein concentration of 4.5 g/dL (45 g/L) The normal total protein level is 6.4 to 8.3 g/dL (64 to 83 g/L). The normal BUN is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Expected outcomes for nutritional problems in an unconscious client include stable weight, intake equaling output, evidence of wound healing, and normal BUN, total protein, and hemoglobin levels. The only abnormal finding in the options is the protein level.

The nurse instructs a client with coronary artery disease about a low-fat diet. Which menu selection indicates that the client understands the nurse's instructions? a. Shrimp and bacon salad b. Liver, potato salad, sherbet c. Turkey breast, boiled rice, and fruit d. Lean hamburger steak and macaroni and cheese

c. Turkey breast, boiled rice, and fruit Major sources of fats include meats, salad dressings, eggs, butter, cheese, and bacon. Options 1, 2, and 4 all contain high-fat foods.

The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the patient complains of a "popping sensation" and a wetness in the dressing, the nurse immediately suspects which complication? a. A wound infection b. The stitches came loose c. Wound dehiscence d. Wound crepitus

c. Wound dehiscence Wound dehiscence, which usually occurs in connection with surgical incisions, is the partial or complete separation of the tissue layers during the healing process. This is an emergency situation. Stitches can come loose, but there is no popping sensation. Wound infections are characterized by redness, warmth, and drainage, and crepitus is air trapped under the skin.

The nurse provides instructions to a client who is scheduled for an electroencephalogram. Which statement by the client indicates a need for further instruction? a. "The test will take between 45 minutes and 2 hours." b. "My hair needs to be washed the evening before the test." c. "Cola, tea, and coffee are restricted on the day of the test." d. "All medications need to be withheld on the day of the test."

d. "All medications need to be withheld on the day of the test." The client is informed that the test will take 45 minutes to 2 hours and that medications usually are not withheld before the test unless specifically prescribed. Preprocedural instructions include informing the client that the procedure is painless. Cola, tea, and coffee are stimulants and need to be restricted on the morning of the test. The hair needs to be washed the evening before the test, and gels, hair sprays, and lotion would be avoided.

The nurse instructs a client suspected of having a urinary tract infection to obtain a clean-catch urine specimen for culture and sensitivity testing. Which statement by the client indicates that the client understands the procedure for collecting the specimen? a. "A urine specimen will be obtained from a catheter." b. "I need to clean the labia with toilet paper and void into the sterile specimen container." c. "I need to empty my bladder into a container so that the full amount of urine can be determined." d. "I need to cleanse the labia using cleansing towels, void into the toilet, and then void into the sterile specimen container."

d. "I need to cleanse the labia using cleansing towels, void into the toilet, and then void into the sterile specimen container." Urine specimens for culture and sensitivity need to be obtained with the use of proper cleansing and voiding techniques to avoid contamination from external sources. The use of toilet paper will contaminate the specimen. The procedure described in option 3 would not provide a clean specimen. It is not necessary to obtain the specimen via a catheter.

The nurse is caring for a patient who is to collect a 24-hour urine specimen. Which statement by the patient indicates that additional teaching is required? a. "I will keep the urine container on ice to keep it chilled until I bring it to the lab." b. "I will start the test over if I forget and urinate into the toilet during the testing time." c. "I will start the test tomorrow after I urinate first thing in the morning." d. "I will drink extra fluids so that the lab will have a large specimen to test."

d. "I will drink extra fluids so that the lab will have a large specimen to test." Drinking extra fluids so that the lab will have an extra-large specimen to test is not done as part of 24-hour urine collection, and it may skew the test results. The specimen should be kept chilled on ice or in a refrigerator until it is brought to the lab. If the patient accidentally urinates in the toilet, the test must be started over again. Urine collection is started after the patient's first void of the morning into the toilet.

A young adult client has never had a chest x-ray before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse provides valid reassurance to the client? a. "You'll wear a lead shield to partially protect your organs from harm." b. "The amount of x-ray exposure is not sufficient to cause DNA damage." c. "The test isn't harmful at all. The most frustrating part is the long wait in radiology." d. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation."

d. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation." Clients would be taught that the amount of exposure to radiation is minimal and that the test itself is painless. The wording in each of the other options is only partly true and therefore cannot provide valid reassurance to the client.

A client with type 2 diabetes mellitus presents to the primary health care provider's office with a glycosylated hemoglobin (HgbA1C) level of 10.5%. Which statement by the client indicates an understanding of this test and its results? a. "The results of the test are probably high because I ate a doughnut for breakfast this morning." b. "The results of the test are probably low because I had not eaten anything for 12 hours before my blood was drawn." c. "I know that I need to check my glycosylated hemoglobin before each meal and at bedtime, but I don't always do it. I will do it more regularly." d. "Well, I have 3 months to really work on watching my diet and lowering my blood sugar. My next glycosylated hemoglobin test will be better then."

d. "Well, I have 3 months to really work on watching my diet and lowering my blood sugar. My next glycosylated hemoglobin test will be better then." The HgbA1C test provides a measurement of glycemic control over the previous 2 to 3 months, with increases in the HgbA1C reflecting elevated blood glucose levels. An HgbA1C of less than 6% is recommended by most primary health care providers. Thus, option 4 is the correct answer. Options 1 and 2 are incorrect, as HgbA1C measures glycemic control over a few months, and thus having fasted for a long time or having just eaten something does not affect HgbA1C. Option 3 is incorrect because clients check their blood glucose levels, not their HgbA1C, before meals and at bedtime.

The clinic nurse is providing instructions to a client who is scheduled for a barium enema. What instruction would the nurse provide to the client in preparation for this procedure? a. Liquids are restricted for 24 hours after the test. b. A clear liquid diet is required for 4 days before the test. c. Laxatives would not be taken for at least 1 week before the test. d. A low-fiber diet needs to be maintained for 1 to 3 days before the test.

d. A low-fiber diet needs to be maintained for 1 to 3 days before the test. Preparation for a barium enema includes maintaining a low-fiber diet for 1 to 3 days before the test. Clear liquids or water may be allowed 12 to 24 hours before the test. Laxatives and enemas may be prescribed before the test to cleanse the bowel. The client is encouraged to drink liquids after the procedure to facilitate the passage of barium.

The primary health care provider has prescribed a clear liquid diet for a postoperative client. The nurse prepares to deliver the lunch tray to the client and checks the tray to be sure that which has occurred? a. Sodium foods are restricted. b. At least 1 serving of low-fat milk is served. c. All food items are lukewarm in temperature. d. All food items are liquid at body temperature.

d. All food items are liquid at body temperature. By definition, a clear liquid diet offers foods that are liquid at body temperature. Sodium intake is occasionally restricted if the client is on strict sodium regulation; however, because of the short-term nature of a clear liquid diet for the postoperative client and the limited nutritional content of the diet, electrolytes and minerals generally are lacking. To offer the client some variety and stimulate taste buds, foods of different temperatures would be offered on a clear liquid diet, ranging from frozen (e.g., Popsicles) to warm (e.g., tea). Also, clear liquid diets prohibit milk of any nature because it is not a clear liquid.

A client suspected of having a duodenal ulcer has undergone esophagogastroduodenoscopy. The nurse would place highest priority on which item as part of the client's care plan? a. Monitoring the temperature b. Monitoring complaints of heartburn c. Giving warm gargles for a sore throat d. Assessing for the return of the gag reflex

d. Assessing for the return of the gag reflex The nurse places highest priority on assessing for return of the gag reflex. This assessment addresses the client's airway. The nurse also monitors the client's vital signs and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway is the priority.

A client with coronary artery disease is provided instructions regarding a low-fat diet. The nurse would determine that the client understands the diet if the client states that which food item would be avoided? a. Apples b. Oranges c. Cherries d. Avocados

d. Avocados Fruits and vegetables, except avocados, olives, and coconuts, contain minimal amounts of fat.

In planning a low-sodium diet for a client who has recently been diagnosed with heart failure, the nurse would offer the client which food item? a. Beef bouillon b. Grilled cheese c. Cottage cheese d. Chicken breast

d. Chicken breast Chicken breast has 70 mg of sodium compared with 457 mg for cottage cheese, 700 mg for grilled cheese, and 800 mg for beef bouillon.

The nurse is caring for a client with suspected kidney failure. A 24-hour urine specimen is prescribed. What value, which measures overall kidney function, will the nurse specifically plan to check? a. Sodium levels b. Protein levels c. Blood uric acid levels d. Creatinine clearance levels

d. Creatinine clearance levels Creatinine clearance is a calculated measure of glomerular filtration rate and is the best indication of overall kidney function. The amount of creatinine cleared from the blood (e.g., filtered into the urine) is measured in the total volume of urine excreted in a defined period. The analysis compares the urine creatinine level with the blood creatinine level; therefore, a blood specimen for creatinine must also be collected. Sodium levels are decreased in prerenal acute kidney injury. Increased levels of protein indicate glomerular disease, nephrotic syndrome, diabetic neuropathy, and urinary tract malignancies and irritations. Uric acid levels are increased in conditions such as gout or uric acid calculi.

A client has just returned to a nursing unit following bronchoscopy. Which nursing intervention would the nurse implement? a. Administering atropine intravenously b. Administering small doses of a sedative c. Encouraging additional fluids for the next 24 hours d. Ensuring the return of the gag reflex before offering food or fluids

d. Ensuring the return of the gag reflex before offering food or fluids After bronchoscopy, the nurse keeps the client on NPO (nothing by mouth) status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and a sedative would be administered before the procedure, not after.

A client has been on total parenteral nutrition (TPN) for 8 weeks at home. The primary health care provider prescribes that the TPN be weaned by 50 mL per hour per day until discontinued. The client asks the nurse why the TPN cannot just be stopped. The nurse explains that unless the TPN infusions are tapered gradually, the client is at risk for developing which complication? a. Dehydration b. Hypokalemia c. Hypernatremia d. Hypoglycemia

d. Hypoglycemia Clients receiving TPN are receiving high concentrations of glucose. To give the pancreas time to adjust to decreasing glucose loads, the infusion rate is tapered downward. Before discontinuation of TPN, the body must adjust to the lowered glucose levels. If the TPN is suddenly withdrawn, the client could experience rebound hypoglycemia. Options 1, 2, and 3 are not associated with the discontinuation of the TPN.

The registered nurse is observing a newly hired nurse perform a dressing change on a client with a leg ulcer. An enzymatic agent is being used to treat the ulcer. Which observation, if made by the registered nurse, would indicate a need for further teaching with the newly hired nurse? a. Cleans the wound with a sterile normal saline solution b. Wraps and tapes a gauze dressing in place over the ulcer c. Applies the enzymatic agent to the area of necrosis d. Leaves the ulcer open to the air after the enzymatic agent is applied

d. Leaves the ulcer open to the air after the enzymatic agent is applied The wound needs to be cleansed with a sterile solution, such as normal saline, before applying the enzymatic agent. The nurse then applies a thin film of the enzymatic agent on the necrotic areas only and applies a loose, thin dressing taped securely in place.

The nurse is performing an oral examination on a patient and notices a beefy-red tongue. The nurse identifies this as a characteristic finding for what condition? a. Anorexia nervosa b. Malnutrition c. Bulimia d. Pernicious anemia

d. Pernicious anemia In conditions such as pernicious anemia, a characteristic finding is a sore, smooth-surfaced, beefy-red tongue, which may interfere with the person's ability to chew certain foods. Anorexia nervosa and bulimia are eating disorders. In malnutrition the oral mucosa may be a darker red than normal with oral lesions and/or the tongue may reveal white irregular areas.

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse would take which action after seeing the laboratory results? a. Report the abnormally low count. b. Report the abnormally high count. c. Place the client on bleeding precautions. d. Place the normal report in the client's medical record.

d. Place the normal report in the client's medical record. A normal platelet count ranges from 150,000 to 400,000 mm3 (150 to 400 × 109/L). The nurse would place the report containing the normal laboratory value in the client's medical record. A platelet count of 300,000 mm3 (300 × 109/L) is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed.

A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. How would the nurse describe this test to the client? a. The test may be painful. b. The test will take approximately 2 hours. c. Fluids will be restricted following the test. d. The dye injected may cause a warm, flushing sensation.

d. The dye injected may cause a warm, flushing sensation. CT scanning causes no pain and can take 15 to 60 minutes to perform. The dye may cause a warm, flushing sensation when injected. Fluids are encouraged following the procedure. If an iodine dye is used, the client would be asked about allergies to seafood or iodine.

A client recovering from cardiac surgery has a left pleural effusion and is about to undergo a thoracentesis. What position would the nurse place the client in for the procedure? a. Dorsal recumbent b. Left lateral, with the right arm supported by a pillow c. Right side-lying, with the legs curled up into a fetal position d. Upright and leaning forward with the arms on an over-the-bed table

d. Upright and leaning forward with the arms on an over-the-bed table The client undergoing thoracentesis usually sits in an upright position with the anterior thorax supported by pillows or leaning over an over-the-bed table. The client must be placed in a position that will enlist the aid of gravity in accessing and draining the effusion. The dorsal recumbent position is an inaccessible position. Any side-lying position will cause fluid to accumulate under that side, which is inaccessible to the primary health care provider. However, if the client cannot sit upright, the client will be placed in a side-lying position on the unaffected side, with the side to be tapped uppermost.

The nurse is caring for a woman who has a cyst in her breast that was found at her recent mammogram. The physician wants to make sure that the cyst is not malignant. Which test will be used to determine this? a. Needle aspiration with biopsy b. Paracentesis c. Thoracentesis d. Fiberoptic endoscopy

a. Needle aspiration with biopsy Needle aspirations are procedures that are used to remove fluid and tissue for testing. A biopsy involves removing a larger collection of cells, as in a tumor or mass, and may be used to detect cancer in the skin, breast, or liver. Paracentesis is drainage of fluid from the abdomen, and thoracentesis is drainage of fluid from the pleural cavity. Fiberoptic endoscopy allows the physician to see inside the upper and/or lower GI tract.

The nurse is caring for an elderly patient with dementia. Which laboratory finding indicates to the nurse that that patient is often forgetting to eat meals? a. Serum bilirubin 0.4 mg/dL b. PLT (platelet count) 425,000/mm3 c. Serum cholesterol 175 mg/dL d. Albumin 1.4 g/dL

d. Albumin 1.4 g/dL Albumin level is an indicator of the patient's protein intake and nutritional status. Normal albumin level is 3.3 to 5 g/dL. It is an essential component of fluid balance, responsible for maintaining colloidal oncotic pressure in the vascular and extravascular spaces. Low levels of albumin may indicate malnutrition.

Which foods are high in iron for the vegetarian diet?

Broccoli, pumpkin seeds, figs, kale, avocados, bananas, almonds, tomatoes, brussels sprouts, spinach, potatoes, green peas, collared greens./Red Meats for non vegetarian

What caution does the RN take when a patient is having a CT scan and when a patient is having an MRI?

For the CT scan make sure the patient has no allergies specifically shellfish, and for the MRI make sure there are no magnetic items near the MRI room

What are nursing interventions proven to prevent pressure injuries?

Frequent turning - Q2 hours, Head of bed at 30°, use of moisture barriers/creams and ointments, gel pads, inflatable mattresses/water beds, keeping skin dry & cool

The nurse knows which description would be classified as a closed wound? a. A large bruise on the side of the face b. A surgical incision that is sutured closed c. A puncture wound that is healing d. An abrasion on the leg

a. A large bruise on the side of the face In a closed wound, as seen with bruising, the skin is still intact. An open wound is characterized by an actual break in the skin's surface. For example, an abrasion, a puncture wound, and a surgical incision are types of open wounds.

The nurse knows which factors contribute to the development of wounds and lead to delays in wound healing? (Select all that apply.) a. A patient who has diabetes. b. A patient with COPD. c. A patient with on bed rest who is repositioned. d. A patient who is obese and sweats excessively. e. A patient on long-term steroid therapy.

a. A patient who has diabetes. b. A patient with COPD. c. A patient with on bed rest who is repositioned. d. A patient who is obese and sweats excessively. e. A patient on long-term steroid therapy. Factors that contribute to the development of wounds and lead to delays in wound healing include comorbidities such as vascular disease, which impacts the skin's ability to obtain required oxygen and nutrients, or diabetes, which affects not only the microvasculature, but also the skin's normally acidic pH; malnutrition involving inadequate proteins, cholesterol and fatty acids, and vitamins and minerals; medications such as steroids, nonsteroidal, anti-inflammatories, and anticoagulants; excessive moisture from sweating; and external forces such as pressure, shear, and friction that occur when turning and repositioning the patient in bed.

The nurse is using the Braden scale to assess the patient's risk for a pressure ulcer. Which risk categories are associated with the Braden scale? (Select all that apply.) a. Activity b. Friction and shear c. Moisture d. Sensory perception e. Cognition

a. Activity b. Friction and shear c. Moisture d. Sensory perception The Braden scale ranks the patient on the risk categories of sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The scale does not include cognition.

The nurse is caring for a patient who is scheduled for a needle aspiration and biopsy to rule out cancer. Which Nursing diagnosis is appropriate and important for this patient? a. Anxiety related to potential for cancer diagnosis depending on biopsy results b. Impaired health maintenance related to delayed insurance coverage for procedure c. Powerlessness related to lengthy wait for diagnosis d. Ineffective coping related to patient stated she is a little nervous about the test results.

a. Anxiety related to potential for cancer diagnosis depending on biopsy results Fear is an emotion commonly experienced by patients waiting for diagnostic tests and biopsy results. Impaired health maintenance related to delayed insurance coverage is not a priority diagnosis for this patient at this time. Powerlessness is about the patient's ability to control an outcome and is not related to the wait for test results. The patient statement of feeling a little nervous about the test results is not indicative of ineffective coping.

A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions would the nurse take in the care of the drain? Select all that apply. a. Check the drain for patency. b. Observe for bright red bloody drainage. c. Clamp the drain for 15 minutes every hour. d. Curl the drain tightly, and tape it firmly to the body. e. Maintain aseptic technique when emptying the drain.

a. Check the drain for patency. b. Observe for bright red bloody drainage. e. Maintain aseptic technique when emptying the drain. The nurse would check the tube or drain for patency to provide an exit for the fluid or blood to promote healing. The nurse would monitor the drainage characteristics. Usually the drainage from the wound is pale, red, and watery. Active bleeding will be bright red. The nurse must use aseptic technique for emptying the drainage container or changing the dressing to avoid contamination of the wound. A postoperative drain would not be curled tightly or obstructed in any way, such as with clamping. This could prevent the drain from functioning properly.

The nurse is caring for a postoperative orthopedic patient who has two Hemovac drains in place. Which interventions will the nurse perform? (Select all that apply.) a. Measure the amount of drainage in the device prior to emptying. b. Label each drain and record them separately. c. Recompress the device after emptying. d. Secure the device to the patient's gown above the level of the wound. e. Check for kinks in the tubing.

a. Measure the amount of drainage in the device prior to emptying. b. Label each drain and record them separately. c. Recompress the device after emptying. e. Check for kinks in the tubing. Use a marked, graduated measuring device to collect the drainage when emptying the reservoir to facilitate accurate measurement of the drainage. After emptying, recompress the device to maintain suction. Secure the container(s) to the patient's hospital gown below the level of the wound, avoiding tension on the tubing and making sure there are no kinks. If there are multiple drains, label them and document observations by the drain label.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions would the nurse take? Select all that apply. a. Contact the surgeon. b. Instruct the client to remain quiet. c. Prepare the client for wound closure. d. Document the findings and actions taken. e. Place a sterile saline dressing and ice packs over the wound. f. Place the client in a supine position without a pillow under the head.

a. Contact the surgeon. b. Instruct the client to remain quiet. c. Prepare the client for wound closure. d. Document the findings and actions taken. Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse would call for help, stay with the client, ask another nurse to contact the surgeon, and obtain needed supplies to care for the client. The nurse places the client in a low-Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

The nurse recognizes that cold therapy is contraindicated in which conditions? (Select all that apply.) a. Edema b. Shivering c. Bleeding d. Circulatory problems e. Advanced age

a. Edema b. Shivering d. Circulatory problems Cold should not be used if any of the following is present: edema (cold application slows reabsorption of the fluid), circulatory pathophysiology (cold application causes vasoconstriction, further reducing circulation to the area), and shivering (this is a comfort concern). Bleeding is contraindicated in heat therapy. Advanced age would require frequent observation due to thin skin.

The nurse is caring for a client with a Penrose drain from an abdominal incision. Which is an appropriate nursing intervention for this client? a. Ensure that a sterile safety pin is through the drain. b. Measure the amount of drainage in a measuring container. c. Establish that the drain is at the prescribed amount of suction. d. Squeeze the suction device and close the port after emptying the drain.

a. Ensure that a sterile safety pin is through the drain. A Penrose drain is a soft, flat, flexible drain in which 1 end is placed in the wound or incision and the other end is outside the wound. It is an open drainage system that drains onto the skin surface or onto a dressing. It is not sutured in place and thus would have a sterile safety pin (or other device per agency procedure) inserted through it to prevent the drain from going all the way into the wound. Thus, option 1 is the correct option. Options 2, 3, and 4 are incorrect, as a Penrose drain is an open drainage system with no suction and it drains onto the skin or into a dressing, not into a collection container, so the amount of drainage cannot be measured in a measuring container.

The nurse is caring for a patient who has had severe acid reflux. Which test will allow the physician to directly check for damage to the esophagus? a. Esophagogastroduodenoscopy (EGD) b. MRI scan with contrast c. Abdominal ultrasound d. Positron emission tomography (PET) scan

a. Esophagogastroduodenoscopy (EGD) EGD is performed using a lighted tube that allows for direct visualization of the esophagus, stomach, and upper duodenum. MRI, ultrasound, and PET scanning do not allow physicians to see the esophagus directly.

An older client has been lying in a supine position for the past 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of the client? Select all that apply. a. Heels b. Ankles c. Elbows d. Sacrum e. Back of the head

a. Heels c. Elbows d. Sacrum e. Back of the head When the client is lying supine, the heels, sacrum, and back of the head are all at risk, as are the elbows and scapulae. The greater trochanter and ankles are at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position.

The nurse is caring for a patient who has diabetes. The patient reports compliance with the medical regime. Which test result indicates to the nurse that the patient has not been compliant with the treatment plan? a. Hemoglobin A1c 16% b. Random blood sugar (RBS) 112 mg/dL c. Lactate dehydrogenase (LDH) 55 units/L d. Erythrocyte sedimentation rate (ESR) 14 mm/hr

a. Hemoglobin A1c 16% Hemoglobin A1c (Hgb A1c), or glycosylated hemoglobin, testing evaluates blood sugar levels over a period of 2 to 3 months This blood test is performed to provide the primary care provider (PCP) with information about long-term blood sugar control. The normal value of Hgb A1c in patients without diabetes is 4% to 5.9%. The American Diabetes Association (2016) states that diabetes is diagnosed for Hgb A1c levels greater than 6.5%. A higher level indicates that the patient has had poor blood glucose control during the past few weeks, and increases the patient's risk of long-term complications from hyperglycemia. The other tests are not related to long-term diabetes control.

The nurse recognizes that the cause of pressure ulcers includes which factors? (Select all that apply.) a. Intensity of the pressure b. Duration of the pressure c. Tissue's ability to tolerate the pressure d. Person's age e. Person's nutritional status

a. Intensity of the pressure b. Duration of the pressure c. Tissue's ability to tolerate the pressure d. Person's age e. Person's nutritional status The primary cause of pressure ulcers is, as the name suggests, pressure. However, it is more than just pressure; it is the intensity of the pressure, the length of time that the tissue is subjected to the pressure, and intrinsic and extrinsic factors that affect the tissue's ability to withstand or tolerate that pressure. Intrinsic and extrinsic factors can include nutrition status and age.

When the nurse is performing a focused wound assessment on a patient, what information should be included in the documentation? (Select all that apply.) a. Location and size b. Characteristics of the wound bed c. Patient's response to wound treatment d. Patient's pain level e. Presence of drainage

a. Location and size b. Characteristics of the wound bed c. Patient's response to wound treatment e. Presence of drainage A focused wound assessment includes an evaluation of the wound's location, size, and color; presence of drainage; condition of the wound edges; characteristics of the wound bed; and patient's response to the wound or wound treatment. The patient's pain level would be documented with his/her pain assessment.

The nurse is caring for a patient who will be undergoing flexible sigmoidoscopy testing to screen for colon cancer. What goal will the nurse include in the patient's plan of care? select all that apply. a. Patient will verbalize understanding of preprocedure preparation to be completed at home the day before the test. b. Patient will feel comfortable about the upcoming test and have trust in the health care providers. c. Patient will learn common side effects of the medications used to prepare the GI tract for endoscopy testing. d. Patient will realize how important regular sigmoidoscopy testing is in the prevention of colon cancer.

a. Patient will verbalize understanding of preprocedure preparation to be completed at home the day before the test. b. Patient will feel comfortable about the upcoming test and have trust in the health The patient will need to complete colon preparation prior to the sigmoidoscopy testing. The nurse must determine that the patient understands how and when to complete the prep. Having the patient verbalize understanding of the prep procedure is an objective goal so that the nurse can readily determine whether or not it has been met. The other goals are not objective or measurable, so the nurse cannot determine whether or not they have been met.

The registered nurse (RN) directs the licensed practical nurse (LPN) to assist with the care of a client who has a sacral pressure injury. Which is the most appropriate activity for the RN to delegate to the LPN? a. Place the client in a side-lying position. b. Initiate wound care protocol for standardized ulcer care. c. Meet with the wound specialist to identify measures to improve healing. d. Determine which treatments would best meet the healing needs of the client.

a. Place the client in a side-lying position. The best task for the LPN is to place the client in the side-lying position. Proper positioning requires nursing skills and is within the LPN's abilities and scope of practice. Initiating a wound care protocol, meeting with the wound specialist to identify measures to improve healing, and determining which treatments would best meet the healing needs of the client are outside the LPN's scope of practice, even though the LPN may assist the RN in determining the plan of care. These activities are the RN's responsibilities.

The nurse is caring for a patient who is anemic. Which CBC test results demonstrate that the patient's treatment plan is effective and the anemia is resolving? (Select all that apply.) a. Red blood cell count (RBC) 5.8 million/mm3 b. Hematocrit (HCT) 25% c. Hemoglobin (HGB) 14 g/dL d. White blood cell count (WBC) 4500/mm3 e. Platelet count (PLT) 255,000/mm3

a. Red blood cell count (RBC) 5.8 million/mm3 c. Hemoglobin (HGB) 14 g/dL Red blood cell count of 5.8 million and hemoglobin value of 14 g/dL are both normal. Hematocrit level of 25% is very low and indicative of ongoing anemia. White blood cell and platelet counts are not checked for anemia.

The nurse is concerned about potential skin integrity problems for an unconscious client. Which interventions would be most appropriate to include in the plan of care for this client? Select all that apply. a. Reposition every 2 hours. b. Use a bed cradle as indicated. c. Apply protective pads to heels and elbows. d. Add a small amount of alcohol to the daily bath water. e. Provide perineal care every 8 hours and after incontinence.

a. Reposition every 2 hours. b. Use a bed cradle as indicated. c. Apply protective pads to heels and elbows. e. Provide perineal care every 8 hours and after incontinence. Unconscious clients are completely immobile, having lost the protective reflexes to shift body weight. It is up to the nurse to minimize the risk of prolonged pressure that could cause skin ischemia and breakdown. This is accomplished by repositioning the client every 2 hours. Use of a bed cradle can protect the client's toes from breakdown due to weight from linens. Protective pads can be applied to the heels and elbows to reduce friction and shear. Appropriate perineal care is essential to keep waste products from excoriating the skin. The nurse can reduce skin dryness and irritation by adding a superfatty solution (i.e., baby oil or castile soap) to the daily bath water. Drying agents such as alcohol are avoided because dry skin can crack and break down.

A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new nurse causes the preceptor to intervene? a. The nurse asks the UAP to assess the wound. b. The nurse asks the UAP to report increased wound drainage. c. The nurse asks the UAP to observe changes in dietary intake. d. The nurse asks the UAP to change the dressing.

a. The nurse asks the UAP to assess the wound. Assessment and evaluation of a patient's skin and wounds, and the effectiveness of the treatment plan, are a nurse's responsibility and cannot be delegated to unlicensed assistive personnel (UAP). UAP should report to the nurse any changes in skin condition or integrity; elevation in temperature; complaints of pain; increased wound drainage or incontinence; and observed changes in dietary intake. Some dressing changes can be performed by UAP in some situations.

When discussing stage 3 pressure ulcers with the student nurse, which description would the staff nurse include? a. A pressure ulcer that involves exposure of bone and connective tissue. b. A pressure ulcer that does not extend through the fascia. c. A pressure ulcer that does not include tunneling. d. A partial-thick wound that involves the epidermis.

b. A pressure ulcer that does not extend through the fascia. Stage 3 pressure ulcers are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue. There may be undermining or tunneling present in the wound. Stage 4 pressure ulcers involve exposure of muscle, bone, or connective tissue such as tendons or cartilage. Stage 2 pressure ulcers are partial-thickness wounds that involve the epidermis and/or dermis.

A hydrocolloid dressing is prescribed for a client with a leg ulcer. The home health nurse is preparing a plan of care for the client and would appropriately document which intervention? a. Change the hydrocolloid dressing daily. b. Change the hydrocolloid dressing every 3 to 5 days. c. Apply the hydrocolloid dressing over a dry, sterile dressing. d. Apply the hydrocolloid dressing over a normal saline-soaked dressing.

b. Change the hydrocolloid dressing every 3 to 5 days. A hydrocolloid dressing contains hydroactive particles embedded in a polymer base that are softened by wound moisture and act as a protective gel over healing tissue. It is applied directly to the wound and needs to be changed every 3 to 5 days (or more frequently if drainage from the wound is excessive). It is not applied over a dry, sterile dressing or a normal saline-soaked dressing because it then would not be able to act as a protective gel.

The nurse is caring for a patient who has just undergone bronchoscopy. The patient requests a drink of water. What is the nurse's best action? a. Provide ice chips. b. Check the patient for a gag reflex. c. Provide a small cup of ice water with a straw. d. Keep the patient NPO.

b. Check the patient for a gag reflex. Numbing medication is applied to the back of the throat just before bronchoscopy. This may lead to swallowing difficulty and risk for aspiration until the gag reflex returns. The nurse should keep patient NPO until swallow, gag, and cough reflexes have returned. The nurse does not need to keep the patient NPO after the gag reflex returns so it should be checked in order to allow the patient to have fluids as soon as possible to relieve thirst.

The nurse is caring for a patient with a urinary tract infection. Which test will indicate which antibiotics will be effective to treat the infection? a. Complete blood count (CBC) b. Culture and sensitivity (C&S) c. Renal scan and angiography d. Radioreceptor assay for HCG

b. Culture and sensitivity (C&S) Culture and sensitivity are performed on specimens to determine which bacteria are causing the infection and which antibiotics will be effective treatment. CBC, renal scan, and radioreceptor assay for HCG will not indicate which antibiotics may be used to treat an infection.

The nurse is caring for a patient with diabetes who will be doing fingerstick blood glucose testing at home. What is the best way for the nurse to ensure that the patient can perform the procedure correctly? a. Quiz the patient on the steps of the procedure. b. Have the patient perform the procedure in front of the nurse. c. Ask the patient if he has any questions about the test. d. Use terminology that the patient can easily understand.

b. Have the patient perform the procedure in front of the nurse. Having the patient successfully perform the procedure in front of the nurse is an excellent way for the nurse to ensure that the patient knows how to do it correctly. Quizzing the patient about the procedure, asking the patient if he/she has questions, and using understandable terminology are fine, but only a return demonstration will assess the patient's ability to perform the procedure successfully and correctly.

The nurse is planning care for a client returning from the operating room after having an autograft applied to the right lower extremity. Which nursing intervention is focused on promoting graft "take"? a. Monitor temperature every 4 hours. b. Leave the dressing intact for 3 to 5 days. c. Apply an ice pack to the site to decrease edema formation. d. Maintain the right lower extremity in a dependent position.

b. Leave the dressing intact for 3 to 5 days. After surgery, graft sites are immobilized with a bulky cotton pressure dressing for 3 to 5 days to allow vascularization, or "take," of the newly grafted skin. Dressings would not be disturbed. Elevation and complete rest of the grafted area is required to allow blood vessels to connect the graft with the wound bed. Any activity that might cause movement of the dressing against the body and separation of the graft from the wound is prohibited, such as application of an ice pack. Additionally, cold promotes vasoconstriction.

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse would encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? a. Milk b. Oranges c. Bananas d. Chicken

b. Oranges Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are 2 food groups that are high in the B vitamins.

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? a. Hard reddened skin b. Serous drainage c. Purulent drainage d. Warm, tender skin

b. Serous drainage Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.

The nurse is caring for a patient who recently had a liver biopsy. To whom must the nurse give the results? a. The patient b. The patient's health care provider c. The patient's insurance provider d. The patient's spouse

b. The patient's health care provider HIPAA protects the patient by requiring that testing results be shared only with health care professionals who need the information to provide treatment and with individuals designated in writing by the patient. The patient's provider will need the biopsy results to determine the patient's plan of care. The nurse does not give test results to the insurance company. The nurse may share the results with the patient or spouse, but it is not required, unless designated by the patient in writing.

The nurse is caring for a client with a diabetic ulcer. What discharge instructions would the nurse provide to the client? Select all that apply. a. Wash feet with hot water daily. b. Use a mild soap when washing the feet. c. Use lanolin on the feet to prevent dryness. d. Wear open-toed shoes to allow air flow to the feet. e. Exercise the feet daily by walking and flexing at the ankle.

b. Use a mild soap when washing the feet. c. Use lanolin on the feet to prevent dryness. e. Exercise the feet daily by walking and flexing at the ankle. The client with a diabetic ulcer needs to take strict precautions and implement very specific measures to allow for wound healing. Interventions include washing the feet with warm (not hot) water daily with a mild soap, using lanolin to prevent drying and cracking, wearing closed-toed shoes that are well fitting while avoiding high-heeled and open-toed shoes, and exercising the feet daily by walking and flexing at the ankle to promote circulation.

The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure ulcer who has a Nursing diagnosis of Impaired skin integrity? a. Wound will be completely healed in 72 hours. b. Wound will show signs of healing within 2 weeks. c. Patient will develop no new pressure ulcers. d. Patient will ambulate twice a day.

b. Wound will show signs of healing within 2 weeks. A stage 3 pressure ulcer is a more extensive wound and will take time to heal, so the most appropriate goal will be to show signs of healing in 2 weeks. It will not heal in 72 hours. The goal of no new pressure ulcers is good, but not the most appropriate, and ambulating twice a day is more of an intervention.

The nurse is repositioning the patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the nurse should place the head of the bed in which position? a. Flat b. 90 degrees c. 30 degrees d. 45 degrees

c. 30 degrees When side-lying, patients should be positioned at 30 degrees, as opposed to 90 degrees, to avoid positioning the patient directly on bony prominences such as the head of the trochanter.

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? a. Notify the surgeon. b. Clamp the surgical drain. c. Change the dressing as prescribed. d. Remove and replace the perineal packing.

c. Change the dressing as prescribed. Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore, the nurse needs to change the dressing as prescribed. A surgical drain would not be clamped because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the surgeon at this time because this is expected. Drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse would not remove the perineal packing.

The nurse knows what goal to be appropriate for a patient with a stage 3 pressure ulcer with the nursing diagnosis impaired physical mobility? a. Patient will remain free of wound infections during the hospitalization. b. Patient will report pain management strategies and reduce pain to a tolerable level. c. Patient will be able to assist with position changes using over bed trapeze within 1 week. d. Patient will consume adequate nutrition to meet nutritional requirements within 1 week.

c. Patient will be able to assist with position changes using over bed trapeze within 1 week. Patient will be able to assist with position changes using over bed trapeze within 1 week is an appropriate goal for impaired mobility. The patient remaining free of wound infections during the hospitalization is an appropriate goal for impaired tissue integrity. The patient reporting pain management strategies to reduce pain to a tolerable level is an appropriate goal for acute pain. The patient consuming adequate nutrition to meet nutritional requirements within 1 week is an appropriate goal for Impaired nutritional status.

The nurse understands which rationale to be appropriate for drying a wound after irrigation? a. Ensure the new dressing adheres to the wound. b. Ensure the new dressing remains occlusive. c. Prevent skin breakdown from moisture. d. Prevent infection from irrigate solution.

c. Prevent skin breakdown from moisture. Proper drying prevents further skin breakdown from moisture. Patting (rather than rubbing) prevents healthy tissue from being removed and reduces trauma to the wound. The type of dressing will determine how it lays in the wound and whether it is occlusive. The drying does not prevent infection.

The nurse is caring for a patient who is having blood drawn as part of preoperative testing. Which step is the most important to ensure the safety of the patient and the nurse? a. Ensuring that the tourniquet is not left in place for too long b. Using the smallest possible needle for venipuncture c. Properly disposing of the needle after the specimen is obtained d. Making sure that all of the collection tubes are filled completely

c. Properly disposing of the needle after the specimen is obtained Proper disposal of needles and sharps after procedures is essential for safe nursing practice to ensure the safety of staff as well as patients. Ensuring that the tourniquet is not left on too long, using the smallest needle possible, and making sure that all of the vials are filled are important steps in venipuncture, but only proper sharps disposal will help ensure the safety of the patient and the nurse.

The nurse is caring for a patient who has a bleeding gastric ulcer. How will the nurse expect the patient's stool to appear? a. Soft and formed with bright red streaks b. Watery with particles of undigested food c. Sticky and black d. Hard lumps that are difficult to pass

c. Sticky and black Bleeding anywhere along the GI tract results in blood in the stool. Bleeding that occurs in the upper GI tract produces stools that are black and tarry in appearance. Bleeding within the lower GI tract presents with soft stools that have bright red streaks. Watery stool with particles of food is indicative of gastroenteritis. Hard lumps that are difficult to pass indicate constipation, often from medications or lack of fiber in the diet.

The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What does the nurse do first? a. Notify the provider. b. Notify the wound care nurse. c. Stop the procedure. d. Give the patient pain medication.

c. Stop the procedure. If the patient is complaining of severe pain, the nurse should first stop the procedure and then determine if the pain is new or preexisting. Then the nurse can determine what to do next based on the patient's response.

The nurse identifies which skin layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect? a. Stratum germinativum b. Epidermis c. Subcutaneous layer d. Stratum corneum

c. Subcutaneous layer The subcutaneous layer delivers the blood supply to the dermis, provides insulation, and has a cushioning effect. The stratum germinativum constantly produces new cells that are pushed upward through the other layers of the epidermis toward the stratum corneum, where they flatten, die, and are eventually sloughed off and replaced by new cells. The epidermis is the outermost layer of the skin and the thinnest of the layers. The stratum corneum is made up of flattened dead cells.

When the nurse is caring for a patient with a Penrose drain, what care needs to be carried out? a. The drain must be compressed after emptying to work properly. b. The drain must be connected to suction if ordered. c. The drain is not sutured in place so care is taken to not dislodge it. d. The suction pulls drainage away from the wound as it re-expands.

c. The drain is not sutured in place so care is taken to not dislodge it. The Penrose drain, an open drain that is a flexible piece of tubing, is usually not sutured into place and is not connected to suction. Closed drains are compressed or connected to suction if ordered and pull drainage away as they expand.

The nurse identifies which syringe to use when irrigating a patient's deep wound? a. 5-mL syringe b. 10-mL syringe c. 3-mL syringe d. 30-mL syringe

d. 30-mL syringe A deep wound is irrigated with a 30- to 50-mL piston syringe with an 18-gauge angiocath. Unlike the 1 pound per square inch (psi) of pressure or less that is delivered by a standard bulb syringe, the use of a 30- to 50-mL syringe and 18-gauge catheter has been shown to achieve an irrigation force that falls within the recommended 4 to 15 psi.

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? a. A pink edematous hand b. Fiery red skin with edema in the nail beds c. Black fingertips surrounded by an erythematous rash d. A white color to the skin, which is insensitive to touch

d. A white color to the skin, which is insensitive to touch Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.

The nurse identifies which type of wounds heal by tertiary intention? a. An acute wound in which the patient has sutures placed when it happened. b. A pressure ulcer that was treated with dressing changes and is healed. c. An acute wound in which surgical glue was used to close the wound. d. A wound that was left open initially and closed later with sutures.

d. A wound that was left open initially and closed later with sutures. When a delay occurs between injury and closure, the wound healing is said to happen by tertiary intention. Wounds such as surgical incisions or traumatic wounds in which the edges of the wound can be approximated (brought together) to heal are examples of acute wounds. This type of wound is said to heal by primary intention. When a wound heals by secondary intention, new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue such as a pressure ulcer.

The nurse knows that a hydrocolloid dressing is appropriate for use on which type of wound? a. A wound with a large amount of drainage b. A wound that is tunneling c. A postsurgical incision with staples d. A wound with a moderate amount of drainage

d. A wound with a moderate amount of drainage Hydrocolloids are occlusive, adhesive dressings composed of gelling agents and carboxymethylcellulose. They absorb a small to moderate amount of drainage over a 3- to 7-day period, forming a gel as drainage is absorbed. A wound with a large amount of drainage would require a foam or alginate dressing, a postsurgical incision with staples could use Steri-Strips or gauze, and a wound that is tunneling may require packing.

When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. What would the nurse do next? a. Irrigate the wound, and apply a dry sterile dressing. b. Leave the incision exposed to the air to dry the area. c. Apply a sterile dressing soaked with povidone-iodine. d. Apply a sterile dressing soaked with normal saline.

d. Apply a sterile dressing soaked with normal saline. Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the exposure of underlying tissues. These usually occur 6 to 8 days after surgery. The client needs to be instructed to remain quiet and avoid coughing or straining. The client needs to be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline would be used to cover the wound. The primary health care provider must be notified after applying this initial dressing to the wound.

The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do? a. Cover the wound with a sterile gauze pad. b. Cover the wound with a transparent dressing. c. Put pressure on the wound with a sterile gauze pad. d. Cover the wound with gauze soaked with normal saline.

d. Cover the wound with gauze soaked with normal saline. If dehiscence or evisceration occurs, cover the wound with gauze moistened with a sterile normal saline, and notify the surgeon immediately. Putting pressure on the wound could cause further complications. Transparent films are used for autolytic debridement. A gauze pad will allow the wound to become dry and cause further complications.

A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term? a. Purpura b. Petechiae c. Erythema d. Ecchymosis

d. Ecchymosis Ecchymosis is a type of purpuric lesion, also known as a bruise. Purpura is an umbrella term that incorporates ecchymoses and petechiae. Petechiae are pinpoint hemorrhages and are another form of purpura. Erythema is an area of redness on the skin.

The nurse recognizes which intervention is not a form of mechanical debridement? a. Wet to dry dressings b. Whirlpool baths c. Wet to damp dressing d. Enzymatic dressing

d. Enzymatic dressing Enzymatic debridement is achieved through the application of topical agents containing enzymes that work by breaking down the fibrin, collagen, or elastin present in devitalized tissue, thus allowing for its removal. Mechanical debridement is a nonselective form of debridement because it not only removes the necrotic tissue, but also can remove or disturb exposed viable tissue that may be in the wound. The main forms of mechanical debridement are wet/damp-to-dry dressings and whirlpools.

An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area? a. Heels b. Sacrum c. Back of the head d. Greater trochanter

d. Greater trochanter The greater trochanter is at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position. When the client is lying supine, the heels, sacrum, and back of the head all are at risk, as are the elbows and scapulae.

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? a. Intact skin b. Full-thickness skin loss c. Exposed bone, tendon, or muscle d. Partial-thickness skin loss of the dermis

d. Partial-thickness skin loss of the dermis In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

A client has a wound with a moderate amount of drainage and is scheduled for a dressing change. Which dressing, if selected by the student nurse, requires further intervention by the nursing instructor? a. Foam b. Alginate dressing c. Hydrocolloid dressing d. Semipermeable transparent film

d. Semipermeable transparent film The client's wound has moderate drainage. Recall that foam, alginate, and hydrocolloid dressings are applied to wounds with moderate to heavy drainage. Semipermeable transparent films are applied to dry wounds.

The nurse is caring for a patient who will be receiving iodine-based contrast medium for a CT scan. Which allergy should be reported to the technician and radiologist before the test is performed? a. Gluten and lactose b. Strawberries and blueberries c. Peanuts and cashews d. Shrimp and scallops

d. Shrimp and scallops If the patient is undergoing an examination that involves an iodine contrast medium, check for a history of adverse reactions or allergies to iodine-containing food (e.g., shellfish, cabbage, kale, iodized salt). The other allergies are not related.