Adult Med-surge ATI

¡Supera tus tareas y exámenes ahora con Quizwiz!

A nurse is caring for a client who had a MI 5 days ago. The client has a sudden onset of SOB and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which one of the following adventatious breath sounds should the nurse document? A. Coarse crackles B. Wheezes C. Rhonchi D. Friction rub

Correct Answer: A A client who had a recent MI is at risk for left-sided HF. Crackles are breath sounds caused by movement of air through airways partially or intermittently occlueded with fluid and are associated with HF and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing. Incorrect B. A client who has wheezes will manifest a high-pitched musical squeak on inspiration or expiration through a narrow or obstructed airway C. A client who has Rhonchi will manifest coars, loud, low-pitched sounds during inspiration or expiration. Coughing often clears the airways and stops the sound D. A client who has a friction rub will manifest loud, dry, rubbing or grating sounds over the lower lateral anterior chest surface during inspiration or expiration

A nurse is teaching about a low-cholesterol diet to a client who had a MI. Which of the following meal selections by the client indicates an uderstanding of the teaching? A. Chicken breast and corn on the cob B. Shrimp and rice C. Cheese omelet and turkey bacon D. Liver and Onions

Correct Answer: A The nurse should ID that chicken breast is low in cholesterol, and all vegetables, includign corn, are cholesterol-free; therefore, this food selection by the client indicates an understanding of the teaching Incorrect B. Shrimp are high in cholesterol and should be eaten in moderation, therefore, this food slection does not indicate an understanding of a low-cholesterol diet C. Eggs and cheese are hihg in cholesterol; therefore, this food selection does not indicate an understanding of a low-cholesterol diet D. Liver and other organ meats are high in cholesterol; therefore, this food selection does not indicate an understanding of a low-cholesterol diet

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifesstations of bacterial meningitis. Which of the following findings should the nurse expect? A. Elevated glucose B. Elevated Proteins C. Presence of RBCs D. Presence of D-dimer

Correct Answer: B An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include increased protein in the cerebrospinal fluid Incorrect: A. Manifestations of bacterial meningitis include decreased glucose in the cerebrospinal fluid C. RBCs present in the cerebrospinal fluid can be an indication of bleeidng; However, the presence of WBCs in the cerebrospinal fluid indicates bacterial meningitis D. D-dimer measures coagulation activity and is used to evaluate blood clotting. The presence of D-dimer in the cerebrospinal fluid is not a manifestation of bacterial meningitis

A nurse is conducting a home visit for an older adult client who has DM and takes regular insulin subQ before each meal. The client appears disoriented and weak and has slurred speech. Which of the following conditions should the nurse consider first when responding to these manifestations. A. Dementia B. Hypoglycemia C. Infection D. Transient Ischemic attack

Correct Answer: B EBP indicated the nurse should first check the client for hypoglycemia by drawing a blood glucose level. A client who has hypoglycemia can have slurred speech, disorientation, weakness, and confusion near meal time each day because regular insulin peaks in 2 to 4 hours, causing a drop in the client's blood glucose. Other manifestations of hypoglycemia include Incorrect: A. A client who has manifestations of dementia becomes cognitively impaired and can exhibit varying manifestations throughout each day ( confusion, disorientation, and difficulty with self-expression). However, because the client has DM and takes indulin, EBP indicates the nurse should consider another condition first C. An older adult clietn who has an infection can have manifestations fo disorientation, confusion, and low-grade fever. However, because the client has DM and takes indulin, EBP indicates the nurse should consider another condition first. Other manifestations of infection include fatigue, malaise, and tachypnea. D. A client who is having TIA may present with neurological deficits such as dizziness, Loss of vision in an eye, double vision, weakness, and aphasia. However, because the client has DM and takes insulin, EBP indicates the nurese should consider another condition first.

A nurse is caring for a client who has a pelvic fracture. The client reports sudden SOB, stabbing chest pain, and feelings of doom. This client is experiencing which of the following complications? A. Pneumonia B. Pulmonary embolus C. Tensions pneumothorax D. Tuberculosis

Correct Answer: B Immobility following muscuskeletal trauma places the client at an increased risk of PE. The client might also exhibit tachycardia and chest petechiae and have decreased SaO2. The nurse should notify the rapid response team immediately Incorrect: A. The nurse should expect a productive cough and pleural pain as findings of pneumonia, which is a complication of immobility following pelvic fracture C. The nurse should expect tracheal deviation and absent breath sounds on the affected side for a client experiencing tension pneumothorax, which is a complicaiton of chest trauma or mechanical ventilation D. The nurse should expect anorexia, fatigue, and night sweats in a client who has active TB. Pulmonary TB causes hemoptysis and chest tightness

A nurse is planning care for a client who has cushing's syndrome due to chronic corticosteroid use. Which of the following actions should the nurse include in the plan of care? A. Check the client's blood glucose for hypoglycemia B. Check the client's urine specific gravity C. Weigh the client weekly D. Insert an indwelling urinary catheter for the client

Correct Answer: B The nurse should check the client's urine specific gravity to assess for fluid volume overload Incorrect: A. The nurse should check the client for hyperglycemia becuase hypercortisolism elevates blood glucose levels C. the nurse should weigh the client at the same time each day because treatment decisions are based on these findings D. The nurse should have the client save all urine output to record the results every 24 hr. An indwelling urinary catherer needlessly exposes the client to a potential UTI

A nurse is planning care for a client who has cancer and has developed thrombocytopenia following chemotherapy. Which of the following precautions should the nurse offer to minimize the adverse effects of thrombocytopenia? A. Monitor visitors for manifestations of infection B. Remind the client to use an electric razor C. Encourage frequent rest periods D. Instruct the client to rinse mouth daily with normal saline.

Correct Answer: B Thrombocytopenia is a decrease in the client's blood platelet count, which places the client at an increase risk of bleeding due to the blood's inability to clot. Therefore, the nurse should institute bleeding precautions, including the use of an electric razore Incorrect: A. The client ahs thrombocytopenia, not neutropenia. Neutropenia, which involves a decreased WBC count, places a client at risk of infection; the nurse should monitor for visitors who are ill C. The client has thrombocytopenia, not iron-deficiency anemia. Iron-Deficiency anemia necessitates the encouragement of frequent rest period secondary to fatigue D. Stomatitis, an inflammation of the mucous membranes of the mouth, is not a manifestation of thrombocytopenia. A client who has stomatitis should use blank rinses and avoid commerical mouthwashes that contain alcohol, which migh cause a further breakdown of the oral tissue

A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Wich of the following actions requires the charge nurse to intervene? A. Visualizing the eardrum before irrigating B. Instilling 50 mL of fluid with each irrigation C. Using firm, continuous pressure while irrigating D. Warming the irrigation fluid to at least 37 C (98F)

Correct Answer: B When irrigating a client's ear, the nurse should use no more than 5 to 10 mL of irrigating fluid at a time to decrease the chance of stimualting the vestibular nerve of the inner ear, whihc would result in nausea, vomiting or dizziness. The nurse should stop irrigating if the client experiences pain, nausea, vomiting, or dizziness Incorrect: A. The nurse should use an otoscope to check the location of the impacted cerumen and verify the eardrum is intact efore beginning the irrigation. In order to visualize the ear, the nurse should select a speculum that fits comfortably in the client's ear C. After the client tilts the head slightly towards the unaffected ear, the nurse should gently pull the auricle of the affected ear upward and backward. During irrigation, the nurse should apply gently but firm continuous pressure, allowing the water to flow agains tthe top of the ear canal D. Warming the irrigaition fluid to 98 F will reduce the chance of stimulating the vestibular nerve of the inner ear, which could result in nause, vomiting, or dizziness

A nurse is providing discharge teaching to a client who has aplactic anemia. Which of the following statements indicates that the client understands te instructions? A. "I need to stay active to prevent blood clots in my legs." B. " If I have a bad headache, I can take aspirin to get rid of it." C. " I should eliminate uncooked foods from my diet for now." D. "I should eat more iron-fortified cereal to strengthen my blood."

Correct Answer: C The client can help prevent infection by eating throroughly cooked foods. Fresh fruits, vegetables, eggs, meat, and fish can harbor microorganisms that cooking destroys, so the client should avoid raw foods. Incorrect: A. Although staying active is always a good strategy, clients who have aplastic anemia are not at particular risk for DVT because a common manifestation of this disorder is a low platelet count B. Clients with aplastic anemia should not take aspirin because it can increase bleeding tendencies D. Although iron-fortified cereal is a component of a healthy diet, it is a specific recommendation for clients who have iron-deficiency anemia, not aplastic anemia

A nurse is providing preoperative teaching for a client with colorectal cancer who is scheduled to undergo colostomy placement with perineal wound. Which of the following statements by the client indicates an understanding of the teaching? A. "Not having any more rectal pain will be a relief." B. " I will need to sit on a rubber donut when I am in the chair." C. " I can have only liquids for 2 days before the surgery." D. "The colostomy will start wokring about 7 days after the surgery."

Correct Answer: C The client should consume a full or clear liquid diet 24 to 48 hours before the surgery to decrease bulk. The client should consume a low-residue diet for several days prior to surgery to decrease peristalsis Incorrect: A. Following placement of a clostomy with a perineal wound, rectal sensations such as pain and itching migh occur even after healing the client's surgical wound B. The client should sit on foam pads or soft pillows and avoid the use of rubber donut devices, whihc increase pressure on the incisional site D. Following surgery, the client's colostomy should begin to function within 2 to 4 days

A nurs is caring for a client who is postoperative following a throacic lobectomy. The client has 2 chest tubes in place. 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? A. "Two tubes were necessary due to excessive bleeding from the area of the surgery." B. "the tubes drain blood from 2 different lung areas." C. "The lower tube will drain blood, and the higher tube will remove air." D. "The second tube will tke over if blood clots block the first tube."

Correct Answer: C The tube that is lower ont he thorax will draing blood, adn the tube that is higher on the thorax will allow for removal of air Incorrect A. Excessive bleeding indicates a complication that the surgeon must address B. Blood typically drains from the base of the lung, not the apex D. If a tube becomes blocked, the nurse should report it to the surgeon and prepare to attempt to re-establish patency or remove and replace the tube

A nurse is caring for a client who has a peripherally inserted central catheter (PICC) in place. Which of the following actions should the nurse take when handeling this central venous access device. (SATA) A. Use a 5 mL syringe to flush the line B. Cleanse the insertion site with half-strength hydrogen peroxide C. Flush the line with sterile 0.9% sodium chloride before and after medication administration D. Access the PICC for blood sampling E. Perform a heparin flush of the line at least daily when not in use

Correct Answer: C, D, E The nurse should flush the line with 10 mL of sterile 0.9% NaCl solution before and after adminstering medication through the PICC. The nurse should use a PICC to deliver fluids, medications, and TPN to the client. The PICC is also used to obtain blood samples, and the nurse should practice the appropriate technique to access and flush the line. Ideally, blood samples should come from a 4 French lumen catheter or larger. PICCs can remain in place for months or years. When not actively in use, the nurse should perform heparin flushes at least daily to prevent clotting within the line Incorrect: A. A 5 mL syringe generates too much pressure and could rupture the line. The nurse should use a 10 mL syringe instead B. The nurse should use chlorhexidine for cleansing the insertion site. Chlorhexidine is effective in reducing the incidence of bloodstream infections

A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femure fracture. Which of the following actions should the nurse include in the client's plan of care. A. Offeirng the client a diet high in fluid and fiber B. Encouraging active range of motion on the affected leg. C. Removing weights prior to repositioning the client D. Inspecting the pin site every 24 hr for drainage

Correct Answer: D A client who is immobile is at risk of constipation. The nurse should encourage a diet hihg in fluid and fiber to promote GI function Incorrect: B. Active ROM of the unaffected limbs is encouraged to prevent muscle wasting; however, active ROM of a limb in traction is not feasible, as the traction apparatus limits mobility C. Once the weights are in place, the nurse should not remove them D. The nurse should plan to inspect the client's pin site at least every 8 to 12 hours due to the risk of infection

A nurse is caring for a client following a hip arthroplasty. The nurse places an abduction pillow on the client for which of the following purposes? A. To raise the bed linens off the client's feet to prevent plantar flexion B. To keep the client's heels off the bed to prevent pressure ulcers C. To position the client off the operative site while in bed. D. To prevent dislocation of the hip during position changes or movement

Correct Answer: D Following surgery, the nurse should use an abduction pillow to prevent dislocation of the new hip joint. The nurse should place the wedge-shaped pillow between the client's legs to prevent adduction beyond the midline of the body during position changes or client movement, which can lead to sublucation or total dislocation of the hip joint. Incorrect: A. If the client is at risk for plantar flexion resulting in foot drop, the nurse should place a food cradle at the foot of the bed to raise the bed linens off the feet. B. The nurse should use regualr bed pillows to keep the client's heels off the bed to prevent shearing and skin breakdown C. The nurse should use regular pillows and rolled blankets to position the client off the operative site while in bed

A nurse is teaching a client who has osteoporosis. Which of the following instructions should the nurse include in the teaching? A. Reduce dietary protein intake B. Apply ice to painful areas C. Increase calcium intake to 900 mg per day D. Perform weight-bearing exercises

Correct Answer: D The nurse should instruct the client to perform weight-bearing exercises to promote bone formation and increase strength and mobility Incorrect: A. The nurse should instruct the client to increase the dietary intake of calcium, vitamin D, protein, magnesium, and vitamin K to promote bone formation B. The nurse should instruct the client to apply heat to relieve discomfort C. The nurse should instruct the client to increase the calcium intkae to 1,200 to 1,500 mg per day

A home health nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following foods should the nurse include in the client's plan of care? A. Soft-boiled eggs B. Brie cheese made with unpasteurized milk C. Cold deli-meat sandwiches D. Baked Chicken

Correct Answer: D Well-cooked meats, including baked chicken, do not pose a threat to clients who have neutropenia and may be included in the client's dietary plan. For optimal safety, poultry should be cooked to an internal temp of 74 celcius (165 F) Incorrect: B. Soft cheeses, like brie, which are made with unpasteurized milk, can contain bacteria and should be avoided by clients who have neutropenia. Hard or processed cheeses or those clearly labeled as made with pasteurized milk are an alternative to brie for a client who has neutropenia C. Cold deli meats and lunch meats can contain Listeria monocytogenes. These bacteria remain viable at refrigerated and room temperatures and can make a client who is immunocompromised severely ill. As an alternative, the nurse should recommend heating all deli meats or lunch meats

A nurse is caring for a client who is postoperative following a bilateral adrenalectomy. The nurse should expect to administer glucocorticoids following the procedure to enhance which of the following therapeutic effects? A. Compensations for decreased cortisol levels B. Inhibition of glucose metabolism C. Diuretic action to maintain urine output D. Decreased susceptibility to infection

Correct Answer:A A client who has an adrenalectomy requires glucocorticoids before, during, and after surgery to prevent an adrenal crisis cuased by a sudden drop in cortisol levels. The adrenal glands produce several hormones including cortisol, a glucocorticoid. Loss of glucocorticoid secretion leads to a state of altered metabolism and an inability to deal with stressors; if untreated, this can be fatal Incorrect: B. A client who has an adrenalectomy has increased blood glucose levels due to the increase in the production of glucocorticoids. Glucocorticoids stimulate glucogenesis and are not given to inhibit glucose metabolism C. A client who has an adrenalectomy has fluid retention from the increeased production of glucocorticoids. Glucocorticoids have fluid retention properties and do not act as a diuretic to incresae urine output D. A client who has an adrenalectomy has a higher ris of infection due to the increased production of glucocorticoids. Glucocorticoids have potent anti-inflammatory and immunosuppressive properties and raise the client's susceptibilty to infection

A charge nurse is observing a newly licensed nurse provide care for a client who is receiving internal radiation therapy for the treatment of cervical cancer. For which of the following actions by the newly licensed nurse should the charge nurse intervene? A. Leaving soiled linens in a container in the client's room B. Instructing visitors to remain 2m (6 ft) away from the client C. Borrowing a dosimeter film badge from another nurse before entering the client's room. D. Removing an extra IV pole from the client's room to be used for another client

Correct Answer:C A nurse should never borrow a dosimeter film badge from another staff memeber. Nurses who are caring for the client should each have a personal badge and wear it while in the client's room. The badge measures the radiation exposure that the nurse is receiving , and each film badge will indicate the nurse's cumulative radiation exposure. Incorrect: A. The nurse should keep all dressings and linens in the client's room until after the radiation has been discontinued B. The nurse should instruct visitors to limit their time with the client to 30 minutes per day and stay 2 m ( 6 ft) away from the client D. Equipment can be removed from the client's room at any time without special precautions. the equipment does not pose a hazard to other people becuase it is not emitting radiation. Items that should be given special consideration prior to removal are solid dressings or linen

A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client the lower chest tube is placed for which of the following reasons? A. Removing air from the pleural space B. Creating access for irrigating the chest cavity C. Evacuating secretions from the broncioles and alveoli D. Draining blood and fluid from the pleural space

Correct Answer:D The nurse should inform the client that blood and fluids tend to accumulate in the bases and posterior areas of the pleural cavity following a lobectomy. For this reason. the lower chest tube primarily drains blood and fluid from the pleural space. Incorrect: A. The upper chest tube removes air from the pleural space B. The chest tubes are not used for irrigation following a lobectomy C. Secretions are removed from the airways via tracheal suctioning rather than chest tubes

A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client over 4 hours. A blood administration set is available that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min? (Rounc to the nearest whole number, and use a leading zero if applicable.)

Correct answer: 10 gtt/min

A nurse is teaching a client whom has chronic kidney disease (CKD). Whic of the following instructions should the nurse include? A. Limit fluid intake B. Limit caloric intake C. Eat a diet high in phosphorus D. Eat a diet high in protein

Correct answer: A A client who ahs CKD should limit fluid intake to prevent hypervolemia (excessive fluid overload) Incorrect: B. A client who has CKD should increase caloric intake so that the body can use protein for protein synthesis instead of energy consumptiojn. using protein for energy can lead to a negative nitrogen balance and malnutrition C. A client who has CKD should limit phosphorus intake because the kidneys are unable to excrete it D. A client who has CKD should not eat excessive protein to prevent the build-up of protein waste products and uremia

A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm^3. Which of the following interventions should the nurse include? A. Avoid IM injections B. Assess the client for ecchymosis once per shift C. Do not allow the client to have visitors D. Encourage daily flossing between teeth

Correct answer: A The client's platelet count indicates thrombocytopenia; therefore, the nurse should avoid invasive procedures such as an IM injection which can increase the client's risk of bleeding Incorrect: B. The nurse should assess the client for indications of bleeding, including ecchymosis, at least every 4 hours C. The nurse should limit but not disallow visitors for a client who has neutropenia D. The nurse should promote safe oral hygiene but should instruct the client to avoid flossing due to the risk of bleeding

A nurse is caring for a client who smoked cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation? A. Discuss ways the client can reduce the number of cigarettes smoked per day B. Suggest the client switch from smoking cigarettes to smoking a pipe C. Inform the client that treatment will be ineffective if smoking continues D. Discourage the use of nicotine gum

Correct answer: A The nurse should discuss ways the client can reduce the number of cigarettes smoked per day to assist the client in creating a realistic goal to decrease smoking gradually Incorrect: B. Pipe smoking still exposes the client to harmful smoke C. The client will benefit from treatment if smoking continues; However, treatment is more effective if the client stops smoking cigarettes. D. The nurse should encourage the use of nicotine gum to assist the client in smoking cessation

A nurse is teaching a client who has a cast on his left arm to treat a forearm fracture. Which of the followign statements indicates that the client understands the teaching? A. "I'll call the doctor's office if my fingers get colder on the arm with the cast." B. "If I hav any itching under the cast, I'll try to reach the area with a cotton swab." C. "If my fingers swell, I should put a heating pad on them and rest." D. " If I have any tingling under my cast, I'll know I need to move my fingers more."

Correct answer: A The nurse should emphasize the importance of doing neurovascular checks and notifying the provider of any unexpected findings, such as temperature variances Incorrect: B. The client should not insert any objects under the cast to relieve itching. Instead, the client can try blowing cool air from a blow dryer under the cast to relieve itching. C. The client should elevate his arm to reduce swelling. Some providers prescribe ice packs for the first 24 to 48 hours, which might also help reduce swelling. D. Tingling can indicate compartment syndrome, a complication that involves increased pressure within the fascia leading to reduced circulation to the area. It can also mean the cast is too tight. The client should report this finding to the provider immediately.

A nurse is performing discharge teaching about ostomy care while at home for a client who has newly placed ileostomy. Which of the following insturction should the nurse include in the teaching? A. "empty your ostomy pouch when it becomes half full" B. "place an aspirin in the ostomy pouch to eliminate odor" C. "Change the ostomy appliance every week." D. "Cleanse the site around the stoma with hydrogen peroxide and water."

Correct answer: A The nurse should instruct the client to empty the ostomy pouch when it is one-third to one-half full. This prevents the ostomy from becoming too full of stool and gas and exploding. Incorrect: B. The nurse should instruct the client to avoid placing an aspirin in the ostomy pouch to eliminate odor. This can cause irritation of the skin and ulceration of the stoma. Instead, a breath mint can be place in the ostomy pouch to assisst witht he odor C. The nurse should instruct the client to change the ostomy appliance every 2 weeks. Changing it too prequently can irritate the client's skin D. The nurse should instruct the client to cleanse the site around the stoma with mild soap and water prior to place the appliance

A nurse is preparing to test the function of cranial nerve X. Which of the following assessment procedures should the nurse use? A. Have the client open his mouth and say "aah" B. Ask the client to ID the scent of coffee C. Use a tongue blade to provoke a gag reflex D. Have the client smile and raise his eyebrows

Correct answer: A The vagus or X nerve has both sensory and motor functions. To test the motor function, the nurse should have the client open his mouth and say "aah". The palate and the uvula should move upward in response. The nurse should also assess the client's voice quality for hoarseness Incorrect: B. Asking the client to ID the scent of coffee assesses the fucntion of cranial nerve I, the olfactory nerve C. Using a tongue blade to provoke a gag reflex assesses the function of cranial nerve IX, the glossopharyngeal nerve D. Having the client smile and raise his eyebrow assesses the function of cranial nerve VII, the facial nerve

A nurse is caring for a postmenopausal client who is concerned that she might have an elevated risk of breast cancer. After conducting a risk assessment, the nurse should ID which of the following factors as increasing the client's breast cancer risk? (SATA) A. Increased breast density B. BMI of 32 C. Having given birth to 5 children D. Undergoing hormonal repleacement therapy for 10 years E. Having 1-2 alcoholic drinks per week

Correct answer: A, B, D Women who ahve dense breast tissue are at an increased risk for developing breast cancer because they have more connective and glandular breast tissue. Postmenopausal obesity increases the risk of developing bresat cancer. Hormone-related risks for developing breast cancer include the long-term use of oral contraceptive or hormone replacement therapy, early menarch, late menopause, and first pregnancy after 30 years of age. Incorrect: C. Women who are nulliparous have higher risk of developing breast cancer E. Consuming 3-14 alcoholic beverages per week increases the risk of developing breast cancer

A nurse is caring for a client who had a thyroidectomy to treat hyperthyroidism caused by an adenoma. Which of the following findings should the nurse report to the provider? (SATA) A. Tachycardia and hypertension B. Respiratory rate 16/min C. Negative Chvostek's sign D. Laryngeal stridor and hoarseness E. Positive Trosseau's sign

Correct answer: A, D, E Tachycardia and hypertension are unexpected findings that can indicate teh occurence of thyroid storm following removal of the thyroid gland, especially if the client was in a hyperthyroid stage prior to the surgery. Thyrotoxicity (thyroid storm) is a life-threatening condition with a sudden onset that includes tachycardia, a fever, sweating, restlessness, and tremors. Congestive HF and pulmonary edema can develop rapidly and lead to death Laryngeal stridor and hoarseness are unexpected findings and can indicate swelling in the area of the surgery or damage to the laryngeal nerve. This should be reported to the provider before respiratory distress develops. A positive Trosseau's sign is an indication of hypocalcemia, which is a complication of thyroid removal. This occurs when the parathyroid glands are also removed and regulations of serum calcium is impaired Incorrect: B. A respiratory rate of 16/min is within the expected reference range C. A positive Chvostek's sign (facial muscle spasm after tapping the facial nerve in front of the ear) indicates ypoglycemia, a complication of thyroid removal. This occurs when the parathyroid glands are also removed and regulation of serum calcium is impaired.

A nurse is caring for a client who has breast cancer and is recieving a combination of chemotherapy medications. The client expresses confusion about the therapy. Which of the following explanations should the nurse provide? A. "The risk of renal toxicity is lessened when a combination of chemotherapy medications is used." B. "The chemotherapy medications act at different stages of cell division so more tumor cells are detroyed." C. "The use of more chemotherapy medications will shorten the time you have to be in treatment." D. "The combination of chemotherapy medications will eliminate the potential for bone marrow suppression."

Correct answer: B Different chemotherapeutic agents act at various stages of cellular mitosis. By combining agents, medication therapy is more effective in stopping or slowing the growth of cancerous cells by interfering with their ability to multiply Incorrect: A. A combination of chemotherapeutic agents does not lessentthe incidence of renal toxicity C. A combination of chemotherapeutic agents does not ensure a shorter duration of treatment D. Eliminating the suppression of bone marrow caused by chemotherapeutic medications is not possible. The extent of bone marrow suppression depends on the specific medications being adminstered

A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the nurse expect? A. Excessive Salivation B. Finger contractures C. Periorbital edema D. Alopecia

Correct answer: B Scleroderma is a chronic disease tha can causes thickening, hardening, or tightening of the skin, blood vessels, and internal organs. There are 2 types of scleroderma, which mainly affects the skin, and systemic scleroderma, which can affect internal organs. Manifestation include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and dry mucous membranes. With Scleroderma, the body produces and deposits too much collagen, cuasing thickening and hardening. In addition to the client's skin and subcutaneous tissues becoming increasingly hard and rigid, the extremities stiffen and lose mobility. Constractures develop with advanced systemic scleroderma unless clients follow a regimen of ROM and muscle-strenghtening exercises. Incorrect: A. Clients who have systemic scleroderma experience decreased salvation, which increases the risk of dental carier and gum disease C. Clients who have scleroderma develop ankle and pedal edema due to the constriction of blood vessels as a results of renal failure. D. Clients who have scleroderma can lose hari in affected areas; however, alopecia is not a finding associated with systemic scleroderma

A nurse is reviewing the laboratory report of a client who has chronic kidney disease. The nurse finds the laboratory test results: Potassium 6.8 mEq/L, calcium 7.4 mg/dL, hemoglobin 10.2g/dL, and phosphate 4.8 mg/dL. Which finding is the priority for the nurse to report to the provider? A. Hypocalcemia B. Hyperkalemia C. Anemia D. Hypoalbuminemia

Correct answer: B The nurse should apply the urgent versus nonurgent priority-setting framework when caring for this client. Using this framework, the nurse should consider urgent needs the priority need because they pose more of a threat to the client. The nurse may also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the more urgent. Hyperkalemia, which can cause life-treatening cardiac dysrhytmias, is the prority for the nurse to report to the provider Incorrect: A. Hypocalcemia is an expected finding with CKD; therefore, another finding is the priority for the nurse to report to the provider. The decreased calcium level would require reporting if the client developed muscle spasms or twitching C. Anemia is an expected finding with CKD; therefore, another finidng is the priority for the nurse to report to the provider D. Hyperphosphatemia is an expected finding with CKD; therefore, another finding is the priority for the nurse to report to the provider.

A nurse is preparing a client for a bone scan. Which of the following statements indicates that the client understands the pre-procedure teaching. (SATA) A. "I will have to drink a radioactive solution before the test begins." B. "A special camera will scan the bones in my entire body." C. "There will be better absoprtion of the radiation by healthy bone." D. "I'll have to drink a lot of water to help get the radiation out of my body." E. "I understand the radiation is harmless, and I don't have to worry about it."

Correct answer: B, D, E A bone scan is a radionuclide procedure that allows viewing of the entire skeleton. It is less common than other diagnostic tests but is still useful for identifying hairline fractures and some malignancies. The client should drink plenty of fluids to promote urinary exretion of the radioactive material. Also, the nurse should reassure the client that the radioactive material is not dangerous because it deteriorates quickly in the body and exits via urine and stool. Incorrect: A. For a bone scan, the client will receive the radioactive material via IV injection C. Increased absoprtion of contract material indicates bone disease and disorders

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? A. Bradycardia with ST-segment depression B. Relief of chest pain with deep inspiration C. Dyspnea with hiccups D. Chest pain that increases when sitting upright

Correct answer: C A client who has pericarditis will experience dyspnea, hiccups, and a non-productive cough. These manifestations can indicate HF from pericardial compression due to constrictive or cardiac tamponade Incorrect: A. Pericarditis is usually seen on an ECG as an ST-T spiking. This elevations represents ischemic changes caused by inflammation around the heart. A client who has pericarditis will have tachycardia becuase of dereased cardiac output and oxygen perfusion B. Chest pain associated with pericarditis will increase with deep inspiration duet to greater pressure on the pericardial sac D. Chest discomfort associated with pericarditis will decrease when the client sits upright or leans forward, as this relieves pressure in the pericardial sac

A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? A. Endoscopic sclerotherapy B. Liver lobectomy C. Liver transplant D. Transjugular intrahepatic portal-systemic shunt placement

Correct answer: C Fulminant hepatic failure, most often caused by viral hepatitis is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal, hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients Incorrect: A. Endoscopic sclerotherapy is the injection of schlerotherapy agent during an endoscopy to target esophageal varices that are actively bleeding. This promotes thrombosis, which eventually leads to sclerosis B. A liver lobectomy is used for localized cancer of a lobe of the liver. This is not appropriate for a client experiencing rapidly progressive liver failure D. A transjugular intrahepatic portal-systemic shunt is placed to treat esophageal varices through a stent into the portal vein. The stent serves as a shunt between the portal circulation and the hepatic vein, thereby reducing portal hypertension. It is not used for fulminant hepatic failure.

A nurse is assessing a client who has an exacerbation of herpers zoster. Which of the following manifestations of the client's skin should the nurse expect? A. Confluent, honey-colored, crusted leisons B. A large, tender nodule located on a hair follicle C. Unilateral, localized, nodular leisons. D. A fluid-filled vesicular rash in the genital region

Correct answer: C Herpes Zoster, or shingles, results from the reactivation of a formant varicella virus. it is the acute, unilateral inflammation of the dorsal root ganglion. The infection typically develops in adults and produces localized vesicular leisons confined to a dematome. it produces localized, nodular skin leisons Incorrect: A. Confluent ("gathered together"), honey colored, crusted leisons are typically associated with impetigo B. This describes furuncle or bacterial infection on a hair follicle D. This manifestation indicates genital herpes, which is caused by the herpes simplex virus

A nurse is preparing to transfuse a unit of packed RBCs for a client who has anemia. Which of the following actions should the nurse take first? A. Hang an IV infusion of 0.9& sodium chloride with the blood B. Compare the client's ID number witht he number on the blood C. Witness the informed consent document D. Obtain pretransfusion VS

Correct answer: C The nurse should apply the least invasive priority-setting framework, which assigns priority to nursing interventions that are the least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive; therefore, since witnessing the informed consent is the least invasive action, it should be performed first. Unless it is an emergency, informed consent should be obtained prior to initiating a blood transfusion for a client. Incorrect: A. The nurse should hang an IV infusion of 0.9% sodium chloride with the blood to dilute the blood and maintain the IV infusion line. however, the nurse should perform a less-invasive intervention first. B. The nurse should check the client's ID number against the number on the blood to ensure the client receives the correct unit of blood. With another nurse, the nurse should check the provider prescription, the ID of the blood product, the client, and the compatibility (blood type and Rh factor) of the blood and the client. however, the nurse should perform a less-invasive intervention first. D. The nurse should obtain the client's pretransfusion VS prior to infusing the packed RBCs. however, the nurse should perform a less-invasive intervention first.

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following statements indicates the client understands the instructions? A. "I should try to drink at least 2 L of fluid per day." B. "I can still fly out to visit my sister in Colorado for a while." C. " Physical activity is good for me, but I need to avoid overexertion." D. "I can still go skiing during the cold winter months."

Correct answer: C To help prevent a recurrence of sickle cell crisis, the client should avoud overexertion from especially strenuous activities. Incorrect: A. To help pervent a recurrence of sickle cell crisis, the client should drink 3 to 4 L of fluid per day B. To help prevent a recurrence of sickle cell crisis, the client should avoid traveling tom high altititudes and in airplanes since passenger cabins are non-pressurized D. To help prevent a recurrence of sickle cell crisis, the client should avoid recreation activities that require persistent exposure to cold weather.

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP). After the nurse discontinues the client's urinary catheter, which of the following findings should the nurse report to the provider? A. Pink-tinged urine B. Report fo burning upon urination C. Stress incontinence D. Decreased urine output

Correct answer: D A decrease in urine output after TURP indicates and obstruction to urine flow by a clot or residual prostatic tissue and should be reported to the provider Incorrect: A. Pink-tinged urine and blood clots are expected findings for several days followign a TURP B. Burning with urination and urinary frequency are expected findings after a TURP and should decrease after several days C. Stress incontinence is an expected finding following a TURP due to poor sphincter control

A nurse is planning a presentation for a group of older adults at a community center about risk factors for cancer. Which of the following factors increases the risk of developing cancer after age 60? A. High-protein diet B. Insufficient calcium intake C. Declining muscle mass D. Weakened immune response

Correct answer: D After age 60, clients have a higher risk of cancer due to hormonal changes, altered immune responses, and the accumulation of free radicals. Age is a significant factor because teh longer people are exposed to external carcinogenic facotrs, the greater their risk of developing cancer becomes Incorrect A. A high-fat, low-fiber diet is a risk factor for developing colon cancer B. ALthough an insufficient intake of calcium and vitamin D can cause loss of bone density, it is not a specific risk factor for developing cancer C. Although a decline in muscle mass is common with aging, it is a risk facotr for mobility problems, not for developing cancer

A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should ID that which of the following findings is an adverse effect of this medication? A. Hallucinations B. Pruritus C. Hand and foot syndrome D. Tinnitus

Correct answer: D An adverse effect of cisplatin is ototoxicity, which can cause tinnitus Incorrect: A. Hallucinations are an adverse effect of asparaginase, which is an antineoplastic medication used to treat accute lymphocytic leukemia. B. Prutitus is an adverse effect of methotrexate, which is used to treat cancer and RA C. Hand and foot syndrome is an adverse effect, capecitabine, an antineoplastic medication used to treat breast and colorectal cancer

A nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on the toes. Which of the following findings of PVD is a risk factor for ulceration on the extremities? A. Insufficient skin care B. Dehydration C. Immobility D. Impaired circulation

Correct answer: D Prolonged arterial insufficiency from PVD can contribute to the formation of ulcerations on the client's toes. Severe arterial disease is ID through an assessment of the quality of the client's posterior tibila pulses by comparing the pulsses in both feet. Incorrect: A. Insufficient skin care is not the cause of ulcerations on the toes of a client who has PVD> However, poor skin care can lead to skin infections and breakdown B. Dehydration is not the cause of ulcerations of the client's toes. However, deydration can delay wound healing C. Immobility can cause pressure ulcers if the client is not turned frequently. However, ulcerations of the client's toes are not caused by immobility

A nurse is caring for a client who has COPD and is experiencing SOB. Which of the following actions should the nurse perform first? A. Monitor the client's arterial blood gas results B. Instruct the client to perform controlled coughing C. Teach the client how to use pursed-lip breathing D. Place the client in an upright position

Correct answer:D Using the airway, breathing, and circulation (ABC) approach to client care, the nurse should place the client in an upright position to facilitate chest expansion and proper diaphragmatic contraction. Positioning the cleint upright will also assist with mobilizing secretions that might be impeding airflow Incorrect: A. The nurse should monitor the client's arterial blood gas results to determine oxygenation levels; However, there is another action the nurse should take first B. The nurse should instruct the client to perform controlled coughing when not experiencing SOB; however, there is another action the nurse should take first C. The nurse should teach the client how to use pursed-lip breathing when not experiencing SOB; however, there is another action the nurse should take first


Conjuntos de estudio relacionados

3D Printing: What You Need to Know

View Set

CISSP Official ISC2 practice tests - Domain 6

View Set

Fredrick Taylor Principles of scientific management

View Set

MKTG 350 Chapter 18: Integrated Value Communication

View Set

Three Branches of Government Test Review

View Set