Comprehensive Quiz SS21
Long-term oxygen therapy has been prescribed for a patient whose chronic obstructive pulmonary disease (COPD) has recently increased in severity. When teaching this patient about this treatment modality, what information should the nurse provide? "In time, you will learn to effectively adjust your flow rates depending on the dyspnea you are experiencing or that you anticipate." "It's important to use your oxygen as ordered and not to base it solely on your shortness of breath at the time." "A good rule of thumb is to temporarily stop your oxygen whenever you feel like you could comfortably go without it." "Try to predict those situations where you'll need oxygen and apply your nasal prongs 30 minutes ahead of time."
"It's important to use your oxygen as ordered and not to base it solely on your shortness of breath at the time." Patients requiring oxygen therapy need to be taught the importance of adhering to the oxygen prescription. Patients often think they can tell when they need oxygen by their symptoms. The presence or absence of dyspnea is unreliable in detecting the need for supplemental oxygen. Many hypoxemic patients do not feel dyspnea. Additionally, many patients who are dyspneic do not have significant hypoxemia or oxygen desaturation.
A patient with a diagnosis of peptic ulcer disease has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medication's therapeutic action? "This medication will reduce the amount of acid secreted in your stomach." "This medication will make the lining of your stomach more resistant to damage." "This medication will specifically address the pain that accompanies peptic ulcer disease." "This medication will help your stomach lining to repair itself."
"This medication will reduce the amount of acid secreted in your stomach." Proton pump inhibitors like Prilosec inhibit the synthesis of stomach acid. PPIs do not increase the durability of the stomach lining, relieve pain, or stimulate tissue repair.
A client has been diagnosed with Raynaud's disease. Which self-care strategies minimize risks associated with this disease? Select all that apply. Wear gloves to protect hands from injury when performing tasks. Do not smoke, or stop smoking. Avoid over-the-counter decongestants and cold remedies. Refrain from going outdoors in cold weather. Limit activities that place stress on the ulnar nerve.
-Do not smoke, or stop smoking. -Wear gloves to protect hands from injury when performing tasks. -Avoid over-the-counter decongestants and cold remedies. The nurse instructs clients with Raynaud's disease to quit smoking; avoid over-the-counter decongestants, cold remedies, and drugs for symptomatic relief of hay fever because of their vasoconstrictive qualities; protect hands and feet from injury; and wear warm socks and mittens when going outdoors in the cold weather.
An older adult is postoperative day one, following a coronary artery bypass graft (CABG). The client's family members express concern to the nurse that the client is uncharacteristically confused. After reporting this change in status to the health care provider, what additional action should the nurse take? Educate the family about how confusion is expected in older adults postoperatively. Assess for factors that may be causing the client's delirium. Document the early signs of dementia and ensure the client's safety. Reorient the client to place and time.
Assess for factors that may be causing the client's delirium. Uncharacteristic changes in cognition following cardiac surgery are suggestive of delirium. Dementia has a gradual onset with organic brain changes and is not an acute response to surgery. Assessment is a higher priority than reorientation, which may or may not be beneficial. Even though delirium is not rare, it is not considered to be an expected part of recovery.
A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? Assess pulse of affected extremity every 15 minutes at first. Palpate the affected leg for pain during every assessment. Assess the client for signs and symptoms of compartment syndrome every 2 hours. Perform Doppler evaluation once daily.
Assess pulse of affected extremity every 15 minutes at first. The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the client's status remains stable. Doppler evaluations should be performed every 2 hours. Pain is regularly assessed, but palpation is not the preferred method of performing this assessment. Compartment syndrome results from the placement of a cast, not from vascular surgery.
The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack? Report changes in the usual pattern of chest pain. Avoid situations that contribute to ischemic episodes. Avoid fatty foods and exercise. Take over-the-counter decongestants.
Avoid situations that contribute to ischemic episodes. Teaching for clients with Raynaud's disease and their family members is important. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.
The nurse is caring for a client who is receiving a loop diuretic for the treatment of heart failure. What assessment should the nurse prioritize? Monitoring liver function studies Blood pressure Vitamin D intake Monitoring potassium levels
Blood pressure Diuretic therapy increases urine output and decreases blood volume, which places the client at risk of hypotension. Clients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.
A client sustains a fractured right humerus in an automobile accident. The arm is edematous, the client states that he cannot feel or move his fingers, and the nurse does not feel a pulse. What condition should the nurse be concerned about that requires emergency measures? Compartment syndrome Dislocation Muscle spasms Subluxation
Compartment syndrome Separation of adjacent bones from their articulating joint interferes with normal use and produces a distorted appearance. The injury may disrupt local blood supply to structures such as the joint cartilage, causing degeneration, chronic pain, and restricted movement. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space. The fractured humerus may also be dislocated but is not the result of the impaired circulatory status. Muscle spasms may occur around the fracture site but are not the cause of circulatory impairment. Subluxation is a partial dislocation.
What interventions can the nurse encourage the client with diabetes insipidus to do in order to control thirst and compensate for urine loss? Come to the clinic for IV fluid therapy daily. Limit the fluid intake at night. Consume adequate amounts of fluid. Weigh daily.
Consume adequate amounts of fluid. The nurse teaches the client to consume sufficient fluid to control thirst and to compensate for urine loss. The client will not be required to come in daily for IV fluid therapy. The client should not limit fluid intake at night if thirst is present. Weighing daily will not control thirst or compensate for urine loss.
A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response? Administer a Fleet enema as prescribed and remain with the client. Contact the primary provider promptly and report these signs of perforation. Position the client supine and insert an NG tube. Page the primary provider and report that the client may be obstructed.
Contact the primary provider promptly and report these signs of perforation. The client's change in status is suggestive of perforation, which is a surgical emergency. Obstruction does not have this presentation involving fever and abdominal rigidity. An enema would be strongly contraindicated. An order is needed for NG insertion and repositioning is not a priority.
A diabetes nurse educator is teaching a group of clients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic client? Do not eliminate insulin when nauseated and vomiting. Report elevated glucose levels greater than 150 mg/dL (8.3 mmol/L). Eat three substantial meals a day, if possible. Reduce food intake and insulin doses in times of illness.
Do not eliminate insulin when nauseated and vomiting. The most important issue to teach clients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, and then attempt to consume frequent, small portions of carbohydrates. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL (16.6 mmol/L).
How should the nurse best position a client who has leg ulcers that are venous in origin? Keep the client's legs flat and straight. Keep the client's knees bent to 45-degree angle and supported with pillows. Elevate the client's lower extremities. Dangle the client's legs over the side of the bed.
Elevate the client's lower extremities. Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Dangling the client's legs and applying pillows may further compromise venous return.
The surgeon's preoperative assessment of a client has identified that the client is at a high risk for venous thromboembolism. Once the client is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the client's risk of this complication? Maintain the head of the bed at 45 degrees or higher. Encourage early ambulation. Encourage oral fluid intake. Perform passive range-of-motion exercises every 8 hours.
Encourage early ambulation. The benefits of early ambulation and leg exercises in preventing DVT cannot be overemphasized, and these activities are recommended for all clients, regardless of their risk. Increasing the head of the bed is not effective. Ambulation is superior to passive range-of-motion exercises. Fluid intake is important, but is less protective than early ambulation.
An elderly female resident of a long-term care facility has a diagnosis of Alzheimer's disease (AD). The resident is visibly anxious and is insisting to the nurse that she needs to "take care of my babies." How should the nurse respond to the resident's statement? Reorient the resident to the fact that she does not have young children. Ask the resident questions about her children to help her realize that her children are now adults. Ignore the resident's statement and return to the room later. Engage the resident in a conversation about a different topic.
Engage the resident in a conversation about a different topic. Attempts at reorientation can exacerbate the stress and frustration of an individual with AD. It is inappropriate and ineffective to ignore the resident. Redirection is likely of greater therapeutic benefit.
A 60-year-old man with several health problems and a history of increasing joint stiffness over the past several months is being assessed for the presence of rheumatic diseases. Which of the following laboratory findings is most clearly suggestive of an inflammatory process? Erythrocyte sedimentation rate (ESR) of 22 mm/hr (normal 0 to 20 mm/hr) Ammonia level of 55 µmol/L (normal 12 to 55 µmol/L) Lactic acid of 2.0 mEq/L (normal 0.6 to 1.8 mEq/L) Albumin 3.3 g/dL (normal 3.5 to 5.0 g/dL)
Erythrocyte sedimentation rate (ESR) of 22 mm/hr (normal 0 to 20 mm/hr) An increased ESR is indicative of an inflammatory process. Elevated ammonia, elevated lactic acid, and low albumin are not suggestive of a rheumatoid disorder.
A nurse should perform which intervention for a client with Cushing's syndrome? Offer clothing or bedding that's cool and comfortable. Suggest a high-carbohydrate, low-protein diet. Explain that the client's physical changes are a result of excessive corticosteroids. Explain the rationale for increasing salt and fluid intake in times of illness, increased stress, and very hot weather.
Explain that the client's physical changes are a result of excessive corticosteroids. The nurse should explain to the client that Cushing's syndrome causes physical changes related to excessive corticosteroids. Clients with hyperthyroidism, not Cushing's syndrome, are heat intolerant and must have cool clothing and bedding. Clients with Cushing's syndrome should have a high-protein, not low-protein, diet. Clients with Addison's disease must increase sodium intake and fluid intake in times of stress of prevent hypotension.
A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? Instruct the client to lie on the bed when eating. Offer liquids frequently and in large quantities. Help the client sit upright when eating and feed slowly. Allow optimum physical activity before meals to expedite digestion.
Help the client sit upright when eating and feed slowly. Having the client sit upright, preferably out of bed in a chair, and instructing him or her to tuck the chin toward the chest when swallowing will help prevent aspiration. The client may be started on a thick liquid or puréed diet, because these foods are easier to swallow than thin liquids. The diet may be advanced as the client becomes more proficient at swallowing. If the client cannot resume oral intake, a gastrointestinal feeding tube is placed for ongoing tube feedings and medication administration. The client should be allowed to rest before meals because fatigue may interfere with coordination and following instructions.
The nurse is assessing a client with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which condition as a sign/symptom of possible hemorrhage? Hematemesis Bradycardia Hypertension Polyuria
Hematemesis The nurse interprets hematemesis as a sign/symptom of possible hemorrhage from the ulcer. Other signs that can indicate hemorrhage include tachycardia, hypotension, and oliguria/anuria.
The nurse is assessing a client in the clinic who appears restless, excitable, and agitated. The nurse observes that the client has exophthalmos and neck swelling. What diagnosis do these clinical manifestations correlate with? Hypothyroidism Hyperthyroidism Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Diabetes insipidus (DI)
Hyperthyroidism Clients with hyperthyroidism characteristically are restless despite feeling fatigued and weak, highly excitable, and constantly agitated. Fine tremors of the hand occur, causing unusual clumsiness. The client cannot tolerate heat and has an increased appetite but loses weight. Diarrhea also occurs. Visual changes, such as blurred or double vision, can develop. Exophthalmos, seen in clients with severe hyperthyroidism, results from enlarged muscle and fatty tissue surrounding the rear and sides of the eyeball. Neck swelling caused by the enlarged thyroid gland often is visible. Hypothyroidism clinical manifestations are the opposite of what is seen as hyperthyroidism. SIADH and DI clinical manifestations do not correlate with the symptoms manifested by the client.
A nurse teaches a client with newly diagnosed hypothyroidism about the need for thyroid hormone replacement therapy to restore normal thyroid function. Which thyroid preparation is the agent of choice for thyroid hormone replacement therapy? Methimazole (Tapazole) Thyroid USP desiccated (Thyroid USP Enseals) Liothyronine (Cytomel) Levothyroxine (Synthroid)
Levothyroxine (Synthroid) Levothyroxine is the agent of choice for thyroid hormone replacement therapy because its standard hormone content provides predictable results. Methimazole is an antithyroid medication used to treat hyperthyroidism. Thyroid USP desiccated and liothyronine are no longer used for thyroid hormone replacement therapy because they may cause fluctuating plasma drug levels, increasing the risk of adverse effects.
After suffering a fall, an 81-year-old woman with Alzheimer's disease (AD) is being treated in the hospital. Which of the following measures should be implemented in an effort to support the patient's cognitive function? Maintain consistent, predictable routines whenever possible. Provide an engaging, high-stimulation environment. Establish clear consequences for aggressive behavior. Ensure that the patient has a different care provider each day.
Maintain consistent, predictable routines whenever possible. A calm, predictable environment helps people with AD interpret their surroundings and activities. Consistent staffing may thus be beneficial. It is likely ineffective and inappropriate to use consequences to address unwanted behaviors.
A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which intervention? Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential Monitoring the client's breathing and reviewing the client's arterial blood gases Monitoring the client's heart rate and reviewing the client's hemoglobin Monitoring the client's blood pressure and reviewing the client's hematocrit
Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential Clients with neutropenia often do not exhibit classic signs of infection. Fever is the most common indicator of infection, yet it is not always present. No definite symptoms of neutropenia appear until the client develops an infection. A routine CBC with differential can reveal neutropenia before the onset of infection.
A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments? Oxygen through nasal cannula at 2 L/minute Intravenous methylprednisolone (Solu-Medrol) 120 mg Ipratropium bromide (Alupent) by metered-dose inhaler Vancomycin 1 gram intravenously over 1 hour
Oxygen through nasal cannula at 2 L/minute When a client presents in the emergency department with an exacerbation of COPD, the nurse should first administer oxygen therapy and perform a rapid assessment of whether the exacerbation is potentially life threatening.
Nursing students are reviewing information about Parkinson's disease in preparation for class the next day. The students demonstrate understanding of the material when they identify which of the following as a cardinal sign of this disorder? Select all that apply. Tremor Rigidity Bradykinesia Postural instability Intellectual decline
Rigidity Postural instability Bradykinesia Tremor Cardinal signs of Parkinson's disease are tremor, rigidity, bradykinesia, and postural instability. Although mental status changes can occur over the course of the disease, intellect is usually not affected.
A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage? The client has been lying on his side for 2 hours with the drain positioned upward. The client has a nasogastric (NG) tube in place that drained 400 ml. The Hemovac drain isn't compressed; instead it's fully expanded. There is a moderate amount of dry drainage on the outside of the dressing.
The Hemovac drain isn't compressed; instead it's fully expanded. The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.
A client is prescribed pilocarpine. When preparing the client's teaching plan about this drug, which of the following would the nurse integrate? It acts to decrease aqueous humor production. The client may experience difficulty seeing in the dark. The client's pupils will most likely be dilated. The client may experience a dry mouth and nose.
The client may experience difficulty seeing in the dark. Pilocarpine is a miotic (cholinergic) agent that causes pupillary constriction and increased aqueous fluid outflow. It does not decrease aqueous humor production. Subsequently, the client may experience difficulty seeing in the dark. Dry nose and mouth are associated with alpha-adrenergic agents, such as apraclonidine or brimonidine.
Early this morning, a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client (who now has nausea) and records a temperature of 105°F (40.5°C), tachycardia, and extreme restlessness. What is the most likely cause of these signs? Diabetic ketoacidosis Thyroid crisis Hypoglycemia Tetany
Thyroid crisis Thyroid crisis usually occurs in the first 12 hours after thyroidectomy and causes exaggerated signs of hyperthyroidism, such as high fever, tachycardia, and extreme restlessness. Diabetic ketoacidosis is more likely to produce polyuria, polydipsia, and polyphagia. Hypoglycemia is likely to produce weakness, tremors, profuse perspiration, and hunger. Tetany typically causes uncontrollable muscle spasms, stridor, cyanosis, and possibly asphyxia.
The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse? Administer the medication and inform the charge nurse about the rate. Withhold the medication and notify the physician of the heart rate. Administer atropine to speed the heart rate and then administer the digoxin. Administer the medications and then notify the physician.
Withhold the medication and notify the physician of the heart rate. Digitalis drugs are withheld if the heart rate is less than 60 or more than 120 beats/minute until a physician is consulted. The other choices would have the nurse administer the drug, which would not be the standard of practice.
A nurse is documenting the results of assessment of a client with bronchiectasis. What would the nurse most likely include in documentation? Sudden onset of pleuritic chest pain Wheezes on auscultation Increased anterior-posterior (AP) diameter Clubbing of the fingers
clubbing of the fingers Characteristic symptoms of bronchiectasis include chronic cough and production of purulent sputum in copious amounts. Clubbing of the fingers also is common because of respiratory insufficiency. Sudden pleuritic chest pain is a common manifestation of a pulmonary embolism. Wheezes on auscultation are common in clients with asthma. An increased AP diameter is noted in clients with COPD.
What finding by the nurse may indicate that the client has chronic hypoxia? Crackles Peripheral edema Clubbing of the fingers Cyanosis
clubbing of the fingers Clubbing of the fingers is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the nail bed angle. It is a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung. Cyanosis can be a very late indicator of hypoxia, but it is not a reliable sign of hypoxia. The other signs listed may represent only a temporary hypoxia.
A health care provider orders a unit of packed red blood cells (PRBC) for a postoperative patient. The nurse is responsible for patient assessment and health care information pre- and post-transfusion. Which of the following are the guidelines that the nurse should follow? Select all that apply. a. Determine the history of any previous transfusions and possible reactions. b. Review the signs and symptoms of a transfusion reaction. c. Explain that since 1985 the supply of blood available for transfusions is risk-free. d. Report any increase of 1 degree in temperature, during or after transfusion, which falls into a febrile range. e. Explain that urticaria is a harmless, common reaction to a transfusion occurring at least 50% of the time.
d. Report any increase of 1 degree in temperature, during or after transfusion, which falls into a febrile range. b. Review the signs and symptoms of a transfusion reaction. a. Determine the history of any previous transfusions and possible reactions. Although every unit of blood is carefully tested, it is not completely risk-free. The patient needs to be aware of the risk and sign a consent form. Urticaria only occurs in 1% to 3% of transfusions. Reactions are usually mild and respond to antihistamines.
A client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for: exophthalmos and conjunctival redness. flushed, warm, moist skin. systolic murmur at the left sternal border. decreased body temperature and cold intolerance.
decreased body temperature and cold intolerance. Hypothyroidism markedly decreases the metabolic rate, causing a reduced body temperature and cold intolerance. Other signs and symptoms include dyspnea, hypoventilation, bradycardia, hypotension, anorexia, constipation, decreased intellectual function, and depression. Exophthalmos; conjunctival redness; flushed, warm, moist skin; and a systolic murmur at the left sternal border are typical findings in a client with hyperthyroidism.
A home health nurse sees a client with end-stage chronic obstructive pulmonary disease. An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met? Decreased oxygen requirements Increased sputum production Decreased activity tolerance Hyperthermia
decreased oxygen requirements A client who is free from infection will most likely have decreased oxygen requirements. A client with infection will display increased sputum production, fever, shortness of breath, decreased activity tolerance, and increased oxygen requirements.
A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound dehisced. eviscerated. pustulated. hemorrhaged.
dehisced Dehiscence is the partial or complete separation of wound edges. Evisceration is the protrusion of organs through the surgical incision. Pustulated refers to the formation of pustules. Hemorrhage is excessive bleeding.
A patient admitted with a stroke is coming to the unit from the emergency department. The nurse assigned to care for the new patient knows that what assessment finding is indicative of a stroke? Difficulty speaking Increase in heart rate Facial edema Electrolyte imbalance
difficulty speaking Difficulty speaking is a classic abnormal finding on a physical assessment that may be associated with a stroke. Tachycardia, edema, and electrolyte imbalances are not common initial presentations of stroke.
A nurse is caring for a client with left-sided heart failure. What should the nurse anticipate using to reduce fluid volume excess? antiembolism stockings. oxygen. diuretics. anticoagulants.
diuretics Diuretics, such as furosemide, reduce total blood volume and circulatory congestion. Antiembolism stockings prevent venostasis and thromboembolism formation. Oxygen administration increases oxygen delivery to the myocardium and other vital organs. Anticoagulants prevent clot formation but don't decrease fluid volume excess.
The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for? Pruritus Dyskinesia Lactose intolerance Diarrhea
dyskinesia Within 5 to 10 years of taking levodopa, most patients develop a response to the medication characterized by dyskinesia (abnormal involuntary movements). Another potential complication of long-term dopaminergic medication use is neuroleptic malignant syndrome, characterized by severe rigidity, stupor, and hyperthermia. Side effects of long-term Sinemet therapy are not pruritus, lactose intolerance, or diarrhea.
The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)? Early ambulation Increased dietary intake of protein Maintaining the client in a supine position Administering aspirin with warfarin
early ambulation For clients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The client does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The client should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be given with warfarin because it will increase the client's risk for bleeding.
Which diagnostic method is recommended to determine whether left ventricular hypertrophy has occurred? Echocardiography Electrocardiography Blood chemistry Blood urea nitrogen
echocardiography An echocardiogram is recommended method of determining whether hypertrophy has occurred. Electrocardiography and blood chemistry are part of the routine workup. Renal damage may be suggested by elevations in blood urea nitrogen and creatinine concentrations.
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? Turning the client every 2 hours Elevating the head of the bed 30 degrees Encouraging increased fluid intake Maintaining a cool room temperature
encouraging increased fluid intake Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2 hours would help prevent atelectasis, but will not adequately mobilize thick secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing, but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.
A client with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the client administers the pilocarpine, the client states that her vision is blurred. Which nursing action is most appropriate? Holding the next dose and notifying the physician Treating the client for an allergic reaction Suggesting that the client put on her glasses Explaining that this is an expected adverse effect
explaining that this is an expected adverse effect Pilocarpine, a miotic drug used to treat glaucoma, achieves its effect by constricting the pupil. Blurred vision lasting 1 to 2 hours after instilling the eye drops is an expected adverse effect. The client may also note difficulty adapting to the dark. Because blurred vision is an expected adverse effect, the drug does not need to be withheld, nor does the physician need to be notified. Likewise, the client does not need to be treated for an allergic reaction. Wearing glasses will not alter this temporary adverse effect.
Which condition should a nurse expect to find in a client diagnosed with hyperparathyroidism? Hypocalcemia Hypercalcemia Hyperphosphatemia Hypophosphaturia
hypercalcemia Hypercalcemia is the hallmark of excess parathyroid hormone levels. Serum phosphate will be low (hypophosphatemia), and there will be increased urinary phosphate (hyperphosphaturia) because phosphate excretion is increased.
The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's: level of consciousness (LOC). extremities for signs of cyanosis. oxygen saturation level. hemoglobin, hematocrit, and red blood cell levels.
oxygen saturation level. The effectiveness of the client's oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The client's LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.
A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication? Tetany Hemorrhage Thyroid storm Laryngeal nerve damage
tetany Tetany may result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by tachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severe hyperthyroidism — not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstruction.
A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. This change occurred because: the attack is over. the airways are so swollen that no air can get through. the swelling has decreased. crackles have replaced wheezes.
the airways are so swollen that no air can get through. During an acute asthma attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can't get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Crackles don't replace wheezes during an acute asthma attack.
A patient visits a clinic for an eye examination. He describes his visual changes and mentions a specific diagnostic clinical sign of glaucoma. What is that clinical sign? A significant loss of central vision Diminished acuity Pain associated with a purulent discharge The presence of halos around lights
the presence of halos around lights Colored halos around lights is a classic symptom of acute-closure glaucoma.
A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing? Riboflavin deficiency Folic acid deficiency Vitamin A deficiency Vitamin K deficiency
vitamin K deficiency Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency leads to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Pyridoxine deficiency results in skin and mucous membrane lesions and neurologic changes. Vitamin C deficiency results in the hemorrhagic lesions of scurvy. Vitamin K deficiency results in hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses. Folic acid deficiency results in macrocytic anemia.
