EAQ Grand Total
A client who has been on hemodialysis for several weeks asks the nurse what substances are being removed by the dialysis. Which substance removal should the nurse share with the client? 1 Sodium 2 Bacteria 3 Glucose 4 Blood
1 Sodium is an electrolyte that passes through the semipermeable membrane during hemodialysis. Red blood cells do not pass through the semipermeable membrane during hemodialysis. Glucose does not pass through the semipermeable membrane during hemodialysis. Bacteria do not pass through the semipermeable membrane during hemodialysis.
The most effective method for the nurse to evaluate a client's response to ongoing serum albumin therapy for biliary cirrhosis is to monitor the client's: 1. Weight daily 2. Vital signs frequently 3. Urine output every half hour 4. Urine albumin level every shift
1 The increased osmotic effect of therapy increases the intravascular volume and urinary output; weight loss reflects fluid loss. 2 The vital signs will not change drastically; "frequently" is a nonspecific time frame. 3 The urinary output is measured hourly; half-hour outputs are insignificant in this instance. 4 A serum, not urine, albumin level is significant; albumin in the urine indicates kidney dysfunction, not liver dysfunction.
When admitting a client with benign prostatic hyperplasia, the most relevant assessment made by the nurse is: 1. Perineal edema 2. Urethral discharge 3. Flank pain radiating to the groin 4. Distention of the lower abdomen
4 Distention of the suprapubic area indicates that the bladder is distended with urine and therefore palpable. 1 Perineal edema is not related to urinary retention and benign prostatic hyperplasia. 2 Urethral discharge may be related to sexually transmitted infections. 3 Radiating flank pain may indicate renal calculi.
An obese client with calculi in the calyces of the right kidney is admitted for their removal. The nurse prepares the client for the procedure by explaining that: 1. The right ureter will be removed 2. A suprapubic catheter will be in place 3. The surgery will be performed transurethrally 4. A small incision will be present in the right flank area
4 If the calculi are in the renal pelvis, a percutaneous pyelolithotomy is performed; the calculi are removed via a small flank incision. 1 This is not necessary. 2 This usually is unnecessary. 3 This route is used for calculi in the ureters and renal pelvis.
When assessing a client during peritoneal dialysis, a nurse observes that drainage of the dialysate from the peritoneal cavity has ceased before the required volume has returned. What should the nurse instruct the client to do? 1 Turn from side to side 2 Deep breathe and cough 3 Drink a glass of water 4 Rotate the catheter periodically
1...Turning from side to side will change the position of the catheter, thereby freeing the drainage holes of the tubing, which may be obstructed. Drinking a glass of water and deep breathing and coughing do not influence drainage of dialysate from the peritoneal cavity. The position of the catheter should be changed only by the primary healthcare provider.
828. A nurse has given instructions to a client returning home after knee arthroscopy. The nurse determines that the client understands the instructions if the client states that he or she will: 1. Resume regular exercise the following day. 2. Stay off the leg entirely for the rest of the day. 3. Report fever or site inflammation to the physician. 4. Refrain from eating food for the remainder of the day.
3 Rationale: After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the physician.
499. A client is admitted for repair of bilateral inguinal hernias. Before surgery the nurse assesses the client for signs that strangulation of the intestine may have occurred. What is an early sign of strangulation? 1. Increased flatus 2. Projectile vomiting 3. Sharp abdominal pain 4. Decreased bowel sounds
499. 3. Pain is wavelike, colicky, and sharp because of obstruction and localized bowel ischemia
Left
Signs of ________ ventricular HF are evident in the pulmonary system
When discussing nutrition with a client who has inflammatory bowel disease of the ascending colon, the most appropriate suggestion by the nurse concerning food to include in the diet is: a. Scrambled eggs and applesauce. b. Barbecued chicken and French fries. c. Fresh fruit salad with cheddar cheese. d. Chunky peanut butter on whole wheat bread
a. Scrambled eggs and applesauce.
A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include that will decrease the risk of complications? Select all that apply. A) Examining the feet daily B) Wearing well-fitting shoes C) Performing regular exercise D) Powdering the feet after showering E) Visiting the HCP weekly F) Testing bathwater with the toes before bathing
A) Examining the feet daily B) Wearing well-fitting shoes C) Performing regular exercise
111. Cllents with duodenal ulcers are sometimes given drugs such as propanthellne bromide (Pro-Banthine). The nurse knows that the desired effect of these drugs is to: A. Decrease gastric motility. B. Tranquilize the cIient C. Increase gastric secretions. D. Directly stimulate mucosal cell growth.
A. To decrease gastric motility. These drugs decrease gastric secretions by decreasing gastric motility. B, C, and D are incorrect because the drugs have no tranquilizing effect; decrease, rather than increase, secretions; and do not influence cell growth.
826. After a long leg cast is removed, the client should be instructed to: 1. Elevate the leg when sitting 2. Report stiffness of the ankle 3. Perform full range of motion once a day 4. Cleanse the leg by scrubbing with a washcloth
Ans: 1 1. Elevation will help control the edema that usually occurs after an injury or if the injured part is left in a dependent position.
819. A client with multiple injuries from an automobile collision is now permitted out of bed to a chair but is not permitted to bear weight on the lower extremities. When using a mechanical lift to transfer the client, it is essential that the nurse: 1. Fold the client's arms across, the chest 2. Place the sling so that the top is below the client's scapulae 3. Call the practitioner to secure an order to use a mechanical lift 4. Raise the lift so that the sling is at least twelve inches above the mattress
Ans: 1 1. Folding the arms across the chest maintains both arms in a safe position during the transfer.
427. A client who is diagnosed with a duodenal ulcer asks, "Now that I have an ulcer, what comes next?" The nurse's best response is: 1. "Most peptic ulcers heal with medical treatment." 2. "Clients with peptic ulcers have pain while eating." 3. "Early surgery is advisable, especially after the first attack." 4. "If ulcers are untreated, cancer of the stomach can develop."
Ans: 1 1. Treatment with medications, rest, diet, and stress reduction relieves symptoms, heals the ulcer, and prevents complications and recurrence.
In the immediate postoperative period after a gastrectomy, the client's nasogastric tube is draining a light-red liquid. For how long should the nurse expect this type of drainage? A) 1 - 2 hours B) 3 - 4 hours C) 10 - 12 hours D) 24 - 48 hours
C) 10 - 12 hours
When teaching irrigation of a colostomy, how many inches above the stoma should the nurse teach the client to hold the container? A) 15 cm (6 inches) B) 25 cm (10 inches) C) 30 cm (12 inches) D) 45 cm (18 inches)
C) 30 cm (12 inches)
432. A client progresses to a regular diet after a gastrectomy for gastric cancer. After eating lunch the client becomes diaphoretic and has palpitations. What probably has caused these responses? 1. Intolerance to fatty foods 2. Dehiscence of the surgical incision 3. Extracellular fluid shift into the bowel 4. Diminished peristalsis in the small intestine
Ans: 3 3. Hypertonic food increases osmotic pressure and pulls fluid from the intravascular compartment into the intestine (dumping syndrome).
436. A nurse asks a client to make a list of the foods that cause dyspepsia. If the client has cholecystitis, the foods that are most likely to be included on this list are: 1. Nuts and popcorn 2. Meatloaf and baked potato 3. Chocolate and boiled shrimp 4. Fried chicken and buttered corn
Ans: 4 4. Cholecystitis is often accompanied by intolerance to fatty foods, including fried foods and butter.
397. To motivate an obese client to eventually include aerobic exercises in a weight-reduction program, the nurse discusses exercise and its relationship to weight loss. The nurse evaluates that this teaching is effective when the client states, "I know that exercise will: 1. decrease my appetite." 2. lower my metabolic rate." 3. raise my resting heart rate." 4. increase my lean body mass."
Ans: 4 4. Exercise builds skeletal muscle mass and reduces excess fatty tissues.
402. The nurse teaches the client with gastroesophageal reflux disease that after meals the client should: 1. Drink 8 ounces of water 2. Take a walk for 30 minutes 3. Lie down for at least 20 minutes 4. Rest in a sitting position for 1 hour
Ans: 4 4. Gravity facilitates digestion and prevents reflux of stomach contents into the esophagus
836. A young adult with a herniated nucleus pulposus is scheduled for a diskectomy with fusion. Preoperatively, the nurse should demonstrate the: 1. Use of a trapeze 2. Contour position 3. Traction apparatus 4. Log-rolling technique
Ans: 4 4. Log-rolling to the prone position supports vertebral alignment, decreasing trauma to the operative site.
868. A client with an above-the-knee amputation asks why the residual limb needs to be wrapped with an elastic bandage. The nurse explains that it: 1. Limits the formation of blood clots 2. Decreases the phantom limb sensation 3. Caring for the residual limb. 4. Performing phantom limb exercises
Ans: 4. 4. Pressure supports tissue, promotes venous return, and limits edema, thus promoting shrinkage of the distal part of the residual limb.
392. When preparing a client to go home with total parenteral nutrition (TPN), the nurse helps the client plan: 1. The days to be used for administration 2. For daily insertion of the circulatory access 3. For professional help to administer the TPN 4. A schedule of administration around regular activity
Ans: 4. 4. The less disruptive the procedure, the greater the acceptance by the client.
391. A practitioner orders total parenteral nutrition 1 L every 12 hours. The primary nursing responsibility is to monitor the client's: 1. Electrolytes 2. Urinary output 3. Blood pressure 4. Serum glucose levels
Ans: 4. 4. This is essential because the solution is hyperosmolar, and a concentrated source of glucose can result in hyperglycemia.
A CBC, urinalysis, and x-ray examination of the chest are ordered for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse? A) "Don't worry; these tests are routine." B) "They are done to identify other health risks." C) "They determine whether surgery will be safe." D) "I don't know; your health care provider ordered them."
B) "They are done to identify other health risks."
In today's health care delivery system, a nurse as a teacher is confronted with multiple stressors. What is the major stressor that detracts from the effectiveness of the teaching effort? A) Extent of informed consumerism B) Limited time to engage in teaching C) Variety of cultural beliefs that exist D) Deficient motivation in adult learners
B) Limited time to engage in teaching
A nurse is caring for a client in albor. What client response indicates that the transition phase of labor probably has begun? A) Assume the lithotomy position B) Perspires that he has a flushed face C) Indicates back and perineal pain D) Exhibits decrease in frequency of contractions
B) Perspires that he has a flushed face
A client presents with a localized bacterial infection of mucous membranes. Which organism is most likely responsible for this condition in the client? 1 Giardia 2 Aspergillus fumigatus 3 Corynebacterium diphtheria 4 Mycobacterium tuberculosis
Corynebacterium diphtheria Diphtheria is a re-emerging infection that can be characterized by localized infection of mucous membranes or skin. It is caused by Corynebacterium diphtheria. Giardia, a parasite, causes giardiasis, a diarrheal illness known as traveler's diarrhea. Aspergillosis is a lung disease caused by Aspergillus fumigatus, a fungus. Mycobacterium tuberculosis causes tuberculosis.
Pancreatitis
Cullen's sign and Turner's sign are both indicative of what?
The health care provider prescribes ipratropium (Atrovent) for a client. An allergic reaction to which other medication would cause the nurse to question the prescription for Atrovent? A) Albuterol (Proventil) B) Theophylline (Theo-24) C) Metaproterenol (Alupent) D) Atropine sulfate (Atropine)
D) Atropine sulfate (Atropine) - Clients who have experienced allergic reactions to atropine sulfate (Atropine) (D) and belladonna alkaloids may also be allergic to ipratropium (Atrovent), so the prescription for Atrovent should be questioned. Allergies to (A, B, and C) would not cause the nurse to question a prescription for ipratropium (Atrovent).
Using Piaget's theory of cognitive development, what should the nurse expect a 6-month-old infant to demonstrate? A) Early traces of memory B) Beginning sense of time C) Repetitious reflex responses D) Beginning of object permanence
D) Beginning of object permanence
A client with a high cholesterol level says to the nurse, "Why can't the doctor just give me a medication to eliminate all of the cholesterol in my body so it isn't a problem? Which factor related to why cholesterol is important in the human body should the nurse include in a response to the client's question? A) Blood clotting B) Bone formation C) Muscle contraction D) Cellular metabolism
D) Cellular metabolism
A HCP prescribes simvastatin 20 mg daily for elevated cholesterol and triglyceride levels for a middle-age female. Which is most important for the nurse to teach the client to do when initially taking this medication? A) Take the medication with breakfast B) Have liver function tests twice a year C) Wear sunscreen to prevent photosensitivity reactions D) Inform the HCP if becoming pregnant is desired
D) Inform the HCP if becoming pregnant is desired - Simvastatin use is contraindicated during pregnancy.
Hypertensive crisis
Levodopa taken with an MAOI can cause ________
Infection
Major cause of death in the immunosuppressed client
Guillain-Barré syndrome
Major concern is difficulty breathing; monitor respiratory status closely
1
More than _____ saturated pad per hour may indicate excessive bleeding
Urinary output
Most reliable and most sensitive noninvasive assessment parameter for cardiac output and tissue perfusion
Level of consciousness
Most sensitive indicator of neurological status
Phenytoin
Must be given slowly to prevent hypotension and cardiac dysrhythmias; may also decrease effectiveness of birth control
Infection (Sites are either catheter insertion site or peritoneum, causing peritonitis)
Of concern with peritoneal dialysis
How long will a client's ovum stay viable after its release to get fertilized? 1 72 hours 2 78 hours 3 76 hours 4 74 hours
Ovum can be fertilized up to 72 hours after its release. The ovum disintegrates after 72 hours, and menstruation begins soon after. Therefore the ovum cannot be viable for 74, 76, or 78 hours, and fertilization will not occur.
ACE inhibitor
Persistent, dry cough is a common SE of a ________
Cardiac monitoring
Place client with kidney disease on continuous ________
Dumping syndrome
Prevents ___________ Avoid sugar, salt, milk. Eat a high protein, high fat, low carb diet. Eat small meals and avoid consuming fluids with meals. Lie down after meals. Take antispasmodic meds as prescribed to delay gastric emptying.
Hyperkalemia
Primary concern with administering potassium-retaining diuretics is ?
Respiratory depression
Primary concern with morphine sulfate
OA
Progressive degeneration of articular cartilage; causes bone buildup and affects weight-bearing joints, such as hips, knees, lower vertebral column, and hands
Creatinine clearance test
Provides the best estimate of GFR (Normal GFR is 125 mL/minute)
Hand washing
Strict and frequent ________ is key to preventing the spread of all types of hepatitis
The nurse is assisting the primary healthcare provider during a renal ultrasonography. Arrange the steps involved in the procedure in correct sequence. Incorrect 2 Apply gel over skin Incorrect 4 Wipe cotton pad over gel Correct 3. Move transducer across skin Incorrect 1 Place client in prone position
The client undergoing renal ultrasonography should first be placed in the prone position. Then the sonographic gel should be applied on the client's skin over the back and flank regions. Then the transducer is moved across the client's skin to measure the echoes. The images are visualized on the display screen. At the end of the procedure the gel is removed from the client's skin by using a piece of wet cotton or cloth over the gel.
A client is scheduled to receive phenytoin 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? A) Sprinkle the powder from the capsule into a cup of water B) Insert a rectal suppository containing 100 mg of phenytoin C) Administer 4 mL of phenytoin suspension containing 125 mg/5 mL D) Obtain a change in the administration route to allow an IM injection
C) Administer 4 mL of phenytoin suspension containing 125 mg/5 mL
A client is taking hydromorphone (Dilaudid) PO q4h at home. Following surgery, Dilaudid IV q4h PRN and butorphanol tartrate (Stadol) IV q4h PRN are prescribed for pain. The client received a dose of the Dilaudid IV four hours ago, and is again requesting pain medication. What intervention should the nurse implement? A) Alternate the two medications q4h PRN for pain. B) Alternate the two medications q2h PRN for pain. C) Administer only the Dilaudid q4h PRN for pain. D) Administer only the Stadol q4h PRN for pain.
C) Administer only the Dilaudid q4h PRN for pain. - Dilaudid is an opioid agonist. Stadol is an opioid agonist-antagonist. Use of an agonist-antagonist for the client who has been receiving opioid agonists may result in abrupt withdrawal symptoms, and should be avoided (C). (A, B, and D) do not reflect good nursing practice.
A client is admitted to the ED with a contaminated wound. The client is a poor historian, and the nurse realizes that it is impossible to determine whether the client is immunized against tetanus. Which medication does the nurse expect the HCP to prescribe because it will provide passive immunity for several weeks with minimal danger of an allergic reaction? A) Tetanus toxoid B) Equine tetanus antitoxin C) Human tetanus antitoxin D) DTaP vaccine
C) Human tetanus antitoxin
A thin older adult client is diagnosed with osteoporosis. What should the nurse include in the discharge plan for this client? A) Encouragement of gradual weight gain B) Monitoring for decreased urine calcium C) Instructions relative to diet and exercise D) Safety factors when using opioids and NSAIDS
C) Instructions relative to diet and exercise
Acetaminophen
Contraindicated in clients with hepatic or renal disease, alcoholism, and/or hypersensitivity
A client is to receive total parenteral nutrition (TPN). To administer TPN, the piece of equipment that is most important for the nurse to obtain is a/an: a. Tall intravenous (IV) pole b. Infusion pump c. Clamp taped at the bedside d. Infusion set delivering 60 gtts/mL
b. Infusion pump
A client with lymphosarcoma is receiving allopurinol (Zyloprim) and methotrexate (Rheumatrex). The nurse can help the client prevent complications related to uric acid nephropathy by administering the: a. Allopurinol and promoting urine acidity b. Methotrexate after providing an antacid c. Allopurinol and encouraging the intake of fluid d. Methotrexate while restricting the intake of fluid
c. Allopurinol and encouraging the intake of fluid
A client with chronic liver disease reports, "My gums have been bleeding spontaneously." The nurse identifies small hemorrhagic lesions on the client's face. The nurse concludes that the client needs additional: a. Bile salts b. Folic acid c. Vitamin A d. Vitamin K
d. Vitamin K
Medical Diagnosis: Laennec's cirrhosis; hepatic encephalopathy • Nursing Problems/Diagnosis: - Inadequate breathing patterns - Impairment of digestion. - Fluid volume deficit. - Altered nutrition: less than body requirements. - Altered thought processes. • Chief Complaint: Joseph Mesta, Is 55-years-old and married. He complains of vomiting, confusion, restlessness, and increased abdominal size. • History of Present Illness: Six episodes of coffee-ground emesis in past 24 hours. According to wife, he has intermittent disorientation to place and time. Also reports an 18-pound weight gain in past 6 months and a gradual increase in abdominal girth • Past History: Discharged from hospital 6 months ago with diagnosis of Laennec's cirrhosls. Responded well to treatment with diuretics and salt and protein restrictions. • Family History: Mother and father died of "old age" In their 80s. • Review of Symptoms: Admits to difficulty following doctor's prescribed diet. Avoids hard liquor but consumes 4-6 beers each night. • Physical Exam: Lungs: Bilateral, basilar crackles. Abdomen: Marked distention; liver barely palpable; distended veins visible in right and left upper quadrants. Rectal: Black, tarry stools hematest-positive. Extremities: 2 + pitting edema both legs; 1+ arms. Skin: Jaundice; multiple abrasions on forearms which bleed easily. Neurologic: Lethargic; disoriented to time and place; tremor, both upper arms. • Laboratory and X-ray Data: Hgb: 10.1 g. Hct: 31.3%. WBC: 10,200 mcgL. BUN: 62 mg/dL. Creatinine: 3.3 mg/dL. Total bilirubln: 7.3 mg/dL. Albumin: 2.3 g/dL. CK: 460 mU/mL. AST: 180 U/mL. LDH: 451 U/mL. ALT: 488 U/mL. Uric acid: 10.5 mg/dL. UGI: Varices of esophagus and stomach. Paracentesis: 400 mL clear, straw-colored fluid.
...
The nurse is caring for a client with ureteral colic. To prevent the development of renal calculi in the future, which strategy should be included in the client's plan of care? 1 Excluding milk products from the diet 2 Interventions to decrease the serum creatinine level 3 Instructing the client to drink 8 to 10 glasses of water daily 4 A urinary output goal of 2000 mL per 24 hours
.3..Increasing fluid intake [1] [2] dilutes the urine, and crystals are less likely to coalesce and form calculi. An elevated serum creatinine has no relationship to the formation of renal calculi. Calcium restriction is necessary only if calculi have a calcium phosphate basis. Producing only 2000 mL of urine per 24 hours is inadequate. STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.
847. Allopurinol (Zyloprim) is prescribed for a client and the nurse provides medication instructions to the client. The nurse instructs the client: 1. To drink 3000 mL of fluid a day 2. To take the medication on an empty stomach 3. That the effect of the medication will occur immediately 4. That if swelling of the lips occurs, this is a normal expected response
1 Rationale: Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day. A full therapeutic effect may take 1 week or longer. Allopurinol is to be given with, or immediately after, meals or milk. A client who develops a rash, irritation of the eyes, or swelling of the lips or mouth should contact the physician because this may indicate hypersensitivity.
843. A nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be concerned especially with which of the following assessment findings? 1. Temperature of 101.6° F orally 2. Complaints of discomfort during repositioning 3. Old bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep-breathing exercises
1 Rationale: The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6° F should be reported.
A client reports to a health clinic because a sexual partner recently was diagnosed as having gonorrhea. The health history reveals that the client has engaged in receptive anal intercourse. What should the nurse assess for in this client? 1 Anal itching 2 Ribbon-shaped stools 3 Melena 4 Constipation
1 Anal itching and irritation can occur from having anal intercourse with a person infected with gonorrhea. Frank rectal bleeding, not upper gastrointestinal bleeding (melena), occurs. Painful defecation, not constipation, occurs. The shape of formed stool does not change; however, defection can be painful.
Which is an abnormal finding of the urinary system? 1 Pain in the flank region upon hitting 2 Presence of bowel sounds 3 Nonpalpable urinary bladder 4 Nonpalpable left kidney
1 Normally, a blow in the flank region should not elicit pain. Pain in the flank region upon hitting indicates kidney infection or polycystic kidney disease. But the client experiences pain when his/her flank area is hit; therefore, this is an abnormal finding. The left kidney is covered by the spleen and is not palpable, which is a normal finding. The client has bowel sounds. However, no alteration of bowel sounds is seen. Therefore it is a normal finding. The urinary bladder is not normally palpable, unless it is distended with urine.
A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. How should this be documented in the client's medical record? 1 Overflow incontinence 2 Stress incontinence 3 Functional incontinence 4 Urge incontinence
1 Overflow incontinence [1] [2] [3] describes what is happening with this client; overflow incontinence occurs when the pressure in the bladder overcomes sphincter control. Urge incontinence describes a strong need to void that leads to involuntary urination regardless of the amount in the bladder. Stress incontinence occurs when a small amount of urine is expelled because of an increase in intraabdominal pressure that occurs with coughing, lifting, or sneezing. Functional incontinence occurs from other issues rather than the bladder, such as cognitive (dementia) or environmental (no toileting facilities). Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume review of the question.
The nurse is performing a physical examination of a client by placing the left hand on the back and supporting the client's right side between the rib cage and the iliac crest. Which physical assessment maneuver is the nurse performing on this client? 1 Palpation 2 Percussion 3 Auscultation 4 Inspection
1 The physical assessment involves inspection, palpation, percussion, and auscultation. During palpation of the right kidney, the nurse places the left hand behind and supports the client's right side between the ribcage and the iliac crest. During an inspection, the nurse assesses the client for changes in skin, abdomen, weight, face, and extremities. During percussion, the nurse strikes the fist of one hand against the dorsal surface of the other hand, which is placed flat along the post costovertebral angle (CVA) margin. While performing auscultation, the nurse uses the bell of the stethoscope over both CVAs and in the upper abdominal quadrants.
A tuberculin skin test with purified protein derivative (PPD) tuberculin is performed as part of a routine physical examination. The nurse instructs the client to make an appointment so the test can be read in: 1. 3 days 2. 5 days 3. 7 days 4. 10 days (Nugent 20) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 It takes this length of time for antibodies to respond to the antigen and form an indurated area. 2 This is longer than necessary; the site will reveal induration in 2 to 3 days. 3 This is longer than necessary; the site will reveal induration in 2 to 3 days. 4 This is longer than necessary; the site will reveal induration in 2 to 3 days. (Nugent 100) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client with a tentative diagnosis of cholecystitis is discharged from the emergency department with instructions to make an appointment for a definitive diagnostic workup. The recommendation that will produce the most valuable diagnostic information is: 1. "Keep a journal related to your pain." 2. "Save all stool and urine for inspection." 3. "Follow the physician's orders exactly without question." 4. "Keep a record of the amount and type of fluid you are drinking daily."
1 Pain is a cardinal symptom; it is helpful to have as much specific information about it as possible, particularly its description and its relationship to foods ingested. 2 It is not necessary to save all urine and stool, although changes in color should be reported. 3 The client should be free to question orders that are not understood or agreed with. 4 Although the quality of fluid (e.g., high fat) may be significant, the amount of fluid will not add any valuable information.
Because of prolonged bile drainage from a T-tube after a cholecystectomy, the nurse must monitor the client for responses related to a lack of fat-soluble vitamins such as: 1. Easy bruising 2. Muscle twitching 3. Excessive jaundice 4. Tingling of the fingers
1 Vitamin K, a precursor for prothrombin, cannot be absorbed without bile. 2 This is commonly related to electrolyte imbalances, not fat-soluble vitamin deficiency. 3 Jaundice results from a backup of bile, not a deficiency of fat-soluble vitamins. 4 This may be related to electrolyte imbalances or deficiency of B vitamins, which are water soluble.
838. A nurse is caring for a client being treated for fat embolus after multiple fractures. Which of the following data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1. Minimal dyspnea 2. Clear mentation 3. Oxygen saturation of 85% 4. Arterial oxygen level of 78 mm Hg
2 Rationale: An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be higher than 95%.
850. A nurse is providing discharge instructions to a client receiving baclofen (Lioresal). Which of the following would be included in the teaching plan? 1. Restrict fluid intake. 2. Avoid the use of alcohol. 3. Notify the physician if fatigue occurs. 4. Stop the medication if diarrhea occurs.
2 Rationale: Baclofen is a skeletal muscle relaxant. The client should be cautioned against the use of alcohol and other central nervous system depressants because baclofen potentiates the depressant activity of these agents. Constipation rather than diarrhea is an adverse effect. Restriction of fluids is not necessary, but the client should be warned that urinary retention can occur. Fatigue is related to a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. The client does not need to notify the physician about fatigue.
846. The client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept (Enbrel), it is most important for the nurse to assess: 1. The injection site for itching and edema 2. The white blood cell counts and platelet counts 3. Whether the client is experiencing fatigue and joint pain 4. A metallic taste in the mouth, with a loss of appetite
2 Rationale: Infection and pancytopenia are side effects of etanercept (Enbrel). Laboratory studies are performed prior to and during medication treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potentially life-threatening infection. Injection site itching is a common occurrence following administration. A metallic taste with loss of appetite are not common signs of side effects of this medication.
A nurse is teaching a birthing/prenatal class about breast-feeding. Which hormone stimulates the production of milk during lactation? 1 Progesterone 2 Prolactin 3 Inhibin 4 Estrogen
2...Prolactin is the hormone that initiates and produces milk during lactation. Inhibin prevents the secretions of follicle stimulating hormone and gonadotropin releasing hormone. Estrogen and progesterone are the sex hormones produced by the ovaries.
841. A nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. The nurse immediately: 1. Calls the physician 2. Applies ice to the site 3. Rewraps the stump with an elastic compression bandage 4. Applies a dry sterile dressing and elevates it on one pillow
3 Rationale: If the client with an amputation has a cast or elastic compression bandage that slips off, the nurse must wrap the stump immediately with another elastic compression bandage. Otherwise, excessive edema will form rapidly, which could cause a significant delay in rehabilitation. If the client had a cast that slipped off, the nurse would have to call the physician so that a new one could be applied. Elevation on one pillow is not going to impede the development of edema greatly once compression is released. Ice would be of limited value in controlling edema from this cause. If the physician were called, the prescription likely would be to reapply the compression dressing anyway.
833. A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. The nurse interprets that this pain may be caused by: 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The recent occurrence of the fracture
3 Rationale: Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved by these measures should be reported to the physician because the pain unrelieved by medications and other measures may indicate neurovascular compromise. Because this is a new closed fracture and cast, infection would not have had time to set in.
After a transurethral prostatectomy, a client returns to the postanesthesia care unit with a three-way indwelling catheter with continuous bladder irrigation. Which nursing action is the priority? 1 Observing the suprapubic dressing for drainage 2 Maintaining the client in the semi-Fowler position 3 Monitoring for bright red blood in the drainage bag 4 Encouraging fluids by mouth as soon as the gag reflex returns
3 Blood clots are normal 24 to 36 hours after surgery, but bright red blood can indicate hemorrhage. The surgery is performed through the urinary meatus and urethra; there is no suprapubic incision. It is unnecessary to keep the client in the semi-Fowler position. The client is initially allowed nothing by mouth and then advanced to a regular diet as tolerated. Continuous irrigation supplies enough fluid to flush the bladder.
Which statement indicates the nurse has a correct understanding about kidney ultrasonography? 1 Kidney ultrasonography primarily makes use of iodinated contrast dye. 2 Kidney ultrasonography gives three-dimensional information regarding kidneys. 3 Kidney ultrasonography makes use of sound waves and has minimal risk. 4 Kidney ultrasonography is performed on the client with an empty bladder.
3 Kidney ultrasonography is a minimal risk diagnostic procedure. Ultrasonography makes use of sound waves which, when reflected from internal organs of varying density, will produce the images of the kidneys, bladder, and associated structures on the display screen. While a dye can be used in computed tomography (CT), it is not the primary method. Generally kidney ultrasonography is performed on the client with full bladder. A CT gives three-dimensional information about the kidney and associated structures.
After reviewing the urinalysis reports of a client with kidney dysfunction, the nurse suspects the presence of myoglobin. Which finding in the test reports supports the nurse's suspicion? 1 Very pale yellow colored urine 2 Dark amber colored urine 3 Red-colored urine 4 Brown-colored urine
3 Red-colored urine in clients with kidney dysfunction indicates the presence of myoglobin. Brown-colored urine indicates increased bilirubin levels. Dark amber urine indicates concentrated urine. Very pale yellow urine indicates dilute urine.
Which part of the reproductive system secretes androgens in female clients? 1 Ovarian follicle 2 Uterus 3 Ovaries 4 Fallopian tube
3 The ovaries and adrenal glands produce androgens in women. The fetus develops in the uterus during pregnancy. Fallopian tubes facilitate fertilization of oocyte and sperm. Ovarian follicle is a collection of oocytes in the ovary.
A client arrives at a health clinic reporting hematuria, frequency, urgency, and pain on urination. Which diagnosis will the nurse most likely observe written in the client's medical record? 1 Pyelonephritis 2 Nephrotic syndrome 3 Cystitis 4 Chronic glomerulonephritis
3 CORRECT Cystitis is an inflammation of the bladder that causes frequency and urgency of urination, pain on micturition, and hematuria. Chronic glomerulonephritis is a disease of the kidney that is associated with manifestations of systemic circulatory overload. Nephrotic syndrome is a condition of increased glomerular permeability characterized by severe proteinuria. Pyelonephritis is a diffuse, pyogenic infection of the pelvis and parenchyma of the kidney that causes flank pain, chills, fever, and weakness
A nurse teaches the signs of organ rejection to a client who had a kidney transplant. Which sign would the client have to identify for the nurse to determine that the client understands the teaching? 1. Weight loss 2. Subnormal temperature 3. Elevated blood pressure 4. Increased urinary output
3 Hypertension is caused by hypervolemia because of the failure of the new kidney. 1 Weight gain, not loss, occurs with a rejection of the kidney because of fluid retention. 2 The client will have an elevated temperature exceeding 100° F with kidney rejection. 4 Urine output will be decreased or absent, depending on the degree of kidney rejection.
A client progresses to a regular diet after a gastrectomy for gastric cancer. After eating lunch the client becomes diaphoretic and has palpitations. What probably has caused these responses? 1. Intolerance to fatty foods 2. Dehiscence of the surgical incision 3. Extracellular fluid shift into the bowel 4. Diminished peristalsis in the small intestine
3 Hypertonic food increases osmotic pressure and pulls fluid from the intravascular compartment into the intestine (dumping syndrome). 1 Increased carbohydrates, not fats, are responsible for the increased osmotic pressure often associated with the dumping syndrome. 2 This is separation of the wound edges, usually accompanied by a gush of pink-tinged fluid; it is unrelated to dumping syndrome. 4 Although peristalsis may be decreased because of surgery, it does not account for the adaptations.
A female client has a tentative diagnosis of Cushing's syndrome. The nurse's physical assessment of this client probably will reveal the presence of: 1. Fever and tachycardia 2. Lethargy and constipation 3. Hypertension and moon face 4. Hyperactivity and exophthalmos (Nugent 29) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 Increased glucocorticoids cause sodium and water retention, hypertension, and fat deposition, resulting in a moon face. 1 These characteristics are associated with hyperthyroidism. 2 These characteristics are associated with hypothyroidism. 4 These characteristics are associated with hyperthyroidism. (Nugent 111) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
830. A client with a hip fracture asks the nurse why Buck's (extension) traction is being applied before surgery. The nurse's response is based on the understanding that Buck's (extension) traction primarily: 1. Allows bony healing to begin before surgery 2. Provides rigid immobilization of the fracture site 3. Lengthens the fractured leg to prevent severing of blood vessels 4. Provides comfort by reducing muscle spasms and provides fracture immobilization
4 Rationale: Buck's (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps immobilize the fracture. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. Traction also does not allow for bony healing to begin.
840. A client with diabetes mellitus has had a right below-knee amputation. The nurse would assess specifically for which of the following signs because of the history of diabetes? 1. Hemorrhage 2. Edema of the stump 3. Slight redness of the incision 4. Separation of the wound edges
4 Rationale: Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative stump edema and hemorrhage are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as it is dry and intact.
851. A nurse is analyzing the laboratory studies on a client receiving dantrolene sodium (Dantrium). Which of the following laboratory tests would identify an adverse effect associated with the administration of this medication? 1. Creatinine level determination 2. Platelet count determination 3. Blood urea nitrogen level determination 4. Liver function tests
4 Rationale: Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, liver function tests should be performed before treatment and throughout the treatment interval. Dantrolene is administered in the lowest effective dosage for the shortest time necessary.
839. A nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which of the following early symptoms of compartment syndrome? 1. Cold, bluish-colored fingers 2. Pain that is out of proportion to the type of injury or condition 3. Pain that increases when the arm is dependent 4. Numbness and tingling in the fingers
4 Rationale: The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign.
Which instruction would be most beneficial for an aging African-American client with hypertension? 1 "Record blood pressure weekly." 2 "Check the pulse daily." 3 "Visit an ophthalmologist monthly." 4 "Have an annual urinalysis."
4 African-American clients have 20% less blood flow to the kidneys because of high sodium consumption. This causes anatomical changes in the blood vessels, thereby increasing the risk of kidney failure. Therefore instructing the client with hypertension to have an annual urine examination would be beneficial. If the client has protein in the urine, this is a sign of high blood pressure and can signify kidney damage. Checking the pulse daily poses no harm to the individual, but does not determine if the client has hypertension. Recording the blood pressure weekly is not a good indicator of an aging African-American client with hypertension. The client's blood pressure should be taken at least daily to determine if the client has problems. If the client has an eye-related problem, visiting an ophthalmologist should be suggested.
The nurse is performing bedside sonography for a female client who underwent a hysterectomy. Which nursing intervention needs correction? 1 Pointing the scan head so the ultrasound is projected towards the client's coccyx 2 Placing the midline of the probe over the abdomen about 1.5 inches (3.8 cm) above the pubic bone 3 Placing an ultrasound gel pad right above the pubic bone 4 Using the female icon on the bladder scanner
4 Before performing a bedside sonography, the male or female icon on the scanner should be selected. The male icon should be selected for men and for women who have undergone a hysterectomy. An ultrasound gel pad should be placed right above the pubic bone. The scan head should be pointed in such a way that the ultrasound is projected towards the client's coccyx. The midline of the probe should be placed over the abdomen about 1.5 inches (3.8 cm) above the pubic bone.
A client scheduled for a hemicolectomy because of ulcerative colitis asks if having a hemicolectomy means wearing a pouch and having bowel movements in an abnormal way. Which is the best response by the nurse? 1 "Yes, but it will be temporary until the colitis is cured." 2 "No, that is necessary when a tumor is blocking the rectum." 3 "Yes, hemicolectomy is the same as a colostomy." 4 "No, only part of the colon is removed and the rest reattached."
4 Hemicolectomy [1] [2] is removal of part of the colon with an anastomosis between the ileum and transverse colon; a colostomy is not necessary. With a colostomy the intestine opens on the abdomen, whereas in a hemicolectomy a portion of the intestine is resected and the ends reconnected. "Yes, but it will be temporary until the colitis is cured" is the description of a temporary colostomy; a cure occurs only when the entire colon is removed. A colostomy is done for a variety of reasons other than a tumor; a colectomy with a colostomy is only one intervention that may be used to treat a tumor.
After prostate surgery a client's indwelling catheter and continuous bladder irrigation (CBI) are to be removed. The nurse discusses the procedure with the client. The nurse evaluates that the teaching is understood when the client states, "After the catheter is removed I probably will: 1. have dilute urine." 2. be unable to urinate." 3. produce dark red urine." 4. experience some burning on urination."
4 Because of the trauma to the mucous membranes of the urinary tract, burning on urination is an expected response that should subside gradually. 1 The urine should no longer be dilute after the continuous bladder irrigation is discontinued and removed. However, the urine may have a slight pink tinge because of the trauma from the surgery and the presence of the catheter. 2 This should not occur unless the indwelling catheter is removed too soon and there is still edema of the urethra. 3 This is a sign of hemorrhage, which should not occur.
The nurse teaches the client with gastroesophageal reflux disease that after meals the client should: 1. Drink 8 ounces of water 2. Take a walk for 30 minutes 3. Lie down for at least 20 minutes 4. Rest in a sitting position for 1 hour
4 Gravity facilitates digestion and prevents reflux of stomach contents into the esophagus. 1 Water should not be taken with or immediately after meals because it overdistends the stomach. 2 Exercise immediately after eating may prolong the digestive process. 3 Lying down immediately after eating facilitates reflux of the stomach contents into the esophagus.
A client has a colostomy after surgery for cancer of the colon. What is the nurse's most therapeutic intervention during the postoperative period? 1. Empty the colostomy bag when it is three fourths full 2. Allow one half inch between the stoma and the appliance 3. Help the client to remove the appliance on the first postoperative day 4. Apply stoma adhesive around the stoma and then attach the appliance
4 Stoma adhesive protects the skin and helps to keep the appliance attached to the skin. 1 The appliance should be emptied when it is one third to one half full. 2 This is too much space between the stoma and the appliance; the enzymes in feces can erode the skin. 3 Initially the nurse should change the appliance; self-care usually is instituted more gradually depending on the client's physical and emotional response to the surgery.
A nurse's postoperative plan of care for a client who had a nephrectomy should include: 1. Clamping the client's nephrostomy tube when out of bed 2. Giving the client a regular diet on the first postoperative day 3. Replacing the client's original dressing after the first 48 hours 4. Turning the client from the back to the operated side every 2 to 3 hours
4 Turning the client prevents respiratory complications. 1 There is no need for a nephrostomy tube because the kidney has been removed. 2 Because clients are prone to develop paralytic ileus, food and fluid intake are delayed until bowel sounds are auscultated. 3 The first dressing change is performed by the practitioner.
The nurse understands that shock associated with a ruptured abdominal aneurysm is called: 1. Vasogenic shock 2. Neurogenic shock 3. Cardiogenic shock 4. Hypovolemic shock (Nugent 20-21) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 When an abdominal aneurysm ruptures, hypovolemic shock ensues because fluid volume depletion occurs as the heart continues to pump blood out of the ruptured vessel. 1 Vasogenic shock results from humoral or toxic substances acting directly on the blood vessels, causing vasodilation. 2 Neurogenic shock results from decreased neuromuscular tone, causing decreased vasoconstriction. 3 Cardiogenic shock results from a decrease in cardiac output. (Nugent 101) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
484. After the surgical creation of an ileostomy, a client is transferred to a rehabilitation unit. The client asks for help in selecting breakfast. What should the nurse encourage the client to eat or drink? 1. Hot coffee and oranges 2. Shredded wheat and mille 3. Toast and a western omelet 4. Cream of wheat and bananas
484. 4 Low-residue foods will not increase motility.
485. When teaching a' community health class about the signs of colorectal cancer, the nurse stresses that the most common complaint of persons with colorectal cancer is: 1. Rectal bleeding 2. Abdominal pain 3. Change in bowel habits 4. Decrease in diameter of stools
485. 3 Constipation, diarrhea, and/or constipation alternating with diarrhea are the most common signs of colorectal cancer.
488. A middle-aged male client has an adenocarcinoma of the colon. The practitioner suspects that this has metastasized and orders a CT scan of the liver. When preparing the client for the CT scan the nurse explains that: 1. After the procedure he must rest in bed for about six hours to prevent complications 2. There will be some discomfort during the procedure but the practitioner will administer an analgesic 3. He will be in tWilight sleep during the procedure and may be able to hear people talking in the same room 4. He will be given an IV infusion containing a contrast medium before the procedure and must lie as still as possible for a period of time
488. 4 This is an accurate explanation of what the client can expect during the CT scan.
490. A client with carcinoma of the colon is scheduled for an abdominoperineal resection. Preparation of this client several days before surgery should include: 1. Medications to promote diuresis 2. Restriction of fluids to one L daily 3. Antibiotics to reduce intestinal bacteria 4. Abdominal exercises to facilitate recovery
490. 3. 3. Except in an emergency, the client received an intestinal antibiotic for several days preoperatively to reduce the amount of intestinal bacteria
492. On the second day after an abdominoperineal resection, the nurse anticipates that the colostomy stoma will appear: 1. Dry, pale pink, and flush with the skin 2. Moist, red, and raised above the skin surface 3. Dry, purple, and depressed below the skin surface 4. Moist, pink, flush with the skin, and painful when touched
492. 2. 2. The surface of a stoma is mucous membrane and should be dark pink to red, moist and shiny; the stoma is usually raised beyond the skin surface.
493. The nurse teaches a client to irrigate a new sigmoid colostomy when the: 1. Stool starts to become formed 2. Client can lie on the side comfortably 3. Abdominal incision is closed and contamination is no longer a danger 4. Perineal wound heals and the client can sit comfortably on the commode
493. 1. 1. Once stool is formed, peristalsis needs to be stimlated to promote the passage of stool.
495. A Client has a surgical creation of a colostomy for cancer of the rectum. When comparing the procedures of a colostomy irrigation and an enema, the nursing intervention that is unique to a colostomy irrigation is: 1. Positioning the client for evacuation of the bowel 2. Lubricating the catheter tip with a water-soluble jelly 3. Instilling the irrigating solution using a cone-shaped tip catheter 4. Clearing the tubing of air before insertion of the irrigating solution
495. 3. 3. A cone-shaped tip controls the depth of insertion of the catheter; which prevents perforation of the bowl and limits leakage of water from the stoma during fluid insertion
497. The nurse evaluates that dietary teaching for a client with a colostomy is effective when the client states, "It is important that I eat: 1. food low in fiber so that there is less stool." 2. bland foods so that my intestines do not become irritated." 3. everything I ate before the operation and avoid foods that cause gas." 4. soft foods that are more easily digested and absorbed by my large intestine."
497. 3. 3. Clients with a colostomy can eat a regular diet; only gas-forming foods that cause distention and discomfort should be avoided.
498. Part of discharge teaching for a client with a sigmoid colostomy includes how to protect clothing from colostomy leakage. What is the nurse's most appropriate response when the client asks about the use of appliances and dressings? 1. "Appliances are used to avoid soiling your clothing." 2. "Special appliances are expensive but they provide for better bowel control." 3. "I will give you enough appliances to last until your next visit to the physician." 4. "Many people do not need appliances once they regulate their bowels with routine irrigations."
498. 4. 4. Regular irrigation and effective evacuation prevent unexpected bowl movement; generally a drainage pouch is needed only immediately after an irrigation.
617. The client is admitted to the hospital with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1. Select foods high in fat. 2. Increase intake of fluids, including juices. 3. Eat a good supper when anorexia is not as severe. 4. Eat less often, preferably only three large meals daily.
617. 2 Rationale: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet because fat may be tolerated poorly because of decreased bile production. Small frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.
618. A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following? 1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant discomfort
618. 1 Rationale: Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.
619. A client has just had a hemorrhoidectomy. What nursing intervention is appropriate for this client? 1. Instruct the client to limit fluid intake to avoid urinary retention. 2. Instruct the client to eat low-fiber foods to decrease the bulk of the stool. 3. Apply and maintain ice packs over the dressing until the packing is removed. 4. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding.
619. 3 Rationale: Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding. An ice pack will increase comfort and decrease bleeding. Options 1, 2, and 4 are incorrect interventions.
620. The nurse is planning to teach the client with gastroesophageal reflux disease about substances that will increase the lower esophageal sphincter pressure. Which item should the nurse include on this list? 1. Coffee 2. Chocolate 3. Fatty foods 4. Nonfat milk
620. 4 Rationale: Foods that increase lower esophageal sphincter (LES) pressure will decrease reflux and lessen the symptoms of gastroesophageal reflux disease (GERD). The food that will increase LES pressure is nonfat milk. The other substances listed decrease LES pressure, thus increasing reflux symptoms. Aggravating substances include chocolate, coffee, fatty foods, and alcohol.
626. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? 1. Bradycardia 2. Numbness in the legs 3. Nausea and vomiting 4. A rigid, board-like abdomen
626. 4 Rationale: Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and board-like. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.
629. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which of the following indicate this occurrence? 1. Sweating and pallor 2. Bradycardia and indigestion 3. Double vision and chest pain 4. Abdominal cramping and pain
629. 1 Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
630. The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to note documented in the client's record? 1. Diarrhea 2. Chronic constipation 3. Constipation alternating with diarrhea 4. Stool constantly oozing from the rectum
630. 1 Rationale: Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options 2, 3, and 4 are not characteristics of Crohn's disease.
631. The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1. Dorsiflex the client's foot. 2. Measure the abdominal girth. 3. Ask the client to extend the arms. 4. Instruct the client to lean forward.
631. 3 Rationale: Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect.
632. The nurse is reviewing the laboratory results in a client with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this client? 1. Low-protein diet 2. High-protein diet 3. Moderate-fat diet 4. High-carbohydrate diet
632. 1 Rationale: Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. If the client has hepatic encephalopathy, a low-protein diet would be prescribed.
638. The nurse is doing preoperative teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which statement? 1. "I will be able to pass stool by the rectum eventually." 2. "The drainage from this type of ostomy will be formed." 3. "I will need to drain the pouch regularly with a catheter." 4. "I will need to wear a drainage bag for the rest of my life."
638. 3 Rationale: A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining to about three times a day, or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure.
643. The client has begun medication therapy with pancrelipase (Pancrease). The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed? 1. Weight loss 2. Relief of heartburn 3. Reduction of steatorrhea 4. Absence of abdominal pain
643. 3 Rationale: Pancrelipase (Pancrease) is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. Its use could result in weight gain but should not result in weight loss if it is aiding in digestion.
644. An older client recently has been taking cimetidine (Tagamet). The nurse monitors the client for which most frequent central nervous system side effect of this medication? 1. Tremors 2. Dizziness 3. Confusion 4. Hallucinations
644. 3 Rationale: Cimetidine is a histamine 2 (H2)-receptor antagonist. Older clients are especially susceptible to central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations.
645. The client with a gastric ulcer has a prescription for sucralfate (Carafate), 1 g by mouth four times daily. The nurse schedules the medication for which times? 1. With meals and at bedtime 2. Every 6 hours around the clock 3. One hour after meals and at bedtime 4. One hour before meals and at bedtime
645. 4 Rationale: Sucralfate is a gastric protectant. The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is timed to allow it to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation. The other options are incorrect.
648. A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin (Biaxin), esomeprazole (Nexium), and amoxicillin (Amoxil). Which statement by the client indicates the best understanding of the medication regimen? 1. "My ulcer will heal because these medications will kill the bacteria." 2. "These medications are only taken when I have pain from my ulcer." 3. "The medications will kill the bacteria and stop the acid production." 4. "These medications will coat the ulcer and decrease the acid production in my stomach."
648. 3 Rationale: Triple therapy for Helicobacter pylori infection usually includes two antibacterial drugs and a proton pump inhibitor. Clarithromycin and amoxicillin are antibacterials. Esomeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production.
649. The client has a new prescription for metoclopramide (Reglan). On review of the chart, the nurse identifies that this medication can be safely administered with which condition? 1. Intestinal obstruction 2. Peptic ulcer with melena 3. Diverticulitis with perforation 4. Vomiting following cancer chemotherapy
649. 4 Rationale: Metoclopramide is a gastrointestinal stimulant and antiemetic. Because it is a gastrointestinal stimulant, it is contraindicated with gastrointestinal obstruction, hemorrhage, or perforation. It is used in the treatment of emesis after surgery, chemotherapy, and radiation.
650. The nurse has given instructions to a client who has just been prescribed cholestyramine (Questran). Which statement by the client indicates a need for further instructions? 1. I will continue taking vitamin supplements. 2. This medication will help lower my cholesterol. 3. This medication should only be taken with water. 4. A high-fiber diet is important while taking this medication.
650. 3 Rationale: Cholestyramine (Questran) is a bile acid sequestrant used to lower the cholesterol level and client compliance is a problem because of its taste and palatability. The use of flavored products or fruit juices can improve the taste. Some side effects of bile acid sequestrants include constipation and decreased vitamin absorption.
The nurse performs a client assessment prior to the administration of a prescribed dose of dipyridamole and aspirin (Aggrenox) PO. The nurse notes that the client's carotid bruit is louder than previously assessed. Which action should the nurse implement? A) Administer the prescribed dose of Aggrenox as scheduled. B) Hold the dose of Aggrenox until the health care provider is contacted. C) Advise the client to take nothing by mouth until further assessment is completed. D) Elevate the head of the bed and apply oxygen by nasal cannula.
A) Administer the prescribed dose of Aggrenox as scheduled. - A carotid bruit reflects the degree of blood vessel turbulence, which is typically the result of atherosclerosis. Aggrenox is prescribed to reduce platelet aggregation and should be administered to this client, who is at high risk for thrombus occlusion (A). (B, C, and D) are not necessary interventions at this time.
A nurse is providing discharge instructions for a client with a diagnosis of GERD. What should the nurse advise the client to do to limit symptoms of GERD? Select all that apply. A) Avoid heavy lifting B) Lie down after eating C) Avoid drinking alcohol D) Eat small, frequent meals E) Increase fluid intake with meals F) Wear an abdominal binder or girdle
A) Avoid heavy lifting C) Avoid drinking alcohol D) Eat small, frequent meals
A client who had surgery for a ruptured appendix develops peritonitis. What clinical findings related to peritonitis should the nurse expect the client to exhibit. Select all that apply. A) Fever B) Hyperactivity C) Extreme hunger D) Urinary retention E) Abdominal muscle rigidity
A) Fever D) Urinary retention
An active adolescent is admitted to the hospital for surgery for an ileostomy. WHen planning a teaching session about self-care, the nurse includes sports that should be avoided by this client. Which should be included on the list of sports to avoid? Select all that apply. A) Football B) Swimming C) Ice hockey D) Track events E) Cross-country skiing
A) Football C) Ice hockey
When planning care for a client with polycystic kidney disease, which collaborative problem has the highest priority? A) Hypertension. B) Calculi formation. C) Acute renal failure. D) Infection.
A) Hypertension. - Blood pressure control (A) has the highest priority, which is necessary to reduce cardiovascular complications and slow the progression of renal dysfunction, which can contribute to (B, C, and D).
A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the infant is receiving adequate intake? (Select all that apply.) A) Monitor the the infant's weight and number of wet diapers per day. B) Increase the infant's intake per feeding by 1 to 2 ounces per week. C) Mix the dose of prophylactic antibiotic in a full bottle of formula. D) Allow the infant to rest and refeed on demand or every 2 hours. E) Use a softer nipple or increase the size of the nipple opening.
A) Monitor the the infant's weight and number of wet diapers per day. B) Increase the infant's intake per feeding by 1 to 2 ounces per week. D) Allow the infant to rest and refeed on demand or every 2 hours. E) Use a softer nipple or increase the size of the nipple opening. - Correct responses are (A, B, D, and E). Neonates who have VSD may fatigue quickly during feeding and ingest inadequate amounts. They should be monitored for weight gain and at least 6 wet diapers per day (A). A one-month old infant should ingest 2 to 4 ounces of formula per feeding and progress to about 30 ounces per day by 4-months of age (B). Due to fatigue, the infant should rest, but feed at least every 2 hours to ensure adequate intake (D). A softer (preemie) nipple or a larger slit in the nipple (E) helps to reduce the sucking effort and energy expenditure, thus allowing the infant to ingest more with less effort. Antibiotic prophylaxis is recommended for infants with VSDs, but should not be mixed in a bottle of formula (C) because it is difficult to ensure that the total dose is consumed.
Which glands secrete hormones that regulate metabolism of carbohydrates, proteins, and fats? Select all that apply. A) Pancreas B) Thyroid gland C) Adrenal cortex D) Adrenal medulla E) Parathyroid gland
A) Pancreas B) Thyroid gland C) Adrenal cortex - The pancreas secretes insulin and glucagon, which affects the body's metabolism of carbohydrates, proteins, and fats. The thyroid gland secretes thyroid hormones T3 and T4 that regulate carbohydrates, proteins, and fat metabolism. Cortisol is a glucocorticoid secreted by the adrenal cortex that affects carbohydrates, proteins, and fat metabolism. Adrenal medulla secretes catecholamines, which do not affect metabolism of carbohydrates, proteins, and fats. Hormones secreted by the parathyroid gland mainly regulate calcium and phosphorus metabolism.
A nurse is teaching sterile technique to a family member of a client who is to be discharged with a large abdominal wound that requires a dressing change twice a day. What does the family member do during a return demonstration that indicates further teaching is necessary? A) Sets the sterile field on the client's linens at the front of the bed B) Touches the outer inch of the sterile field when placing it on a flat surface C) Checks expiration dates on the sterile packages before donning sterile gloves D) Picks up wet gauze with sterile plastic forceps, holding the tips lower than the wrist
A) Sets the sterile field on the client's linens at the front of the bed
An internal fetal monitor is applied while a client is in labor. What should the nurse explain about positioning while this monitor is in place? A) The most comfortable position can be assumed B) Monitoring is more accurate in the side-lying position C) The monitor leads can be detached when sitting on the bedpan D) Maintaining a supine position holds the internal electrodes in place
A) The most comfortable position can be assumed
A nurse checking the perineum of a client with a radium implant for cervical cancer observes the packing protruding from the vagina. Why must the nurse notify the HCP to remove it immediately? A) The radioactive packing will injure healthy tissue B) Removal of the packing will prevent excessive blood loss C) The exposure of radium to the environment will diminish its effectiveness D ) Removal of the packing will minimize life-threatening contact with the radiation
A) The radioactive packing will injure healthy tissue
A client with schizophrenia has been experiencing hallucinations. During what client behaviors should the nurse expect the hallucinations to be more frequent? A) Trying to rest B) Playing sports C) Watching television D) Interacting with others
A) Trying to rest
862. A client with rheumatoid arthritis is in the convalescent stage of an exacerbation. What should the nurse encourage the client to do when the client says, "The only time I am without pain is when I lie perfectly still." 1. Active joint flexion and extension 2. Flexion exercises three times a day 3. Range-of-motion exercises once a day 4. Continued immobility until remission occurs
Ans: 1 1. Active exercises (e.g., alternating extension, flexion, abduction, and adduction) mobilize exudate in the joints and relieve stiffness and pain.
405. A client with achalasia is to have bougienage to dilate the lower esophagus and cardiac sphincter. After the procedure the nurse assesses the client for esophageal perforation, which is indicated by: 1. Tachycardia and abdominal pain 2. Faintness and feelings of fullness 3. Diaphoresis and cardiac palpitations 4. Increased blood pressure and urinary output
Ans: 1 1. An increased heart rate is related to an autonomic nervous system response; pain is related to the trauma of the perforation and possibly gastric reflux.
841. A back brace is prescribed for a client who has had a laminectomy. What instruction should the nurse include in the teaching plan? 1. Apply the brace before getting out of bed 2. Put the brace on while in the sitting position 3. Use the brace when the back begins to feel tired 4. Wear the brace when performing twisting exercises
Ans: 1 1. This is done while in the supine position before the body is subjected to the force of gravity in a vertical position. Anatomical landmarks are easier to located for correct application of the braace, and intra-abdominal organs have not shifted toward the pelvic floor by gravity.
466. When preparing a client for a liver biopsy, the nurse explains that during the test the client will be placed: 1. In the supine position, with the right arm raised behind the head 2. On the right side, with the left arm stretched up and over the head 3. On the left side, with the right arm extended out in front across the bed 4. In the prone position, with both elbows flexed and the hands resting on the pillow
Ans: 1 1. This position exposes the right intercostal space, making the large right lobe of the liver accessible.
850. The most appropriate action by the nurse when assisting a client who has had a hip replacement to get out of bed 4 hours after surgery is to: 1. Tell the client that weight bearing must be on both legs equally 2. Advise the client that the legs must be kept wide apart continually 3. Sit the client in a straight-back chair so that the hips are kept flexed 4. Transfer the client using a mechanical lift because weight bearing on the leg is not allowed
Ans: 2 2. Abduction keeps the prosthesis firmly in place; adduction of the extremity may cause the prosthesis to dislocate.
838. The nurse teaches a male client who developed degenerative joint disease of the vertebral column to turn himself from his back to his side, keeping his spine straight. The nurse explains that the least effort will be exerted if he crosses his arm over his chest and: 1. Uses his overbed table to pull himself to one side 2. Bends his top kuee to the side to which he is turning 3. Crosses his ankles while turning with both his legs straight 4. Flexes his bottom knee to the side to which he wishes to turn
Ans: 2 2. Putting the upper arm and leg toward the side to which the client is turning uses body weight to facilitate turning; the spine is kept straight.
422. A client has just undergone a subtotal gastrectomy. Part of discharge teaching includes information about dumping syndrome. What instructions by the nurse will best minimize dumping syndrome? Select all that apply. 1. Drink fluids with meals 2. Eat small frequent meals 3. Lie down for 1 hour after eating 4. Chew food five times before swallowing 5. Increase the carbohydrate component of the diet
Ans: 2,3 2. Small, frequent meals keep the volume within the stomach to a minimum at anyone time, limiting dumping syndrome. Dumping syndrome occurs after eating because of the rapid movement of food into the jejunum without the usual digestive mixing in the stomach and processing in the duodenum. 3. Lying down delays emptying of the stomach contents, which will limit dumping syndrome.
815. A male college basketball player comes to the infirmary complaining of a "click" in his knee when walking. He states that it occasionally gives way when he is running and sometimes locks. He does not recall any specific injury. Which condition should the nurse anticipate that the practitioner primarily will consider when determining the diagnostic tests to order? 1. Cracked patella 2. Ruptured Achilles tendon 3. Injured cartilage in the knee 4. Stress fracture of the tibial plateau
Ans: 3 3. These adaptations are consistent with a torn cartilage; this injury is common among basketball players.
861. The physiotherapist in a nursing home develops an exercise program for an 82-year-old resident with rheumatoid arthritis. The nurse evaluates that the client understands the purpose of this program when the client states: 1. "I know the exercises are important, so I do them whenever I can." 2. "I do my exercises when I go to physical therapy in the morning and afternoon." 3. "Since I'm stiff in the morning, I do most of my exercises then, so I'm done for the day." 4. "After I eat breakfast, I do one set of exercises slowly, and then I space the rest of them throughout the day."
Ans: 4 4. Spacing activity protects joints from overuse, misuse, and stress, limiting inflammation; it provides a balance between rest and activity.
830. A nurse is performing a physical assessment of a client with gout. What parts of the client's body should the nurse assess for the presence of tophi (urate deposits)? Select all that apply. 1. Feet 2. Ears 3. Chin 4. Buttocks 5. Abdomen
Answer: 1, 2 1. Clients with gout may develop deposits of monosodium urate in their tissues (tophi); these consist of a core of monosodium urate with a surrounding inflammatory reaction. Also, urate crystals form in the synovial tissue, typically the metatarsophalangeal joint of the great toe of a foot.
A nurse is performing the physical assessment of a client admitted to the hospital with a diagnosis of cirrhosis. What skin conditions should the nurse expect to observe? Select all that apply. 1. _____ Vitiligo 2. _____ Hirsutism 3. _____ Melanosis 4. _____ Ecchymoses 5. _____ Telangiectasis
Answer: 4, 5 1 This refers to patches of depigmentation resulting from destruction of melanocytes. 2 This is excessive growth of hair; with cirrhosis, endocrine disturbances result in loss of axillary and pubic hair. 3 Dark pigmentary deposits result from a disorder of pigment metabolism. 4 Ecchymoses are small areas of bleeding into the skin or mucous membrane forming a blue or purple patch. With cirrhosis there is decreased synthesis of prothombin in the liver. 5 Telangiectasis is a vascular lesion formed by dilation of a group of small blood vessels. When cirrhosis causes an increase in pressure in the portal circulation that results in a dilation of cutaneous blood vessels around the umbilicus, it is specifically called caput medusae.
After a teaching session, the nurse evaluates the client's understanding of hypoparathyroidism. Which statement made by the client indicates the need for further education? A) "I should eat an orange a day." B) "I should include yogurt in my diet." C) "I should perform mild exercises daily." D) "I should sit outside in the sun."
B) "I should include yogurt in my diet." - Further education is needed for the client. Clients with hypoparathyroidism have hypocalcemia. In order to replenish the calcium levels of the body, the client should consume foods that are rich in calcium. However, foods rich in phosphorus such as yogurt, processed cheese, and milk should be avoided. All the other comments are correct and require no further education by the nurse. Oranges are good source of vitamin C and fibers. They help to improve healing and remove wastes from the body. Exercising is good for overall health. Sitting in the sun allows exposure of the client to sunlight, which is a natural source of vitamin D. Vitamin D helps in the absorption of calcium from the gastrointestinal tract.
The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that A) Only an RN should be assigned to monitor this child's temperature. B) A tympanic measurement of temperature will provide the most accurate reading. C) The licensed practical nurse should be instructed to obtain rectal temperatures on this child. D) The healthcare provider should be asked to prescribe the method for measurement of the child's temperatures.
B) A tympanic measurement of temperature will provide the most accurate reading. - (B) A tympanic membrane sensor is an excellent site because both the eardrum and hypothalamus (temperature-regulating center) are perfused by the same circulation. The sensor is unaffected by cerumen and the presence of suppurative or unsuppurative otitis media does not effect measurement. RULE OF THUMB: for management--sterile procedures should be assigned to licensed personnel. Management skills will be tested on the NCLEX! An RN is not required (A). Rectal temperature measurement (C) is less accurate because of the possibility of stool in the rectum. (D) is unnecessary.
A nurse is educating a client with a colostomy of the ascending colon about using a colostomy appliance. Which instructions should the nurse provide to help prevent leakage of stool from the appliance? A) Irrigate the colostomy to establish an expected pattern of elimination B) Empty the appliance when it is approximately half full C) Use an antiseptic to clean the peristomal skin before applying the appliance D) Select an appliance with a pouch opening of at least 5 cm or larger than the stoma
B) Empty the appliance when it is approximately half full
A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to be exhibiting? A) Hyperexcitability of reflexes B) Hyperextension of the head and back C) Inability to flex the chin to the chest D) Lateral facial paralysis
B) Hyperextension of the head and back - Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by attempting to flex the neck and place the chin to the chest (C). Although (A, B, and D) may occur in meningitis, (A) describes exaggerated spinal nerve reflex responses, (B) describes opisthotonus, and (D) may be related to cranial nerve pathology of the trigeminal nerve.
A client who begins an exercise program asks the nurse about carbohydrate loading. What concepts should the nurse include in teaching the client ways to increase glycogen store in muscles? A) Moderate exercise and low fat intake. B) Rest and increased carbohydrate intake. C) Intense exercise and decreased carbohydrate intake. D) Intense exercise and high intake of complex carbohydrates.
B) Rest and increased carbohydrate intake. - Carbohydrate loading is the process of changing foods eaten and adjusting exercise intensity to increase glycogen stores in the muscle. To achieve maximum muscle glycogen stores, a high carbohydrate diet should be consumed as part of a regular exercise program (60%-70% of total kilocalories from carbohydrate that tapers off to allow muscles to rest (B). (A, C, and D) do not balance the client's exercise intensity with an intake of high complex carbohydrates needed to provide maximum glycogen stores to maintain muscular conditioning.
A nurse is caring for a client with CBI. Which is the most important nursing action? A) Monitoring USG to determine hydration B) Subtracting irrigant from output to determine the urine volume C) Recording UO every hour to determine kidney function D) Obtaining a 24 hour urine specimen to determine urine concentration
B) Subtracting irrigant from output to determine the urine volume
A family of a client with myasthenia gravis asks the nurse whether the client will be an invalid. What is the nurse's best response? A) "Medications will mask the signs of the disease." B) "With continuous treatment, the progression of the disease can usually be controlled." C) "There will be periods when bed rest will be necessary and times when regular activity will be possible." D) "The progression generally is slow, so people with myasthenia will spend their younger life with few problems."
C) "There will be periods when bed rest will be necessary and times when regular activity will be possible."
A client who is about to have a blood transfusion asks the nurse, "Which type of hepatitis is most frequently transmitted by transfusions?" The nurse should response, "Although the risk is minimal, the type of hepatitis associated with blood transfusions is hepatitis: A) A B) B C) C D) D
C) C
When performing a newborn assessment after a vaginal birth, a nurse observes a swelling on one side of the top of the head. What clinical manifestation did the nurse identify? A) Caput succedaneum that will spread across the scalp and then resolve B) Fontanelle that bulges when the infant cries and then will close in eighteen months C) Cephalohematoma that does not cross the suture line and will resolves in several weeks D) Molding that results from the skull taking the shape of the vagina and will disappear in several days
C) Cephalohematoma that does not cross the suture line and will resolves in several weeks - This is a description of a cephalohematoma because it is only on one side of the head and does not cross the suture line.
Two hours after a subtotal gastrectomy, the nurse identifies that the drainage from the client's NG tube is bright red. What should the nurse do first? A) Notify the HCP B) Clamp the NG tube for one hour C) Determine that this is an expected finding D) Irrigate the NG tube with iced saline
C) Determine that this is an expected finding
A client has surgery to repair a fractured right hip. Where should the nurse stand when assisting the client to ambulate? A) Behind the client B) In front of the client C) On the client's left side D) On the client's right side
C) On the client's left side - When the nurse is assisting the client to ambulate, she should stand on the client's stronger, unaffected side.
Which hormones are secreted by the client's hypothalamus? Select all that apply. A) Growth hormone B) Follicle-stimulating hormone C) Prolactin-inhibiting hormone D) Corticotropin-releasing hormone E) Melanocyte-stimulating hormone
C) Prolactin-inhibiting hormone D) Corticotropin-releasing hormone - The hormones that are secreted by the hypothalamus include prolactin-inhibiting hormone and corticotropin-releasing hormone. Growth hormone, follicle-stimulating hormone, and melanocyte-stimulating hormone are hormones secreted by the anterior pituitary gland.
Which nursing action is protected from legal action? A) Providing health teaching regarding family planning B) Offering first aid at the scene of an automobile collision C) Reporting incidence of suspected child abuse to the appropriate authorities D) Administering resuscitative measures to an unconscious child pulled out of a swimming pool
C) Reporting incidence of suspected child abuse to the appropriate authorities -
A client is receiving an opioid analgesic every 2 hours for intractable pain. Which pathophysiological consequence should the nurse identify if the client receives the medication at regular intervals? A) Metabolic acidosis. B) Metabolic alkalosis. C) Respiratory acidosis. D) Respiratory alkalosis.
C) Respiratory acidosis. - Respiratory acidosis (C) results from retention of CO2 secondary to hypoventilation due to respiratory depression, which is an adverse effect of opiates. Metabolic acidosis (A) is caused by chronic renal failure, loss of bicarbonates during diarrhea, and metabolic disorders that result in overproduction of lactic acid or ketoacids. Metabolic alkalosis (B) is caused by excessive loss of gastric acid and administration of alkalinizing salts. Respiratory alkalosis (D) is precipitated by hyperventilation.
31. Which laboratory result may the nurse expect to find during the initial phases of hepatitis? A. Increased LDH and CK B. Normal prothrombin time. C. Elevated serum transaminases. D. Decreased alkaline phosphatase.
C. Elevated serum transaminases. C is correct because the serum transaminases, ALT and AST, increase during the initial stage of the disease process, reflecting the liver cell injury present. A is incorrect because although moderate elevation of LDH levels is common in acute viral hepatitis, the CK level remains unchanged. CK is elevated in myocardial infarction, not in liver disease. B is also incorrect. Prothrombin is synthesized in the liver and variations in the prothrombin time can be expected because the liver cells are injured. D is incorrect because there is an increased release of, not a decrease in, alkaline phosphatase. Because of an Impaired hepatic excretory function, enzyme synthesis is increased-subsequently, an increased release of alkaline phosphatase.
114. Mr. Williams begins to hemorrhage from his ulcer and will have surgery. The nurse considers that the urgency of this surgery is: A. Planned. B. Imperative. C. Emergency. D. Optional.
C. Emergency This Is a life-threatening situation because of the blood loss. The client's surgery is an emergency and must take priority over other surgeries scheduled. Surgery can be described as planned, A, when conditions necessitate it but it can be scheduled at a convenient time. Imperative surgery, B, must be done within 24 hours. Optional surgery, D, is done at the client's request. The client can survive without having this surgery performed.
The nurse is caring for a client with ureteral colic. To prevent the development of renal calculi in the future, which strategy should be included in the client's plan of care? 1 Excluding milk products from the diet 2 Interventions to decrease the serum creatinine level Correct 3 Instructing the client to drink 8 to 10 glasses of water daily 4 A urinary output goal of 2000 mL per 24 hours
Correct 3 Increasing fluid intake [1] [2] dilutes the urine, and crystals are less likely to coalesce and form calculi. An elevated serum creatinine has no relationship to the formation of renal calculi. Calcium restriction is necessary only if calculi have a calcium phosphate basis. Producing only 2000 mL of urine per 24 hours is inadequate. STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question
A client is scheduled to have an indwelling urinary catheter inserted before abdominal surgery. The nurse should insert the catheter in what location in the illustration? 3142352560 1 d 2 c 3 a 4 b
Correct 4 b Option B is the urethral orifice, which anatomically is between the clitoris and the vagina; it is the opening into the urethra, the tubular structure that drains urine from the bladder. Option A is the clitoris, which is situated beneath the anterior commissure, partially hidden between the anterior extremities of the labia minora. Option C is the opening of the vagina; it is the part of the female genitalia that forms a canal from the vaginal orifice through the vestibule to the uterine cervix. Option D is the anus; it is the terminal end of the anal canal that is connected to the rectum; the rectum is a portion of the large intestine that is between the anal canal and the descending sigmoid colon. Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.
A client who has trouble swallowing pills intermittently has been prescribed venlafaxine (Effexor XR) for depression. The medication comes in capsule form. What should the nurse include in the discharge teaching plan for this client? A) Capsule contents can be sprinkled on pudding or applesauce. B) Chew the medication thoroughly to enhance absorption. C) Take the medication with a large glass of water or juice. D) Contact the health care provider for another form of medication.
D) Contact the health care provider for another form of medication. - Venlafaxine (Effexor XR) is administered PO in capsule form. Capsules that are extended-release (XR) or continuous-release (CR) contain delayed-release, enteric-coated granules to prevent decomposition of the drug in the acidic pH of the stomach. The client should notify the health care provider about the inability to swallow the capsule (D). This medication should not be chewed or opened so that the delayed-release, enteric-coated granules can remain intact (A and B). Water or juice (C) will not affect the medication.
A client with a tentative diagnosis of Cushing syndrome has an increased cortisol level. What response should the nurse assess this client for? A) Hypovolemia B) Hyperkalemia C) Hypoglycemia D) Hypernatremia
D) Hypernatremia - A client with Cushing syndrome secretes excess amounts of cortisol, a corticosteroid that acts to retain sodium and water, resulting in hypernatremia and edema. Hypervolemia, not hypovolemia, is caused by fluid retention. Hypokalemia, not hyperkalemia, occurs because potassium is lost when there is sodium retention. Hyperglycemia, not hypoglycemia, results from cortisol-induced glucose intolerance.
What are the cardiovascular manifestations observed in a client with adrenal insufficiency? A) Fatigue B) Salt craving C) Weight loss D) Hyponatremia
D) Hyponatremia - Hyponatremia is a decrease in serum sodium levels, which is the cardiovascular manifestation of adrenal insufficiency. Fatigue is a neuromuscular manifestation observed in clients with adrenal insufficiency, while salt cravings and weight loss are the abdominal manifestations observed in clients with adrenal insufficiency.
The nurse notes that the hemoglobin level of a client receiving darbepoetin alfa (Aranesp) has increased from 6 to 10 g/dL over the first 2 weeks of treatment. Which action should the nurse take? A) Encourage the client to continue the treatment, because it is effective. B) Advise the client that the dose will need to be increased. C) Assess the client's skin color for continued pallor or cyanosis. D) Notify the health care provider of the change in the client's laboratory values.
D) Notify the health care provider of the change in the client's laboratory values. - Although an increase in the client's hemoglobin level is desired, a rapid increase (more than 1 g/dL in a 2-week period) may lead to hypertension, so the health care provider should be notified of this excessive increase (D). (A and B) may lead to a dangerous increase in blood pressure. Because the client's anemia has improved, (D) is of greater priority than continuing to monitor for signs of anemia (C).
A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the HCP? A) Passage of pink-tinged sputum B) Pink drainage on the dressing C) Intake of 1750 mL in 24 hours D) Urine output of 20 - 30 ml/hr
D) Urine output of 20 - 30 ml/hr
A client is admitted to the hospital with deep partial-thickness burns to both hands and forearms after an accident. How should the nurse apply the prescribed antimicrobial medication? a. Place the medication directly on the dressing in a thick layer using clean gloves. b. Place the medication directly on the burn wound in a thin layer using sterile gloves. c. Put the medication in a Hubbard tank and saturate sterile dressings with it before applying the dressings to the burns. d. Put the medication in a Hubbard tank and allow the client to soak in the tank for several minutes every day.
b. Place the medication directly on the burn wound in a thin layer using sterile gloves.
Musculoskeletal System - Blackboard questions
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On the third postoperative day after a subtotal gastrectomy, a client complains of severe abdominal pain. The nurse palpates the client's abdomen and identifies rigidity. The nurse should first: 1. Assist the client to ambulate 2. Obtain the client's vital signs 3. Administer the prescribed analgesic 4. Encourage the use of the spirometer
. 2 Rigidity and pain are hallmarks of bleeding from the suture line and/or of peritonitis; vital signs provide supporting data. 1 Ambulation is indicated if the pain is the result of flatulence; however, rigidity is clearly associated with bleeding or peritonitis and more data are needed. 3 An analgesic may mask the symptoms, delaying diagnosis. 4 This is unrelated to the adaptations presented.
ATI Case Management Scenarios with Critical Thinking Exercises, Questions and Answers
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Gastrointestinal System - Blackboard questions
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Gastrointestinal System - Saunders printed book
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The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis results. Which urinary finding should the nurse conclude needs to be reported to the primary healthcare provider? 1 Acidic pH 2 Glucose negative 3 Presence of large proteins 4 Bacteria negative
...3..The glomeruli are not permeable to large proteins such as albumin or red blood cells (RBCs), and it is abnormal if albumin or RBCs are identified in the urine; their presence should be reported. The urine can be acidic; normal pH is 4.0 to 8.0. Glucose and bacteria should be negative; these are normal findings.
A nurse is caring for a client who had a nephrectomy because of cancer of the kidney. Which factor will influence the client's ability to deep breathe and cough postoperatively? 1 Pulmonary congestion from preoperative medications 2 Location of the surgical incision 3 Inflammatory process associated with surgery 4 Increased anxiety about the prognosis
2 The location of the surgical site in relation to the diaphragm increases incisional pain when deep breathing or coughing. Anxiety about the prognosis should not interfere with the ability to deep breathe and cough, especially when encouraged by the nurse. Inflammatory changes will cause discomfort in the area of any incision but are not necessarily the prime factor preventing deep breathing after a nephrectomy. The client will need to cough and deep breathe if there is congestion in the lungs.
A client is admitted to the hospital with severe flank pain, nausea, and hematuria caused by a ureteral calculus. What should be the nurse's initial intervention? 1 Obtain a urine specimen for culture. 2 Administer the prescribed analgesic. 3 increase oral fluid intake. 4 Strain all urine output.
2...Pain of renal colic may be excruciating; unless relief is obtained, the client will be unable to cooperate with other therapy. Urine can be saved and strained after the client's priority needs are met. Increasing fluid intake may or may not be helpful. If the stone is large the fluid can build up, leading to hydronephrosis; however, if the stone is small, fluids may help flush the stone. Although a culture generally is prescribed, this is not the priority when a client has severe pain.
Dopamine (Intropin), 5 mcg/kg/min, is prescribed for a client who weighs 105 kg. The nurse mixes 400 mg of dopamine in 250 mL D5W for IV administration via an infusion pump. What is the hourly rate that the nurse should set on the pump?
20 mL/hr
A middle-aged male client has an adenocarcinoma of the colon. The practitioner suspects that this has metastasized and orders a CT scan of the liver. When preparing the client for the CT scan the nurse explains that: 1. After the procedure he must rest in bed for about six hours to prevent complications 2. There will be some discomfort during the procedure but the practitioner will administer an analgesic 3. He will be in twilight sleep during the procedure and may be able to hear people talking in the same room 4. He will be given an IV infusion containing a contrast medium before the procedure and must lie as still as possible for a period of time
4 This is an accurate explanation of what the client can expect during the CT scan. 1 It is not necessary to rest in bed for 6 hours. 2 The procedure causes no physical pain, and an analgesic is not necessary. 3 The client will be awake; neither sedation nor anesthesia is used with a CT scan.
476. When assessing a client who had abdominal surgery, the nurse determines that peristalsis has returned when the client first: 1. Passes flatus 2. Has bowel sounds 3. Tolerates clear liquids 4. Has a bowel movement
476. 2 Bowel sounds are the result of peristaltic movements that propel intestinal contents through the alimentary tract, causing characteristic sounds.
651. A histamine (H2)-receptor antagonist will be prescribed for a client. The nurse understands that which medications are H2-receptor antagonists? Select all that apply. 1. Nizatidine (Axid) 2. Ranitidine (Zantac) 3. Famotidine (Pepcid) 4. Cimetidine (Tagamet) 5. Esomeprazole (Nexium) 6. Lansoprazole (Prevacid)
651. 1, 2, 3, 4 Rationale: H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions. The other medications listed are proton pump inhibitors.
851. A client returns from surgery with a hip prosthesis. An abductor splint is in place. The nurse should remove the splint: 1. When the client gets up in a chair 2. If the client needs a change of position 3. Once the client's edema and pain have ceased 4. During the client's skin care and physical therapy
851. Ans: 4 4. Until the order is written to discontinue the abduction splint, it is only removed for mobility such as physical therapy and hygiene; adduction to or beyond the midline is not permitted until allowed by the practitioner.
A client enters the emergency department, reporting shortness of breath and epigastric distress. What should be the triage nurse's first intervention? A) Assess vital signs B) Insert a saline lock C) Place client on oxygen D) Draw blood for troponins
A) Assess vital signs
The nurse notes a client's postoperative leg is cool with a capillary refill greater than 4 seconds and calls the healthcare provider. After 30 minutes of not receiving a return call from the healthcare provider, which action should the nurse take first? A) Attempt to recall the same healthcare provider. B) Notify the hospital's on call nursing supervisor. C) Continue to monitor and call if there is a change. D) Describe the problem to the answering service.
A) Attempt to recall the same healthcare provider. - The healthcare provider may have inadvertently not received the first call, so (A) is the best action to take first. According to the TeamSTEPPS, two attempts should be made to notify the provider before proceeding through the chain of command (B). (C) should be implemented, but these assessment findings require immediate medical action. Although (D) is an option, the client's urgent condition needs treatment.
The nurse is preparing a client for surgical stabilization of a fractured lumbar vertebrae. Which indication(s) best supports the client's need for insertion of an indwelling urinary catheter? (Select all that apply.) A) Hourly urine output B) Bladder distention C) Urinary incontinence D) Intraoperative bladder decompression E) Urine sample for culture
A) Hourly urine output B) Bladder distention D) Intraoperative bladder decompression - Continuous bladder drainage using an indwelling catheter is indicated for monitoring hourly urinary output (A), bladder distention (B), and bladder decompression (D) related to urinary retention under anesthesia. Less invasive measures, such as a condom catheter or bladder training for urinary incontinence (C) or midstream collection of urine for culture (E) are not indicated based on the client's description.
The nurse administers levothyroxine (Synthroid) to a client with hypothyroidism. Which data indicate(s) that the drug is effective? (Select all that apply.) A) Increase in T3 and T4 B) Decrease in heart rate C) Increase in TSH D) Decrease in urine output E) Decrease in periorbital edema
A) Increase in T3 and T4 E) Decrease in periorbital edema - Levothyroxine is a thyroid replacement drug that increases thyroid hormone levels (T3 [triiodothyronine] and T4 [thyroxine]) and decreases periorbital edema, a symptom of hypothyroidism (A and E). Decrease in heart rate and an increased level of thyroid-stimulating hormone (TSH) are not therapeutic results from taking levothyroxine (Synthroid) (B and C). Levothyroxine does not affect urine output (D).
The nurse teaches a class on bioterrorism. Which method(s) of transmission is(are) possible with the biologic agent Bacillus anthracis (Anthrax)? (Select all that apply.) A) Inhalation of powder form B) Handling of infected animals C) Spread from person to person through coughing D) Eating undercooked meat from infected animals E) Direct cutaneous contact with the powder
A) Inhalation of powder form B) Handling of infected animals D) Eating undercooked meat from infected animals E) Direct cutaneous contact with the powder - Anthrax can be transmitted by the inhalation, cutaneous, and digestive routes (A, B, D, and E); however, the disease is not spread from person to person (C).
Which clinical indicators can the nurse expect when assessing a client with Cushing syndrome? Select all that apply. A) Lability of mood B) Slow wound healing C) A decrease in the growth of hair D) Ectomorphism with a moon face E) An increased resistance to bruising
A) Lability of mood B) Slow wound healing
When a disaster occurs, the nurse may have to treat mass hysteria first. Which response indicates that an individual should be cared for first? A) Panic B) Coma C) Euphoria D) Depression
A) Panic
A child with cystic fibrosis is receiving ticarcillin disodium (Ticar) for Pseudomonas pneumonia. For which adverse effect should the nurse assess and report promptly to the health care provider? A) Petechiae B) Tinnitus C) Oliguria D) Hypertension
A) Petechiae - Adverse effects of ticarcillin disodium (Ticar) include hypothrombinemia and decreased platelet adhesion, which can result in the presence of petechiae (A). (B, C, and D) are not adverse effects primarily associated with the administration of Ticar.
A nurse is counseling a couple in the fertility clinic. Which aspect of the protocol is the most stressful for the couple? A) Planning when to have intercourse B) Obtaining the necessary specimens C) Visiting the fertility clinic frequently D) Taking daily basal body temperatures
A) Planning when to have intercourse
What should the nurse teach the parents about preventing sudden infant death syndrome (SIDS)? Select all that apply. A) Refrain from smoking around the infant. B) Refrain from co-sleeping or bed-sharing. C) Position the infant on the side while sleeping. D) Use soft pillows to support the infant while sleeping. E) Refrain from placing stuffed toys on the infant's bed.
A) Refrain from smoking around the infant. B) Refrain from co-sleeping or bed-sharing. E) Refrain from placing stuffed toys on the infant's bed. - The nurse should instruct the parents to avoid exposing the infant to cigarette smoke because the chemicals place the infant at a greater risk for sudden infant death syndrome (SIDS). Co-sleeping or bed-sharing is also associated with SIDS. The nurse should ask the parents to refrain from placing stuffed toys on the infant's bed as a precautionary measure against SIDS. The infant should be positioned on his or her back to reduce the incidence of SIDS. Parents should not use soft mattresses or pillows in the infant's crib to reduce the risk for SIDS.
A client with diabetes states, "I cannot eat big meals; I prefer to snack throughout the day." What information should the nurse include in a response to this client's statement? A) Regulated food intake is basic to control B) Salt and sugar restriction is the main concern C) Small, frequent meals are better for digestion D) Large meals can contribute to weight problems
A) Regulated food intake is basic to control
Which client is most likely to be at risk for spiritual distress? A) Roman Catholic woman considering an abortion B) Jewish man considering hospice care for his wife C) Seventh-Day Adventist who needs a blood transfusion D) Muslim man who needs a total knee replacement
A) Roman Catholic woman considering an abortion - In the Roman Catholic religion, any type of abortion is prohibited (A), so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith (B). Jehovah's Witnesses prohibit blood transfusions, not Seventh-Day Adventists (C). There is no conflict in the Muslim faith with regard to joint replacement (D).
The nurse is preparing to administer amphotericin B (Fungizone) IV to a client. What laboratory data is most important for the nurse to assess before initiating an IV infusion of this medication? A) Serum potassium level B) Platelet count C) Serum creatinine level D) Hemoglobin level
A) Serum potassium level - The nurse should obtain baseline potassium levels (A) prior to beginning drug therapy because amphotericin B (Fungizone) changes cellular permeability, allowing potassium to escape from the cell, which could lead to a decrease in the serum potassium level and severe hypokalemia. (B, C, and D) are helpful laboratory values, but they do not have the importance of (A) in determining if amphotericin B (Fungizone) can be administered safely via IV infusion
A nurse is teaching clients to determine the time of ovulation by taking the basal temperature. What change is expected to occur in the basal temperature during ovulation? A) Slight drop and then rises B) Sudden rise and then drops C) Marked rise and remains high D) Marked drop and remains lower
A) Slight drop and then rises
A client is recovering from an acute episode of alcoholism that included esophageal involvement. What are the components of a therapeutic diet that are most appropriate for the nurse to include in the teaching plan for this client? Select all that apply. A) Soft diet B) Regular diet C) Low-protein diet D) High-protein diet E) Low-carbohydrate diet F) High-carbohydrate diet
A) Soft diet D) High-protein diet F) High-carbohydrate diet
A client has a thyroidectomy for cancer of the thyroid. When evaluating for nerve injury, what should the client be asked to do? A) Speak B) Swallow C) Purse the lips D) Turn the head
A) Speak - The laryngeal nerve is close to the operative site and can be damaged inadvertently. Loss of the gag reflex occurs with general anesthesia; the ability to swallow signifies its return. The ability to purse the lips tests the seventh cranial (facial) nerve, which is not affected in thyroid surgery. The nerves involved in turning the head are not near the thyroid gland.
Oxytocin (Pitocin) augmentation via IV piggyback (IVPB) is prescribed for a client in labor after a period of ineffective uterine contractions. What nursing interventions are most important if strong contractions that last 90 seconds or longer occur? Select all that apply. A) Stop the infusion B) Turn the client on her side C) Notify the HCP D) Verify the length of contractions E) Administer oxygen via a face mask
A) Stop the infusion B) Turn the client on her side C) Notify the HCP D) Verify the length of contractions E) Administer oxygen via a face mask
Methenamine mandelate (Mandelamine) is prescribed for a client with a urinary tract infection and renal calculi. Which finding indicates to the nurse that the medication is effective? A) The frequency of urinary tract infections decreases. B) The urine changes color and pain is diminished. C) The dipstick test changes from +1 to trace. D) The daily urinary output increases by 10%.
A) The frequency of urinary tract infections decreases. - Mandelamine is prescribed to acidify the urine, decreasing the incidence of calcium phosphate calculi and urinary tract infections (A). (B) is related to the administration of pyridine (Pyridium). Mandelamine has no effect on (C or D).
A client has a total hip arthroplasty. What should the nurse do when caring for this client after surgery? A) Use a pillow to keep the legs abducted B) Elevate the client's affected limb on a pillow C) Turn the client using the log-rolling technique D) Place a trochanter roll along the entire extremity
A) Use a pillow to keep the legs abducted
A client is diagnosed with hyperthyroidism and is experincing exophthalmia. Which measures should the nurse include when teaching this client how to manage the discomfort associated with exophthalmia? Select all that apply. A) Use tinted glasses B) Use warm, moist compresses C) Elevated the HOB 45 degrees D) Tape eyelids shut at night if they do not close E) Apply a petroleum-based jelly along the lower eyelid
A) Use tinted glasses C) Elevated the HOB 45 degrees D) Tape eyelids shut at night if they do not close
A newborn with acquired herpes simplex virus infection is being discharged. Which developmental pattern is important for the nurse to teach the parents to monitor? A) Visual clarity B) Renal function C) Long bone growth D) Responses to sounds
A) Visual clarity - Ocular disease is common in patients with herpes simplex virus infections.
124. The first IV infusion began at 8 AM. At 11 A.M., given a correct flow rate and no interference, the nurse expects the first 1000-mL container to contain: A. 625 mL. B. 736 mL. C. 840 mL. D. 437 mL.
A. 625 mL. 3000 mL in 24 hours = 125 mL per hour. 125 mL x 3 hours = 375 mL. 1000 - 375 = 625 mL.
112. Mr. Williams enters the hospital reporting that he has vomited a very large amount of blood. The nurse should expect which sign to be present? A. Decreased blood pressure. B. Decreased pulse. C. Decreased respirations. D. Increased urinary output.
A. Decreased blood pressure. The decreased blood pressure is due to a fall in cardiac output because of loss of volume. Band C are Incorrect because both pulse and respirations are increased. D is incorrect because urinary output is decreased.
152. Which nursing observation Is an Inappropriate indicator of GI bleeding? A. Elevated BUN. B. Coffee-ground emesis. C. Black, tarry stools. D. Lowered hemoglobin.
A. Elevated BUN. BUN levels reflect the kidney's ability to excrete urea, an end product of protein metabolism. B, C, and D are classic signs of GI bleeding.
Acute gastritis
Abdominal discomfort, anorexia, N/V, headache, hiccuping, reflux
Fluoroquinolone
Administer ________ with a full glass of water and ensure that the client maintains a urine output of at least 1200-1500mL daily to minimize the development of crystalluria
70%
If the pulse oximetry is lower than ________, it's life-threatening
At the conclusion of visiting hours, the parent of a 14-year-old adolescent scheduled for orthopedic surgery the next day hands the nurse a bottle of capsules and says, "These are for my child's allergy. Will you be sure my child takes one about 9 tonight?" What is the nurse's best response? A) "I will give one capsule tonight before bedtime." B) "I will get a prescription so that the medication can be taken." C) "Does your HCP know about your child's allergy?" D) "Did you ask your HCP if your child should have this tonight?"
B) "I will get a prescription so that the medication can be taken." - Legally, a nurse cannot administer medications without a prescription from a legally licensed individual.
A client is learning alternative site testing for glucose monitoring. Which client statement indicates to the nurse that additional teaching is necessary? A) "I need to rub my forearm vigorously until warm before testing at this site." B) "The fingertip is prefered for glucose monitoring if hyperglycemia is suspected." C) "Alternative site testing is unsafe if I am experiencing a rapid change in glucose levels." D) "I have to make sure that my current glucose monitor can be used at an alternative site."
B) "The fingertip is prefered for glucose monitoring if hyperglycemia is suspected." - The fingertip is prefered for glucose monitoring if HYPOGLYCEMIA is suspected, not hyperglycemia.
The nurse administers regular insulin (human), 8 units subcutaneously, to a client at 8:00 AM, 30 minutes before breakfast. At what time is the client most at risk for a hypoglycemic reaction? A) 9:30 Am B) 10:30 am C) 12:00 pm D) 3:00 pm
B) 10:30 am - Regular insulin is short-acting and peaks between 2 and 3 hours after administration (B). The client is most at risk for a hypoglycemic reaction during the peak times. (A, C, and D) are not high-risk times for the client to experience hypoglycemia because they do not fall within the peak time.
The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document? A) 14 B) 16 C) 17 D) 28
B) 16 - The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled (B). (A, C, and D) are inaccurate recordings.
A Harris flush is ordered to reduce a client's flatus after abdominal surgery. How many inches should the nurse insert the rectal catheter? A) 2 B) 4 C) 6 D) 8
B) 4
A client is receiving pyridostigmine bromide (Mestinon) to control the symptoms of myasthenia gravis. Which client behavior would indicate that the drug therapy is effective?A) Decreased oral secretions B) Clear speech C) Diminished hand tremors D) Increased ptosis
B) Clear speech - Clear speech (B) is the result of increased muscle strength. Muscle weakness characteristic of myasthenia gravis often first appears in the muscles of the neck and face. (A and D) are symptoms of multiple sclerosis that would persist if the medication was ineffective. Hand tremors (C) are not typical symptoms of the disease.
The nurse is teaching a client with cancer about opioid management for intractable pain and tolerance related side effects. The nurse should prepare the client for which side effect that is most likely to persist during long-term use of opioids? A) Sedation. B) Constipation. C) Urinary retention. D) Respiratory depression.
B) Constipation. - The client should be prepared to implement measures for constipation (B) which is the most likely persistent side effect related to opioid use. Tolerance to opiate narcotics is common, and the client may experience less sedation (A) and respiratory depression (D) as analgesic use continues. Opioids increase the tone in the urinary bladder sphincter, which causes retention (C) but may subside.
An exploratory laparotomy is performed on a client with melena, and gastric cancer is discovered. A partial gastrectomy is performed, and a jejunostomy tube is surgically implanted. A NG tube to suction is in place. What should the nurse expect regarding the client's NG tube drainage during the first 24 hours after surgery? A) Green and viscid B) Contain some blood and clots C) Contain large amounts of frank blood D) Similar to coffee grounds in color and consistency
B) Contain some blood and clots
A 6-year-old child is admitted to the emergency department with status epilepticus. His parents report that his seizure disorder has been managed with phenytoin (Dilantin), 50 mg PO bid, for the past year. Which drug should the nurse plan to administer in the emergency department? A) Phenytoin (Dilantin) B) Diazepam (Valium) C) Phenobarbital (Luminal) D) Carbamazepine (Tegretol)
B) Diazepam (Valium) - Diazepam (Valium) (B) is the drug of choice for treatment of status epilepticus. (A, C, and D) are used for the long-term management of seizure disorders but are not as useful in the emergency management of status epilepticus.
A client with a diagnosis of personality disorder with antisocial behavior is hospitalized. The client is openly discussing interpersonal difficulties with family members and the boss at work with whom money has been stolen. The client presently is facing criminal charges. Which behavior indicates that the client is meeting treatment goals? A) Expression of feelings of resentment toward the employer B) Discussion of plans for each of the possible outcomes of a trial C) Expression of resignation about difficult spousal and children relationships D) Discussion of the decision to file a grievance against the employer after discharge from the hospital
B) Discussion of plans for each of the possible outcomes of a trial
A 19-year-old male client who has sustained a severe head injury is intubated and placed on assisted mechanical ventilation. To facilitate optimal ventilation and prevent the client from "fighting" the ventilator, the health care provider administers pancuronium bromide (Pavulon) IV, with adjunctive opioid analgesia. What medication should the nurse maintain at the client's bedside? A) Dantrolene sodium (Dantrium) B) Neostigmine bromide (Prostigmin) C) Succinylcholine bromide (Anectine) D) Epinephrine (Adrenalin)
B) Neostigmine bromide (Prostigmin) - Neostigmine bromide (Prostigmin) (B) and atropine sulfate (Atropine), both anticholinergic drugs, reverse the respiratory muscle paralysis caused by pancuronium bromide. (A, C, and D) are not antagonists to pancuronium bromide and would not be helpful in reversing the effects of the drug compared with the use of anticholinergics.
A client who had a suprapubic prostatectomy returns from the PACU and accidentally pulls out the urethral catheter. What should the nurse do first? A) Reinsert a new catheter B) Notify the HCP C) Check for bleeding by irrigating the suprapubic catheter D) Take no immediate action if the suprapbuic tube is draining
B) Notify the HCP
A nurse is caring for a male client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? Select all that apply. A) Polyuria B) Obese trunk C) Hypotension D) Sleep disturbance E) Thin arms and legs
B) Obese trunk D) Sleep disturbance E) Thin arms and legs
The nurse is providing comfort and palliative care for a terminally ill client who is experiencing nausea and vomiting. Which action is best for the nurse to take to promote the client's comfort? A) Increase fluid intake. B) Offer high-protein foods. C) Provide a high-residue diet. D) Give prompt mouth care.
B) Offer high-protein foods. - Measures to manage nausea and vomiting include the use of antiemetics and avoiding foods and liquids that increase stomach acidity, such as coffee, milk, and citrus acid juices. For some clients, an empty stomach exacerbates the nausea, so offering frequent, small amounts of foods that appeal to the client, such as dry cracker or bland, high protein foods (B), help maintain nutritional status. Although (A and C) may help prevent constipation or diarrhea, the best action is to meet the client's basic needs for hydration and nutrition. Although (D) is a comfort measure that minimizes nausea, the presence of protein in the stomach may be more effective.
A client is being admitted for total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation has been completed? Select all that apply. A) After reporting severe pain B) On admission to the hospital C) Upon entering the OR D) Before transfer to a rehabilitation unit E) At the time of scheduling for the surgical procedure
B) On admission to the hospital D) Before transfer to a rehabilitation unit
A nurse is caring for a client with myxedema who has undergone abdominal surgery. What should the nurse consider when administering opioids to this client? A) Tolerance to the drugs develops readily B) One third to one half the usual dose should be prescribed C) Opioids may interfere with the secretion of thyroid hormones D) Sedation will have a paradoxical effect, causing hyperactivity
B) One third to one half the usual dose should be prescribed - Patients with myxedema have an increased sensitivity to opioids and need less of a drug.
Biphosphonates
Because of the risk of esophagitis, ________ must be administered in the morning before eating or drinking with a full glass of water; client must remain sitting or standing and postpone ingesting anything for at least 30 minutes.
O2
Before defibrillating a client, be sure that ________ is shut off to avoid the hazard of fire and be sure that no one is touching the bed or the client
Turner's sign
Bluish discoloration of the flanks
Duodenal ulcer
Burning pain that occurs in the mid-epigastric region 1.5-3 hours after a meal and during the night (often wakes client). Melena is more common than hematemesis. Pain is often relieved by ingestion of food.
A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent's last tetanus toxoid booster was received eight years ago. What action should the nurse take? A) Dispense a tetanus antitoxin. B) Prepare human tetanus immune globulin. C) Administer tetanus toxoid booster. D) Delay the tetanus toxoid booster until due.
C) Administer tetanus toxoid booster. - After the completion of the initial tetanus immunization schedule, the recommended booster for an adolescent or adult is every ten years or less if a traumatic injury occurs that is contaminated by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions, wounds from missiles, burns, or frostbite. The adolescent's injury is considered a contaminated wound requiring prophylactic therapy, so the tetanus toxoid booster should be administered (C). (A, B, and D) are not indicated.
A client is experiencing an adverse effect of the gastrointestinal stimulant metoclopramide HCl (Reglan). Which assessment finding would require immediate intervention by the nurse? A) Complains of dizziness when first getting up B) Describes an unpleasant metallic taste in the mouth C) Demonstrates Parkinson's-like symptoms, such as cogwheel rigidity D) Refuses to drive after 6 pm because of an inability to see well at night
C) Demonstrates Parkinson's-like symptoms, such as cogwheel rigidity - Metoclopramide HCl (Reglan) blocks dopamine receptors in the brain, which can cause the extrapyramidal symptoms associated with Parkinson's disease (C). Reglan has been associated with hypertension, not (A). (B) is often associated with metronidazole (Flagyl), not metoclopramide HCl (Reglan). (D), and other vision problems, have not been associated with metoclopramide HCl (Reglan).
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. A) Tetany B) Seizures C) Diarrhea D) Weakness E) Dysrhythmias
C) Diarrhea D) Weakness E) Dysrhythmias
The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A) Review the chart for a signed consent for hospitalization. B) Get the health care provider's permission to give the medication. C) Do not give the medication and document the reason. D) Complete an incident report and notify the parents.
C) Do not give the medication and document the reason. - The nurse should not give the medication and should document the reason (C) because the client is a minor and needs a guardian's permission to receive medications. Permission to give medications is not granted by a signed hospital consent (A) or a health care provider's permission (B), unless conditions are met to justify coerced treatment. (D) is not necessary unless the medication had previously been administered.
A nurse is caring for a client after radioactive iodine is administered for Graves disease. What information about the client's condition after this therapy should the nurse consider when providing care? A) Not radioactive and can be handled as any other individual B) Highly radioactive and should be isolated as much as possible C) Mildly radioactive but should be treated with routine safety precautions D) Not radioactive but may still transmit some dangerous radiations and must be treated with precautions.
C) Mildly radioactive but should be treated with routine safety precautions
After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation on the operative site. For which most critical reaction should the nurse assess the client? A) Dry skin B) Skin reactions C) Mucosal edema D) Bone marrow suppression
C) Mucosal edema - Mucosal edema can lead to airway obstruction, therefore it is the most critical reaction to assess for.
A client with metastatic cancer who has been receiving fentanyl (Duragesic) for several weeks reports to the nurse that the medication is not effectively controlling the pain. Which intervention should the nurse initiate? A) Instruct the client about the indications of opioid dependence. B) Monitor the client for symptoms of opioid withdrawal. C) Notify the health care provider of the need to increase the dose. D) Administer naloxone (Narcan) per PRN protocol for reversal.
C) Notify the health care provider of the need to increase the dose. - Clients can develop a tolerance to the analgesic effect of opioids and may require an increased dose (C) for effective long-term pain relief. The client is not exhibiting indications of dependence (A), withdrawal (B), or toxicity (D).
A client with hemiplegia is staring blankly at the wall and reports feeling like half a person. What is the initial nursing action? A) Use techniques to distract the client B) Include the client in decision making C) Offer to spend more time with the client D) Help the client to problem-solve personal issues
C) Offer to spend more time with the client
A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's outburst, what is the best indication that the nurse-client interaction has been therapeutic? A) Increased physical activity B) Absence of further outbursts C) Relaxation of tensed muscles D) Denial of the need for further discussion
C) Relaxation of tensed muscles - Relaxation of muscles and facial expression are examples of nonverbal behavior; nonverbal behavior is an excellent index of feelings because it is less likely to be consciously controlled. Increased activity may be an expression of anger or hostility. Clients may suppress verbal outbursts despite feelings and become withdrawn. Refusing to talk may be a sign that the client is just not ready to discuss feelings.
121. In preparing Ms. Norfolk for the surgical experience, the nurse Is least likely to Initiate teaching about: A. The reason for being NPO after midnight prior to surgery. B. Deep breathing, coughing, and turning techniques. C. The expected results of the surgical procedure. D. The availability of pain medication pm.
C. The expected results of the surgical procedure. The surgeon usually initiates this information; the nurse reinforces the Information as needed by the client. A, B, and D are all Included by the nurse in routine preoperative teaching, and are therefore not the correct answers.
When planning care for a child with autism, the nurse understands that given a choice, the child with autism usually enjoys playing: A) On a jungle gym B) With a cuddly toy C) With a small yellow block D) On a playground merry-go-round
D) ON a playground merry-go-round
In conducting a routine assessment, which question should the nurse ask to determine a client's risk for open-angle glaucoma? A) "Have you ever been told that you have hardening of the arteries?" B) "Do you frequently experience eye pain?" C) "Do you have high blood pressure or kidney problems?" D) "Does anyone in your family have glaucoma?"
D) "Does anyone in your family have glaucoma?" - Glaucoma has a definite genetic link, so clients should be screened for a positive family history, especially an immediate family member (D). (A and C) are not related to glaucoma. Glaucoma rarely causes pain (B), which is why screening is so important.
A nurse is teaching a client about a restricted diet. What is the nurse's best initial comment? A) "What type of foods do you usually eat?" B) "You should follow this diet exactly as written." C) "You must limit the intake of foods on this special list." D) "What do you know about this diet that was ordered for you?"
D) "What do you know about this diet that was ordered for you?"
The nurse has completed diabetic teaching for a client who has been newly diagnosed with diabetes mellitus. Which statement by this client would indicate to the nurse that further teaching is needed? A) "Regular insulin can be stored at room temperature for 30 days." B) "My legs, arms, and abdomen are all good sites to inject my insulin." C) "I will always carry hard candies to treat hypoglycemic reactions." D) "When I exercise, I should plan to increase my insulin dosage."
D) "When I exercise, I should plan to increase my insulin dosage." - Exercise helps facilitate the entry of glucose into the cell, so increasing insulin doses with exercise would place the client at high risk for a hypoglycemic reaction (D). (A, B, and C) reflect accurate statements about the use of insulin and management of hypoglycemic reactions.
What clinical finding indicates to the nurse that the client may have hypokalemia? A) Edema B) Muscle spasms C) Kussmaul breathing D) Abdominal distension
D) Abdominal distension
The nurse is caring for a client who is diagnosed with hyperpituitarism due to a prolactin-secreting tumor. Which clinical manifestation can help confirm the diagnosis? A) Hypertrophy of skin B) Enlargement of liver C) Hypertrophy of the heart D) Absence of menstruation
D) Absence of menstruation - A prolactin-secreting tumor is a common type of pituitary adenoma that results from excessive secretion of prolactin. Therefore, ultimately, there are associated clinical symptoms, such as absence of galactorrhea and menstruation and infertility. Excessive production of growth hormone is manifested by clinical symptoms, such as skin hypertrophy and enlargement of organs (e.g., liver and heart).
A nurse is teaching a group of women about the side effects of different types of contraceptives. What is the most frequent side effect associated with the use of an intrauterine device (IUD)? A) A tubal pregnancy B) A rupture of the uterus C) An expulsion of the device D) An excessive menstrual flow
D) An excessive menstrual flow
A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting ascites and 4+ pitting edema of the feet and legs. The nurse identifies fluid leaking from his skin when he is turned. Which intervention is most important for the nurse to include in the client's plan of care? A) Turn the client every 4 hours. B) Restrict dietary protein intake. C) Perform passive range of motion 4 times per day. D) Apply a pressure-relieving mattress under the client.
D) Apply a pressure-relieving mattress under the client. - The client's risk for impaired skin integrity requires meticulous skin care because the edematous tissues are showing indications of breakdown. A pressure-relieving mattress (D) should be used to reduce the risk of skin tearing with manual turning. Although (A and C) are valuable in preventing complications of immobility, the client's skin integrity is threatened by fluid retention and requires measures to prevent breakdown. Dietary protein (B) may be indicated with hepatic encephalopathy, but the client's skin integrity is threatened by pitting edema and ascites and should be addressed.
A nurse in the surgical ICU is caring for a client with a large surgical incision. What medication does the nurse anticipate will be prescribed for this client? A) Vitamin A B) Cyanocobalamin C) Phytonadione D) Ascorbic Acid
D) Ascorbic Acid - Ascorbic Acid is also known as Vitamin C and aids in collagen production.
A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan? A) Invite other children home to share meals. B) Accept that he will eat when he is hungry. C) Reward the child with a nap after eating. D) Consistently follow a set mealtime routine.
D) Consistently follow a set mealtime routine. - A 2-year-old child is comforted by consistency (D). (A) is contraindicated because two-year-olds may participate in parallel activities with other children but are too young to feel comfort and support by the presence of other children when anxious or afraid. (B) may or may not be true and does not address the child's fears. The child with reflux should remain upright at least two hours after eating (C) to reduce symptoms.
A client's arterial blood gas report indicates the pH is 7.52, PCO2 is 32 mm Hg, and HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? A) Airway obstruction B) Inadequate nutrition C) Prolonged gastric suction D) Excessive mechanical ventilation
D) Excessive mechanical ventilation - The patient is exhibiting symptoms of respiratory alkalosis, which is commonly caused by mechanical ventilation.
Which intervention is most important for the nurse to include in the plan of care for a client with ankylosing spondylitis? A) Limit the client's daily fat intake to 30%. B) Increase the client's fluid intake to 3000 ml daily. C) Place pillows under the client when lying supine. D) Initiate a smoking cessation program.
D) Initiate a smoking cessation program. - As the spine progressively stiffens, the client with ankylosing spondylitis should be encouraged to stop smoking (D) to decrease the risk for pulmonary complications related to reduced chest expansion and movement. Although recommended health promotion practices (A and B) should be encouraged, the risk of complications with ankylosing spondylitis is increased if the client continues to smoke. Using pillows under the client when lying supine may promote comfort, but should be evaluated to prevent flexion that increases the client's risk for flexion or fixation deformity (D).
A nurse is instructing a group of volunteer nurses on the technique of administering the smallpox vaccine. What injection method should the nurse teach? A) Z-track B) IV C) SQ D) Intradermal scratch
D) Intradermal scratch
What does the nurse expect to be the priority concern of a 28-year-old woman who has to undergo a laparoscopic bilateral salpingo-oophrectomy? A) Acute pain B) Risk for hemorrhage C) Fear of chronic illness D) Loss of childbearing potential
D) Loss of childbearing potential
During the postpartum period a nurse identifies a client's rubella titer is negative. What action should the nurse plan to take? A) Check for allergies to penicillin B) Alert the staff in the newborn nursery C) Assure the client that she has active immunity D) Obtain a prescription for an immunization before discharge
D) Obtain a prescription for an immunization before discharge
An older adult is hospitalized for weight loss and dehydration because of nutritional deficits. What should the nurse consider when caring for this client? A) Financial resources usually are unrelated to nutritional status B) An older adult's daily fluid intake must be markedly increase C) The client's diet should be high in carbohydrates and low in proteins D) The nutritional needs of an older adult are unchanged except for a decreased need for calories
D) The nutritional needs of an older adult are unchanged except for a decreased need for calories
A newborn is Rh positive, and the mother is Rh negative. The infant is to receive an exchange transfusion. The nurse explains to the parents that their baby will receive RH-negative blood because: A) It is the same as the mother's blood B) It is neutral and will not react with the baby's blood C) The possibility of a transfusion reaction is eliminated D) The red blood cells will not be destroyed by maternal anti-Rh antibodies
D) The red blood cells will not be destroyed by maternal anti-Rh antibodies
What is important for a nurse to discuss with a client who had a vasectomy? A) Recanalization of the vas deferens is impossible B) Unprotected coitus is safe within 1 week to 10 days C) Some impotency is to be expected for several weeks D) There must be 15 ejaculations to clear the tract of sperm
D) There must be 15 ejaculations to clear the tract of sperm
110. Mr. Williams goes to the drugstore to buy an antacid. The nurse should teach him of the laxative effect of: A. Calcium carbonate (Tltralac). B. Aluminum hydroxide gel (Amphojel). C. Magaldrate (Rlopan). D. Magnesium hydroxide (magnesium magma).
D. Magnesium hydroxide (magnesium magma). Milk of magnesia (magnesium hydroxide) has a laxative effect. A, B, and C all have a constipating effect.
The nurse finds that a client with a urinary disorder has very pale-yellow-colored urine. What is the significance of this abnormal finding? 1 It indicates dilute urine. 2 It indicates concentrated urine. 3 It indicates the presence of myoglobin. 4 It indicates blood in the urine.
Dilute urine tends to appear very pale-yellow in color. Dark-red or brown color urine indicates the presence of blood in the urine. Dark-amber color urine indicates concentrated urine. Red color urine may indicate the presence of myoglobin.
Cullen's sign
Discoloration of the abdomen and periumbilical area
Nephrotoxic
Dye used in IV urography may be
Digoxin
Early signs of ________ toxicity present as GI manifestations (anorexia, N/V, diarrhea)
When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report the classic signs of diabetes, which are: 1. Irritability, polydipsia, polyuria 2. Polyuria, polydipsia, polyphagia 3. Nocturia, weight loss, polydipsia 4. Polyphagia, polyuria, diaphoresis (Nugent 31) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Excessive thirst (polydipsia), excessive hunger (polyphagia), and frequent urination (polyuria) are caused by the body's inability to metabolize glucose adequately. 1 Although polydipsia and polyuria occur with type 1 diabetes, lethargy occurs because of a lack of metabolized glucose for energy. 3 Although polydipsia and weight loss occur with type 1 diabetes, frequent urination occurs throughout a 24-hour period because glucose in the urine pulls fluid with it. 4 Although polyphagia and polyuria occur with type 1 diabetes, diaphoresis occurs with severe hypoglycemia, not hyperglycemia. (Nugent 113) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Atropine sulfate
Have ________ available when performing the Tensilon test
A client with an indwelling catheter is prescribed a urinalysis test. Arrange the steps involved in the collection of the urine sample in correct order. 1.Clamp drainage tubing 2.Attach a sterile syringe 3.Aspirate the urine 4. Remove the clamp
In a client with an indwelling catheter, urine sample is collected by first applying a clamp, distal to the injection port, on to the drainage tubing. Then the injection port cap of the catheter drainage tubing is cleaned with alcohol. The next step is to attach a 5-mL sterile syringe into the port and aspirate the urine sample required. Finally the clamp is removed so that the drainage is resumed.
Tetraplegia
Injury occurring between C1-C8; paralysis involving all four extremities
Paraplegia
Injury occurring between T1-L4; paralysis involving only the LE
Aortic aneurysm
Instruct client with ________ to report immediately signs of chest/back pain, SOB, dysphagia, or hoarseness.
Fistula or graft
To ensure patency, palpate for a thrill or auscultate for a bruit over a ________. Notify HCP if thrill or bruit is absent
Meningitis
Transmission of ________ is by direct contact, including droplet spread
Orthostatic hypotension
Vasodilators cause ________
Sterility
What can be possible following a TURP?
Beefy red (A dark blue, purple, or black stoma indicates compromised circulation, requiring HCP notification.)
What color should a stoma be?
Vaginal bleeding
What do you assess following a hysterectomy?
Transurethral resection syndrome or severe hyponatremia caused b excessive absorption of bladder irrigation during surgery
What do you monitor after a TURP?
Coronary arteries
________ supply the capillaries of the myocardium with blood
Reye's syndrome
Adolescents and kids with flu symptoms, viral illness, and varicella shouldn't take aspirin because of the risk of ________
Medical Diagnosis: Cholelithiasis. • Surgical Treatment: Open cholecystectomy. • Nursing Problems/Diagnosis: - Altered comfort (pain). - Fluid volume deficit. - Health-seeking behaviors: preparation for diagnostic procedures. - Effective individual management of therapeutic regimen. - Risk for injury: postoperative complications. - Altered nutrition: less than body requirements. - Self-care deficit: medication administration. • Chief Complaint: Adele Norfolk, 47-years-old, was admitted to the hospital, complaining of severe pain in her right upper quadrant. • History of Present Illness: Ms. Norfolk has noticed an intolerance to fatty foods over the past few months. She has also noted general indigestion. Prior to this admission, no serious episodes of pain were noted. Her present pain began 6 hours ago; Its onset was sudden and the pain increased in severity. She complained of nausea and vomited twice prior to admission. • Past Health History: Twenty-five pounds overweight. Three normal deliveries; all children living and well. Appendectomy at age 14. Smokes 1 pack of Cigarettes a day. • Family History: No history of gallbladder disease in mother, father, two brothers, or one sister. Diet has been high in fat content throughout lifetime. • Review of Systems: Weight gain gradual over past 5 years. Unsuccessful in own attempts to control Weight. Distress when eating fatty foods; complains of "bloating feeling." Denies cough. • Physical Exam: Vital signs: BP: 140/92, Temperature: 101F. P: 92. R: 26. Head and neck: Tongue dry; face flushed; no jaundice noted. Chest: Some wheezing noted at base of lungs. Difficulty in coughing due to acute distress. Abdomen: Severe pain and tenderness in right upper quadrant. Positive Murphy's sign. Extremities: Some evidence of varicosities In posterior aspect of lower legs. • Laboratory and X-ray Data: X-ray: Absence of opaque materials in the gallbladder-cholecystography. Chest x-ray: Within normal limits. GI series: Negative. WBC: 12,500/microliter. Cholesterol level: 290 mg/dL Urine specific gravity: 1.040
...
852. Cyclobenzaprine hydrochloride (Flexeril) is prescribed for a client for muscle spasms. The nurse is reviewing the client's record. Which of the following disorders, if noted in the record, would indicate a need to contact the physician about the administration of this medication? 1. Glaucoma 2. Emphysema 3. Hypothyroidism 4. Diabetes mellitus
1 Rationale: Because cyclobenzaprine (Flexeril) has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, glaucoma, and increased intraocular pressure. Cyclobenzaprine should be used only for a short term (2 to 3 weeks).
A client with multiple myeloma asks how the disease and therapy may progress. When teaching this client, the nurse discusses the possibility that: 1. Blood transfusions may be necessary 2. Frequent urinary tract infections may result 3. IV fluid therapy may be administered in the home 4. The disease is exacerbated by exposure to ultraviolet rays (Nugent 19) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Blood products (packed RBCs or platelets) are administered when warranted. 2 Renal insufficiency, not infections, may occur due to chronic hypercalcemia, proteinemia, and hyperuricemia. 3 Fluid replacement should be provided in carefully supervised clinical settings because if dehydration occurs it may result in renal shutdown. 4 Ultraviolet rays are not related to exacerbations. (Nugent 99-100) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
To determine when a client who had a subtotal gastrectomy can begin oral feedings after surgery, the nurse must assess for the: 1. Presence of flatulence 2. Extent of incisional pain 3. Stabilization of hematocrit levels 4. Occurrence of dumping syndrome
1 Bowel sounds and flatulence indicate the return of intestinal peristalsis; peristalsis is necessary for movement of nutrients through the GI tract. 2 Incisional pain is unrelated to intestinal peristalsis. 3 Hematocrit levels indicate blood loss; they are unaffected by GI functioning. 4 Dumping syndrome occurs after, not before, the ingestion of food and does not indicate readiness to ingest food.
A client who is suspected of having leukemia has a bone marrow aspiration. Immediately after the procedure, the nurse should: 1. Apply brief pressure to the site 2. Have the client lie on the affected side 3. Swab the site with an antiseptic solution 4. Monitor vital signs every hour for 4 hours (Nugent 19) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Brief pressure is generally enough to prevent bleeding at the aspiration site. 2 Complications are rare; no special positions are required. 3 The site is cleaned prior to aspiration. 4 Complications are rare; frequent monitoring is unnecessary. (Nugent 99) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A nurse is performing a physical assessment of a client with ulcerative colitis. The finding most often associated with a serious complication of this disorder is: 1. Decreased bowel sounds 2. Loose, blood-tinged stools 3. Distention of the abdomen 4. Intense abdominal discomfort
1 Decreased intestinal motility is associated with serious problems, such as perforation or toxic megacolon. 2 This is an uncomfortable but less serious manifestation. 3 This is an expected response that is not of primary concern at this time. 4 Intense pain is a symptom of ulcerative colitis, not a complication.
A client with esophageal varices is admitted with hematemesis, and 2 units of packed red blood cells are ordered. The client complains of flank pain halfway through the first unit of blood. The nurse's first action is to: 1. Stop the transfusion 2. Obtain the vital signs 3. Assess the pain further 4. Monitor the hourly urinary output (Nugent 17) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Flank pain is an adaptation associated with a hemolytic transfusion reaction; it is caused by agglutination of red cells in the kidneys and renal vasoconstriction. The infusion must be stopped to prevent further instillation of blood, which is being viewed as foreign by the body. 2 Although this will be done eventually, it is not the priority action. 3 Although this will be done eventually, it is not the priority action. 4 Although this will be done eventually, it is not the priority action. (Nugent 97) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client is admitted to the hospital with diabetic ketoacidosis. The nurse identifies that the elevated ketone level present with this disorder is caused by the incomplete oxidation of: 1. Fats 2. Protein 3. Potassium 4. Carbohydrates (Nugent 32) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Incomplete oxidation of fat results in fatty acids that further break down to ketones. 2 Protein metabolism results in nitrogenous waste production, causing elevated blood urea nitrogen (BUN). 3 Potassium is not oxidized. Ketones do not result when there are alterations in potassium levels. 4 Carbohydrates do not contain fatty acids that are broken down into ketones. (Nugent 114) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
When discussing nutrition with a client who has inflammatory bowel disease of the ascending colon, the most appropriate suggestion by the nurse concerning food to include in the diet is: 1. Scrambled eggs and applesauce 2. Barbecued chicken and French fries 3. Fresh fruit salad with cheddar cheese 4. Chunky peanut butter on whole wheat bread
1 Low-residue foods produce less fecal waste, decreasing bowel contents and irritation; protein promotes healing and calories provide energy. 2 Barbecued foods are spicy; foods high in fat can increase peristalsis. 3 Fruit and aged, sharp cheese can be irritating to the bowel. 4 Chunky peanut butter and whole wheat bread are high-residue foods.
A client with Laënnec's cirrhosis has a Sengstaken-Blakemore tube in place. The client becomes increasingly confused and tries to climb out of bed. The client's breath becomes fetid. What is the nursing priority? 1. Apply a safety jacket 2. Give the prn sedative as ordered 3. Notify the practitioner immediately 4. Provide oxygen via a nasal catheter
1 Measures must be taken immediately to ensure client safety. 2 Sedatives are contraindicated because they mask the progressive signs of hepatic encephalopathy. 3 Although the practitioner should be notified, the nurse should first take measures to ensure client safety. 4 Hepatic encephalopathy is caused by high serum ammonia levels, not hypoxia.
A client with gastric cancer asks whether this cancer will spread. The nurse identifies that the client is looking for reassurance. When preparing a response to the client's question, the nurse recalls that gastric cancers are most likely to metastasize to the: 1. Liver and lung 2. Bone and brain 3. Pancreas and brain 4. Lymph nodes and blood
1 Statistics demonstrate that these are the most likely sites for metastasis of this tumor. 2 It is less likely that the tumor will spread to these areas. 3 It is less likely that the tumor will spread to these areas. 4 These are routes of metastasis.
A farmer steps on a rusty nail and the puncture site becomes swollen and painful. Tetanus antitoxin is prescribed. The nurse explains that this is used because it: 1. Provides antibodies 2. Stimulates plasma cells 3. Produces active immunity 4. Facilitates long-lasting immunity (Nugent 20) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Tetanus antitoxin provides antibodies, which confer immediate passive immunity. 2 Antitoxin does not stimulate production of plasma cells, the precursors of antibodies. 3 Passive, not active, immunity occurs. 4 Passive immunity, by definition, is not long lasting. (Nugent 100) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
The most essential nursing care for a client with a nephrostomy tube is: 1. Ensuring free drainage of urine 2. Milking the tube every 2 hours 3. Instilling 2 mL of normal saline every 8 hours 4. Keeping an accurate record of intake and output
1 The tube must be kept patent to prevent urine backup, hydronephrosis, and kidney damage. 2 This is unnecessary unless the tube is not functioning. 3 This is a dependent function and requires a practitioner's order. 4 Although this is important, it will not ensure free drainage of urine, which is the priority
A client with diabetic ketoacidosis, who is receiving intravenous fluids and insulin, complains of tingling and numbness of the fingers and toes and shortness of breath. The cardiac monitor shows the appearance of a U wave. The nurse concludes that these symptoms indicate: 1. Hypokalemia 2. Hypoglycemia 3. Hypernatremia 4. Hypercalcemia (Nugent 33) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose. 2 Symptoms of hypoglycemia are weakness, nervousness, tachycardia, diaphoresis, irritability, and pallor. 3 Symptoms of hypernatremia are thirst, orthostatic hypotension, dry mouth and mucous membranes, concentrated urine, tachycardia, irregular heartbeat, irritability, fatigue, lethargy, labored breathing, and muscle twitching and/or seizures. 4 Symptoms of hypercalcemia are lethargy, nausea, vomiting, paresthesias, and personality changes. (Nugent 115) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
The nurse explains to a client that a positive diagnosis for HIV infection is made based on: 1. Positive ELISA and Western blot tests 2. Performance of high-risk sexual behaviors 3. Evidence of extreme weight loss and high fever 4. Identification of an associated opportunistic infection (Nugent 18) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 These tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus. 2 This places someone at risk but does not constitute a positive diagnosis. 3 These do not confirm the presence of HIV; these adaptations are related to many disorders, not just HIV infection. 4 The diagnosis of just an opportunistic infection is not sufficient to confirm the diagnosis of HIV. An opportunistic infection (included in the CDC surveillance case definition for AIDS) in the presence of HIV antibodies indicates that the individual has AIDS. (Nugent 97) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
On the fourth postoperative day after a cystectomy and the formation of a continent diversion, the nurse observes mucous threads in a client's urine. The nurse should: 1. Expect this response after the diversion 2. Report this to the practitioner immediately 3. Obtain a specimen for culture and sensitivity 4. Increase the client's fluid intake for the next twelve hours
1 This response is expected because mucus continually is secreted by the intestinal mucosa. 2 This is not necessary; mucus is expected with an ileal conduit. 3 This is not necessary; at this point postsurgically the mucus is not an indication of infection; mucus in the urine after ureterostomy may indicate infection. 4 Although fluids should be encouraged to maintain urine flow, this will not eliminate mucus, which continually is discharged from the intestinal segment.
An abdominoperineal resection with the creation of a colostomy is scheduled for a client with cancer of the rectum. The nurse anticipates that the client must sign a consent for a: 1. Permanent sigmoid colostomy 2. Permanent ascending colostomy 3. Temporary double-barrel colostomy 4. Temporary transverse loop colostomy
1 When intestinal continuity cannot be restored after removal of the anus, rectum, and adjacent colon, a permanent colostomy is formed. 2 The ascending segment of the colon lies on the right side of the abdomen and has no anatomical proximity to the rectum. 3 This temporary procedure is performed to allow a segment of colon to heal; intestinal continuity is eventually restored. 4 This procedure is commonly performed for inflammation of the colon when intestinal continuity eventually can be restored.
Right
Signs of ________ ventricular HF are evident in the systematic circulation
A client comes to the infectious disease clinic because a sexual partner was recently diagnosed as having gonorrhea. The health history reveals that the client has engaged in receptive anal intercourse. The nurse should assess the client for: 1. Melena 2. Anal itching 3. Constipation 4. Ribbon-shaped stools
2 Anal itching and irritation are related to erythema and edema of the anal crypts caused by the gonococci. 1 Frank rectal bleeding, not upper GI bleeding, occurs. 3 Diarrhea, not constipation, occurs. 4 The shape of formed stool does not change; however, diarrhea does occur.
A client has symptoms associated with salmonellosis. Relevant data to gather from this client include a history of: 1. Any rectal cancer in the family 2. All foods eaten in the past 24 hours 3. Any recent extreme emotional stress 4. An upper respiratory infection in the past 10 days
2 The salmonella organism thrives in warm, moist environments; washing, cooking, and refrigeration of food limits the growth of or eliminates the organism. 1 Salmonellosis is unrelated to cancer. 3 Salmonellosis is caused by the salmonella organism, not stress. 4 The salmonella organism is ingested; it is not an airborne or bloodborne infection.
The nurse evaluates that a client who had a transurethral vaporization of the prostate understands the discharge teaching when he says, "I should: 1. sit for several hours daily." 2. report if my urinary stream decreases." 3. attempt to void every 3 hours when I'm awake." 4. avoid vigorous exercise for 6 months after surgery."
2 The urethral mucosa in the prostatic area is affected during surgery, and strictures may form with healing. 1 The client should be ambulating; sitting for several hours is contraindicated because it promotes venous stasis and thrombus formation. 3 The client should void as the need arises; straining can cause pressure in the operative area, precipitating hemorrhage. 4 Although vigorous exercise should be avoided, 6 months is too long for this restriction.
After an acute episode of upper GI bleeding, a client vomits undigested antacids and complains of severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the practitioner, the nurse should: 1. Start oxygen via nasal cannula 2. Keep the client NPO in preparation for surgery 3. Inquire whether any red or black stools have been noted 4. Place the client in the supine position with the legs elevated
2 These are classic indicators of a perforated ulcer, for which immediate surgery is indicated; this should be anticipated. 1 Although oxygen may minimize the tachycardia and tachypnea that are related to pain and possible blood loss, keeping the client NPO is the priority. 3 Keeping the client NPO in preparation for surgery is more important than asking about the presence of black, tarry stools or red stools. Although this question should be asked, knowing this information will not change the medical or nursing care of the client at this time. 4 The adaptations are indicative of perforation and the priority is to prepare the client for surgery.
A client eats a meal that contains 13 g of fat, 31 g of carbs, and 5 g of protein. What is the client's total caloric intake for this meal?
261 calories
The nurse is caring for a client on antiretroviral therapy who has Pneumocystis jiroveci pneumonia. Which action is priority? 1 Assisting the client in eating and drinking 2 Maintaining fluid balance in the client 3 Providing adequate oxygenation for the client 4 Encouraging the client to perform breathing exercise
3
A client has end-stage kidney disease and is receiving hemodialysis. During dialysis the client complains of nausea and a headache and appears confused. Operating on standing protocols, the nurse should: 1. Give an analgesic 2. Administer an antiemetic 3. Decrease the rate of exchange 4. Discontinue the procedure immediately
3 These are signs and symptoms of disequilibrium syndrome, which results from rapid changes in composition of the extracellular fluid and cerebral edema; the rate of exchange should be decreased. 1 Although this may relieve the headache, it will not relieve the other adaptations or the cause of disequilibrium syndrome. 2 Although this may relieve the nausea, it will not relieve the other adaptations or the cause of disequilibrium syndrome. 4 This is unnecessary; reducing the rate of exchange should reduce the adaptations of disequilibrium syndrome.
849. Alendronate (Fosamax) is prescribed for a client with osteoporosis. The nurse instructs the client to: 1. Take the medication at bedtime. 2. Take the medication in the morning with breakfast. 3. Lie down for 30 minutes after taking the medication. 4. Take the medication with a full glass of water after rising in the morning.
4 Rationale: Precautions need to be taken with the administration of alendronate to prevent gastrointestinal side effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client should not eat or drink anything for 30 minutes following administration and should not lie down after taking the medication.
Which component of the client's nephron acts as a receptor site for the antidiuretic hormone and regulates water balance? 1 Proximal convoluted tubule 2 Distal convoluted tubule 3 Bowman's capsule 4 Collecting ducts
4 The collecting ducts regulate water balance and act as a receptor site for antidiuretic hormone. The Bowman's capsule collects glomerular filtrate and funnels it into the tubule. The distal convoluted tubule acts as a site for additional water and electrolyte reabsorption. The proximal convoluted tubule is the site for reabsorption of sodium, chloride, water, and urea.
634. The client with hiatal hernia chronically experiences heartburn following meals. The nurse plans to teach the client to avoid which action because it is contraindicated with a hiatal hernia? 1. Lying recumbent following meals 2. Taking in small, frequent, bland meals 3. Raising the head of bed on 6-inch blocks 4. Taking H2-receptor antagonist medication
634. 1 Rationale: Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm where the esophagus usually is positioned. The client usually experiences pain from reflux caused by ingestion of irritating foods, lying flat following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals, use of H2-receptor antagonists and antacids, and elevation of the thorax following meals and during sleep.
635. The nurse is assessing for stoma prolapse in a client with a colostomy. What should the nurse observe if stoma prolapse occurs? 1. Protruding stoma 2. Sunken and hidden stoma 3. Narrowed and flattened stoma 4. Dark- and bluish-colored stoma
635. 1 Rationale: A prolapsed stoma is one in which the bowel protrudes through the stoma. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with a dusky or bluish color. A stoma with a narrowed opening at the level of the skin or fascia is said to be stenosed.
639. A nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which of the following interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Administer antacids as prescribed. 2. Encourage coughing and deep breathing. 3. Administer anticholinergics as prescribed. 4. Give small, frequent high-calorie feedings. 5. Maintain the client in a supine and flat position. 6. Give Meperidine (Demerol) as prescribed for pain.
639. 1, 2, 3, 6 Rationale: The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication such as meperidine is prescribed. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress gastrointestinal secretions.
852. When assisting a client who had a total hip replacement onto the bedpan on the first postoperative day, the nurse should instruct the client to: 1. Turn toward the operative side 2. Flex both knees while slowly lifting the pelvis 3. Extend both legs and pull on the trapeze to lift the pelvis 4. Flex the unaffected knee and pull on the trapeze to raise the pelvis
852. Ans: 4 4. The pelvis is elevated by actions involving the unaffected upper extremities and unaffected leg.
1-2 LPM
A client who is hypoxemic and has chronic hypercapnia requires low levels of oxygen delivery at ________ because a low arterial O2 level is the client's primary drive for breathing
A nurse is teaching an adolescent about type 1 diabetes and self-care. Which client questions indicate a need for additional teaching in the cognitive domain? Select all that apply. A) "What is diabetes?" B) "What will my friends think?" C) "How do I give myself an injection?" D) "Can you tell me how the glucose monitor works?" E) "How do I get the insulin from the vial into the syringe?"
A) "What is diabetes?" D) "Can you tell me how the glucose monitor works?" - Option C falls in the affective domain. Option E falls into the psychomotor domain.
A nurse is teaching about excellent food sources of vitamin A for a client who is deficient in this vitamin. WHich foods should the nurse include in the teaching? Select all that apply. A) Carrots B) Oranges C) Tomatoes D) Skim milk E) Leafy greens
A) Carrots E) Leafy greens
A nurse is assessing a client with a diagnosis of hemorrhoids. Which factors in the client's history probably played a role in the development of the client's hemorrhoids. Select all that apply. A) Constipation B) Hypertension C) Eating spicy foods D) Bowel incontinence E) Numerous pregnancies
A) Constipation E) Numerous pregnancies
A client has an anterior and posterior surgical repair of a cystocele and rectocele and returns from the PACU with an indwelling catheter in place. What should the nurse tell the client about the primary reasons for the catheter? A) Discomfort is minimized B) Bladder tone is maintained C) Urinary retention is prevented D) Pressure on the suture line is relieved E) Hourly urine output can be easily measured
A) Discomfort is minimized C) Urinary retention is prevented D) Pressure on the suture line is relieved
The nurse is providing care for a client with small-cell carcinoma of the lung who develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What clinical findings correspond with the secretion of antidiuretic hormone (ADH)? Select all that apply. A) Edema B) Polyuria C) Bradycardia D) Hypotension E) Hyponatremia
A) Edema E) Hyponatremia - Edema results as fluid is retained because of the increased secretion of antidiuretic hormone. ADH causes water retention, which dilutes serum electrolytes such as sodium, with a resultant hyponatremia. A decreased urine output occurs with SIADH because ADH causes reabsorption of fluid in the kidney glomeruli. The increased fluid volume associated with SIADH results in tachycardia, tachypnea, and crackles. The increased fluid volume associated with SIADH results in hypertension, not hypotension.
A client with hyperlipidemia receives a prescription for niacin (Niaspan). Which client teaching is most important for the nurse to provide? A) Expected duration of flushing. B) Symptoms of hyperglycemia. C) Diets that minimize GI irritation. D) Comfort measures for pruritis.
A) Expected duration of flushing - Flushing of the face and neck, lasting up to an hour, is a frequent reason for discontinuing niacin. Inclusion of this effect in client teaching (A) may promote compliance in taking the medication. While (B, C, and D) are all worthwhile instructions to help clients minimize or cope with normal side effects associated with niacin (Niaspan), flushing is intense and causes the most concern for the client.
A nurse is caring for an underweight adolescent girl who is diagnosed with anorexia nervosa. WHat are common characteristics of girls with this disorder that the nurse should identify when obtaining a health history and performing a physical assessment. Select all that apply. A) Fatigue B) Pyrexia C) Tachycardia D) Heat intolerance E) Secondary amenorrhea
A) Fatigue E) Secondary amenorrhea
A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive? A) Hepatitis C B) Influenza type B C) MMR D) DTaP
A) Hepatitis C
A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? Select all that apply. A) Hirsutism B) Menorrhagia C) Buffalo hump D) Dependent edema E) Migraine headaches
A) Hirsutism C) Buffalo hump
A nurse applies an ice pack to a client's leg for 20 minutes. What clinical indicator helps the nurse determine the effectiveness of the treatment? A) Local anesthesia B) Peripheral vasodilation C) Depression of VS D) Decreased viscosity of blood
A) Local anesthesia
The nurse assists the health care provider with an amniocentesis during the third trimester of pregnancy. Which intervention(s) would the nurse expect to implement after the procedure? (Select all that apply.) A) Monitor maternal vital signs for hemorrhage. B) Instruct the woman to report any contractions. C) Ensure that the woman has a full bladder prior to beginning. D) Monitor fetal heart rate for 1 hour after the procedure. E) Place the client in a side-lying position.
A) Monitor maternal vital signs for hemorrhage. B) Instruct the woman to report any contractions. D) Monitor fetal heart rate for 1 hour after the procedure. - These are safe measures to implement during an amniocentesis to monitor for and prevent complications (A, B, and D). During late pregnancy the bladder should be emptied so that it will not be punctured, but during early pregnancy the bladder must be full to push the uterus upward (C). The woman should be placed in a supine position with her hands across her chest (E).
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? A) Record the amount on the client's fluid output record. B) Encourage the client to increase oral fluid intake. C) Notify the health care provider of the findings. D) Palpate the client's bladder for distention.
A) Record the amount on the client's fluid output record. - The amount and appearance of the client's urine output is within normal limits, so the nurse should record the output (A), but no additional action is needed (B, C, and D).
A hospitalized client is receiving pyridostigmine for control of myasthenia gravis. In the middle of the night, the nurse finds the client weak and barely able to move. Which additional clinical findings support the conclusion that these responses are related to pyridostigmine? Select all that apply. A) Respiratory depression B) Distension of the bladder C) Decreased blood pressure D) Fine tremor of the fingers E) High-pitched gurgling bowel sounds
A) Respiratory depression C) Decreased blood pressure E) High-pitched gurgling bowel sounds
A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide? A) Save the next urine sample. B) Restrict oral fluid intake. C) Strain all voided urine. D) Reduce physical activity.
A) Save the next urine sample. - The nurse should instruct the client to save the next urine sample (A) for observation of its appearance and for possible urinalysis. The client is reporting symptoms that may indicate the onset of a urinary tract infection. Increased fluid intake should be encouraged, unless contraindicated (B). (C) is only necessary if a calculus (stone) is suspected. (D) is not indicated by this client's symptoms.
Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all that apply.) A) Shave the area where the TENS will be placed. B) Obtain small needles for insertion. C) Place the TENS unit directly over or near the site of pain. D) Explain to the client that drowsiness may occur immediately after using TENS. E) Describe the use of TENS for postoperative procedures such as dressing changes.
A) Shave the area where the TENS will be placed. C) Place the TENS unit directly over or near the site of pain. E) Describe the use of TENS for postoperative procedures such as dressing changes. - The correct choices are (A, C, and E). The TENS unit consists of a battery-operated transmitter, lead wires, and electrodes. The electrodes are placed directly over or near the site of pain (C), and hair or skin preparations should be removed before attaching the electrodes (A). The TENS unit is useful for managing postoperative pain or pain associated with postoperative procedures, such as removing drains or changing dressings (E). Electrodes are used, not needles (B) and, unlike with opioids, pain relief is achieved without drowsiness (D).
How should the nurse prepare an IV piggyback medication for administration to a client receiving an IV infusion? Select all that apply. A) Wear clean gloves to check the IV site B) Rotate the bag after adding the medication C) Use 100 mL of fluid to mix the medication D) Change the needle before adding the medication E) Place the IVPB at a lower level than the existing IV F) Use sterile technique when preparing the medication
A) Wear clean gloves to check the IV site B) Rotate the bag after adding the medication F) Use sterile technique when preparing the medication
38. If the client with severe liver damage is retaining nitrogen waste products, the nurse will note in the lab reports an increase in serum: A. Ammonia. B. Leukocytes. C. Creatinine. D. Urea nitrogen.
A. Ammonia. Ammonia Is formed by the decomposition of nitrogen containing substances, such as proteins and amino acid. It is markedly elevated in clients with a severely damaged liver-specifically, hepatocellular necrosis. The damaged liver is unable to convert ammonia to urea thus, an increased ammonia level is seen. B Is a general Indication of infection, and Is not specific to liver damage. C and D are incorrect. They indicate dysfunction of the kidneys.
36. An Ineffective nursing measure to prevent the progress of hepatic coma is: A. Giving diuretics. B. Making certain that a low-protein diet is served. C. Assessing if there Is adequate renal perfusion. D. Assessing for a patent airway and oxygenation.
A. Giving diuretics. A is the incorrect nursing measure and therefore the correct answer. Diuretics stimulate the excretion of urine. They are not used in clients who are in hepatic coma because they precipitate the occurrence of hypovolemia. Hypovolemia decreases the perfusion of the liver, causing further injury to the already damaged liver cells and potentiating hepatic coma. B, C, and D are appropriate nursing measures, but they are incorrect responses to the question asked. Any source of increase in blood ammonia, such as a high-protein diet and a markedly decreased urine output, should be prevented. Poor tissue oxygenation to the liver cells should also be prevented.
407. When discussing future meal plans with a client who has a hiatal hernia, the nurse asks what beverages the client usually enjoys. The beverage that should be included in the diet when the client is discharged is: 1. Ginger ale 2. Apple juice 3. Orange juice 4. Cola beverages
Ans: 2 2. Apple juice is not irritating to the gastric mucosa.
450. A client is diagnosed with chronic pancreatitis. When providing dietary teaching it is most important that the nurse instruct the client to: 1. Eat a low-fat, low-protein diet 2. Avoid foods high in carbohydrates 3. Avoid ingesting alcoholic beverages 4. Eat a bland diet of six small meals a day
Ans: 3 3. Alcohol increases pancreatic secretions, which cause pancreatic cell destruction.
389. When a client develops steatorrhea, the nurse documents this stool as: 1. Dry and rock-hard 2. Clay colored and pasty 3. Bulky and foul smelling 4. Black and blood-streaked
Ans: 3 3. These characteristics describe steatorrhea, which results from impaired fat digestion.
375. What should the nurse do when a client is scheduled for a barium swallow? 1. Give clear fluids on the day of the test 2. Ask the client about allergies to iodine 3. Administer cleansing enemas before the test 4. Ensure a laxative is ordered after the procedure
Ans: 4 4. Barium will harden and may create an impaction; a laxative and increased fluids promote elimination of barium.
Arterial revascularization
Following ________, monitor for a sharp increase in pain because pain is the first indicator of postoperative graft occlusion.
Chronic kidney disease
Affects all major body systems and requires dialysis or kidney transplantation to maintain life
1 hour
Allow ________ between antacid administration and the administration of other meds
Gastric surgery
Following _________, don't irrigate or remove the NG tube unless specifically ordered because of the risk for disruption of gastric sutures.
416. A client with gastric cancer asks whether this cancer will spread. The nurse identifies that the client is looking for reassurance. When preparing a response to the client's question, the nurse recalls that gastric cancers are most likely to metastasize to the: 1. Liver and lung 2. Bone and brain 3. Pancreas and brain 4. Lymph nodes and blood
Ans: 1 1. 1 Statistics demonstrate that these are the most likely sites for metastasis of this tumor.
415. A client is diagnosed with cancer of the stomach and is scheduled for a partial gastrectomy. Preoperative preparation for this client should include an explanation about the postoperative: 1. Gastric suction 2. Oxygen therapy 3. Fluid restriction 4. Urinary catheter
Ans: 1 1. After gastric surgery a nasogastric tube is in place for drainage of blood and gastric secretions.
438. A client has cholelithiasis with possible obstruction of the common bile duct. Before the scheduled cholecystectomy, nutritional deficiencies and excesses should be corrected. A nutritional assessment is conducted to determine whether the client: 1. Is deficient in vitamins A, D, and K 2. Eats adequate amounts of dietary fiber 3. Consumes excessive amounts of protein 4. Has excessive levels of potassium and folic acid
Ans: 1 1. Bile promotes the absorption of the fat-soluble vitamins. An obstruction of the common bile duct limits the flow of bile to the duodenum and thus the absorption of these fat-soluble vitamins.
425. To determine when a client who had a subtotal gastrectomy can begin oral feedings after surgery, the nurse must assess for the: 1. Presence of flatulence 2. Extent of incisional pain 3. Stabilization of hematocrit levels 4. Occurrence of dumping syndrome
Ans: 1 1. Bowel sounds and flatulence indicate the return of intestinal peristalsis; peristalsis is necessary for movement of nutrients through the GI tract.
410. When performing the initial history and physical examination of a client with a tentative diagnosis of peptic ulcer, the nurse expects the client to describe the pain as: 1. Gnawing epigastric pain or boring pain in the back 2. Located in the right shoulder and preceded by nausea 3. Sudden, sharp abdominal pain, increasing in intensity 4. Heartburn and substernal discomfort when lying down
Ans: 1 1. Classic symptoms of peptic ulcer include gnawing, boring, or dull pain located in the midepigastrium or back; pain is caused by irritability and erosion of the mucosal lining.
419. After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for: 1. Monthly injections of vitamin B12 2. Regular daily use of a stool softener 3. Weekly injections of iron dextran (Imferon) 4. Daily replacement therapy of pancreatic enzymes
Ans: 1 1. Intrinsic factor is lost with removal of the stomach, and vitamin B12 is needed to maintain the hemoglobin level once the client is stabilized; injections are given monthly for life.
384. A practitioner tells a client that an increase in vitamin E and beta-carotene is important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are: 1. Spinach and mangoes 2. Fish and peanut butter 3. Oranges and grapefruits 4. Carrots and sweet potatoes
Ans: 1 1. The antioxidants vitamin E and beta-carotene, which help inhibit oxidation and therefore tissue breakdown, are found in these foods.
448. A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis? 1. Blood glucose 2. Serum amylase 3. Serum bilirubin level 4. White blood cell count
Ans: 2 2 Amylase concentration is increased in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed; this distinguishes pancreatitis from other acute abdominal problems.
837. After a client has spinal surgery, it is essential that the nurse: 1. Encourage the client to drink fluids 2. Log-roll the client to the prone position 3. Assess the client's feet for circulation and sensation 4. Observe the client's bowel movements and voiding patterns
Ans: 3 3. Alteration in circulation and sensation indicates damage to the spinal cord; if this occurs, the surgeon must be notified immediately.
460. The nurse instructs a client diagnosed with hepatitis A about untoward signs and symptoms related to hepatitis that may develop. The one that should be reported to the practitioner is: 1. Fatigue 2. Anorexia 3. Yellow urine 4. Clay-colored stools
Ans: 4 4. Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines.
420. After 2 months of self-management for symptoms of gastritis is unsuccessful, a client goes to the practitioner, and extensive carcinoma of the stomach is diagnosed. The client asks the nurse how the disease got so advanced. The nurse's explanation is based on the knowledge that carcinoma of the stomach is: 1. Painful in the early stages of the disease process 2. Difficult to accurately diagnose until late in the disease process 3. Usually diagnosed after the discovery of enlarged lymph nodes in the epigastric area 4. Rarely diagnosed early because the symptoms usually are nonspecific until late in the disease
Ans: 4 4. This cancer is usually asymptomatic in the early stages; the stomach accommodates the mass.
387. A client with Parkinson's disease complains about a problem with elimination. The nurse should encourage the client to: 1. Eat a banana daily 2. Decrease fluid intake 3. Take cathartics regularly' 4. Increase residue in the diet
Ans: 4 4. This produces bulk, which stimulates defecation; the muscles used in defecation are weak in clients with Parkinson's disease.
451. A client who was diagnosed with cancer of the head of the pancreas 2 months ago is admitted to the hospital with weight loss, severe epigastric pain, and jaundice. When performing the admission history and physical assessment, the nurse expects the client's stool to be: 1. Green 2. Brown 3. Red-tinged 4. Clay-colored
Ans: 4 4. Tumors of the head of the pancreas usually obstruct the common bile duct where it passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The feces will be clay-colored when bile is prevented from entering the duodenum.
455. After surgery for cancer of the pancreas, the client's nutrition and fluid regimen will be influenced by the remaining amount of functioning pancreatic tissue. Considering both the exocrine and the endocrine functions of the pancreas, the client's postoperative regimen will primarily include managing the intake of: 1. Alcohol and caffeine 2. Fluids and electrolytes 3. Vitamins and minerals 4. Fats and carbohydrates
Ans: 4. 4. Formation of lipase necessary for diegstion of fats is an exocrine function; the endocrine function is to secrete insulin, which is a hormone essential in carbohydrate metabolism.
Gastric ulcer
Gnawing, sharp pain in or to the left of the mid-epiglottis region, occurs 30-60 minutes after a meal. Hematemesis is more common than melena
A client with acute renal failure moves into the diuretic phase after 1 week of therapy. For which signs during this phase should the nurse assess the client? Select all that apply. 1. _____ Dehydration 2. _____ Hypovolemia 3. _____ Hyperkalemia 4. _____ Metabolic acidosis
Answer: 1, 2 1 In the diuretic phase, fluid retained during the oliguric phase is excreted and may reach 3 to 5 L daily; dehydration will occur unless fluids are replaced. 2 In the diuretic phase, fluid retained during the oliguric phase is excreted and may reach 3 to 5 L daily; hypovolemia may occur, and fluids should be replaced. 3 Hyperkalemia develops in the oliguric phase when glomerular filtration is inadequate. 4 Metabolic acidosis occurs in the oliguric, not diuretic, phase.
Treatment for Angina
Goals for treatment of ________ 1. Provide relief from acute attack 2. Correct imbalance between myocardial O2 supply and demand 3. Prevent progression and further attacks
No, because a minimal amount of radioactivity exists in the radioisotope used for the procedure
Are there any special precautions following a bone scan?
Suctioning
Avoid ________ the client before drawing an ABG sample because it will deplete the clients oxygen, resulting in inaccurate ABG results
Heat (Can cause rupture of the appendix, leading to peritonitis)
Avoid application of ___ to the abdomen of a client with appendicitis
151. Which is irrelevant In the nursing evaluation of the effectiveness of the treatment for hepatic encephalopathy? A. lessening of flapping tremors of the hands. B. Decreases in pedal edema. C. Improved levels of consciousness. D. Increased cooperativeness.
B. Decreases in pedal edema. Pedal edema suggests circulatory disturbances rather than the cerebral disturbances that are characteristic of hepatic encephalopathy. A, C, and D are examples of improved cerebral functioning.
A health care provider prescribes a diuretic for a client with hypertension. What should the nurse include the teaching when explaining how diuretics reduce blood pressure? A) Facilitates vasodilation B) Promotes smooth muscle relaxation C) Reduces the circulating blood volume D) Blocks the sympathetic nervous system
C) Reduces the circulating blood volume
A client with an inflamed sciatic nerve is to have a conventional TENS device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate? A) Maintain the settings programmed by the HCP B) Turn the machine on several times a day for 10 - 20 min C) Adjust the dial on the unit until the client states that pain is relieved D) Apply the color-coded electrodes to the client where they are most comfortable
C) Adjust the dial on the unit until the client states that pain is relieved
A nurse is counseling a postmenopausal obese client how to prevent bone loss. Which statements indicate understanding of the strategies to prevent bone loss. Select all that apply. A) "I must go on a strict diet." B) "I will take 400 mg of vitamin D daily." C) "I should take 1200 mg of calcium daily." D) "Swimming or bike riding 5 times a week is good for me." E) "Joining an aerobics class 3 times a week will help my bones."
C) "I should take 1200 mg of calcium daily." E) "Joining an aerobics class 3 times a week will help my bones."
A couple indicate that they do not want any more children. The woman is scheduled for a laparoscopic bilateral tubal ligation. What should the nurse include in the preoperative teaching? A) "Menstruation will stop after the surgery." B) "Birth control will be needed until your follow-up appointment." C) "You will be admitted as an outpatient for same-day surgery."
C) "You will be admitted as an outpatient for same-day surgery."
The health care provider prescribes the anticonvulsant carbamazepine (Tegretol) for an adolescent client with a seizure disorder. The nurse should instruct the client to notify the health care provider if which condition occurs? A) Experiences dry mouth B) Experiences dizziness C) Develops a sore throat D) Develops gingival hyperplasia
C) Develops a sore throat - Blood dyscrasias (aplastic anemia, leukopenia, anemia, and thrombocytopenia) can be an adverse effect of carbamazepine (Tegretol). Flulike symptoms (C), such as pallor, fatigue, sore throat, and fever, are indications of such dyscrasias. (A and B) are expected reactions. (D) is a side effect of phenytoin (Dilantin), not carbamazepine (Tegretol).
A client with a history of pancreatitis is scheduled for surgery to excise a pseudocyst of the pancreas. The client asks, "What is a pseudocyst?" What information should the nurse include in response to this question? A) Malignant growth B) Pocked of undigested food particles C) Dilated space of necrotic tissue and blood D) Sack filled with fluid and pancreatic enzymes
C) Dilated space of necrotic tissue and blood
While changing a newborn's diaper, a client expresses concern about a small spot of red vaginal discharge on the diaper. How should the nurse respond to this concern? A) Assess for other signs of bleeding B) Obtain an order for vaginal cultures C) Explain that this is an expected finding D) Apply a urine specimen bag to the perineum
C) Explain that this is an expected finding
Which assessment is most important for the nurse to implement when seeing a client with multiple myeloma? A) Inspection of the skin B) Breath sound auscultation C) Pain scale measurement D) Mobility limitations
C) Pain scale measurement - Multiple myeloma is a tumor that causes bone marrow changes, which most commonly manifest as pain, so measurement of the client's pain is the highest priority (C). (A, B, and D) are part of the complete assessment but do not have the priority of (C) for this client.
A client who is HIV-positive is receiving combination therapy with the antiviral medication zidovudine (Retrovir). Which instruction should the nurse include in this client's teaching plan? A) Take the drug as prescribed to cure HIV infections. B) Use the drug to reduce the risk of transmitting HIV to sexual contacts. C) Return to the clinic every 2 weeks for blood counts. D) Report to the health care provider immediately if dizziness is experienced.
C) Return to the clinic every 2 weeks for blood counts. - Bone marrow depression with granulocytopenia is a severe but common adverse effect of zidovudine (Retrovir). Careful monitoring of CBCs is indicated (C). (A and B) are not correct instructions related to use of this medication. (D) is an expected side effect. The client should be instructed to avoid driving until this reaction improves.
During a prenatal visit, a client at 36 weeks' gestation tells a nurse that she has painful, irregular contractions. What should the nurse recommend? A) Lie down until they stop B) Time them for at least 1 hour C) Walk around until they subside D) Take 1 over-the-counter analgesic
C) Walk around until they subside - Walking around until the contractions subside will differentiate true from false labor.
33. The greatest risk of the spread of hepatitis B Is from contaminated: A. Urine and feces. B. Nasogastrlc secretions. C. Used needles and syringes. D. Feces and oral secretions.
C. Used needles and syringes. Ms. Bee has acute viral hepatitis, type B. Her disease Is spread mainly through contaminated needles and blood products, choice C. Some theorize, however, that it is possible that the disease also spreads through body excretions such as saliva, tears, intestinal fluids, and gastric juice. Hepatitis A Is transmitted by the oral-fecal route. Based on this explanation, A, B, and D are Incorrect.
Acute cardiac tamponade
Can occur when small volumes (20-50 mL) of fluid accumulate rapidly in the pericardium
PAD (Extreme elevation slows arterial blood flow to the feet)
Client with ________ is instructed to elevate the feet at rest but to refrain from elevating them above the level of the heart
A nurse at the fertility clinic is counseling a couple about the tests that will be needed to determine the cause of their infertility. Which test should the nurse describe that will evaluate the woman's organs of reproduction? A) Biopsy B) Cystogram C) Culdoscopy D) Hysterosalpingogram
D) Hysterosalpingogram
When teaching a class about parenting, the nurse asks the participants what they do when their toddlers have a temper tantrum. Which statement demonstrates one parent's understanding of the origin of temper tantrums? A) "After a temper tantrum, I discipline my child by restricting a favorite food or candy." B) "When a temper tantrum begins, I isolate and ignore my child until the behavior improves." C) "During a temper tantrums, I partially give in to my child before the tantrum becomes excessive." D) "I try to prevent a temper tantrum by allowing my child to chose between two reasonable alternatives."
D) "I try to prevent a temper tantrum by allowing my child to chose between two reasonable alternatives."
What should the nurse do when caring for a client with an ileostomy? A) Teach the client to eat foods high in residue B) Explain that drainage can be controlled with daily irrigations C) Expect the stoma to start draining on the third postoperative day D) Anticipate that any emotional stress can increase intestinal peristalsis
D) Anticipate that any emotional stress can increase intestinal peristalsis
A child with acute poststreptococcal glomerulonephritis requests a snack. Which is the most therapeutic selection of food the nurse can provide? A) Peanuts B) Pretzels C) Bananas D) Applesauce
D) Applesauce - Applesauce is the most nutritious selection. Bananas are high in potassium and are contraindicated in patients with glomerulonephritis.
A client undergoes cardiac catheterization via femoral artery because of a history of bilateral mastectomies. What is the most important nursing action after the procedure? A) Provide a bed cradle B) Check for a pulse deficit C) Elevate the head of the bed D) Assess the groin for bleeding
D) Assess the groin for bleeding - Hematoma and hemorrhage are common complications after cardiac catheterization.
The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement? A) Ask the UAP to check for the advanced directive while the nurse completes the assessment. B) Assign the UAP to complete the assessment while the nurse checks for the advanced directive. C) Check the medical record for the advanced directive and then complete the client assessment. D) Call for the charge nurse to check the advanced directive while continuing to assess the client.
D) Call for the charge nurse to check the advanced directive while continuing to assess the client. - Because the client's condition is worsening, the nurse should remain with the client and continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status (D). (A and B) are tasks that must be completed by a nurse and cannot be delegated to the UAP. (C) is contraindicated.
The health care provider has prescribed a low-molecular-weight heparin, enoxaparin (Lovenox) prefilled syringe, 30 mg/0.3 mL IV every 12 hours, for a client following hip replacement. Prior to administering the first dose, which intervention is most important for the nurse to implement? A) Assess the client's IV site for signs of inflammation. B) Evaluate the client's degree of mobility. C) Instruct the client regarding medication side effects. D) Contact the health care provider to clarify the prescription.
D) Contact the health care provider to clarify the prescription. - Lovenox is a low-molecular-weight heparin that can only be administered subcutaneously, so the nurse should contact the health care provider to clarify the route of administration (D). (A and B) are important nursing interventions but not necessary to the administration of this medication. The client should be instructed about medication side effects (C), but this is of lower priority than obtaining a correct prescription.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report? A) The occurrence of any episodes of sleep apnea B) The child's blood pressure, pulse, and respirations C) Length of rapid eye movement (REM) sleep that the child is experiencing D) Description of the family's home environment
D) Description of the family's home environment - School-age children often resist bedtime. The nurse should begin by assessing the environment of the home (D) to determine factors that may not be conducive to the establishment of bedtime rituals that promote sleep. (A) often causes daytime fatigue rather than resistance to going to sleep. (B) is unlikely to provide useful data. The nurse cannot determine (C).
A client is scheduled for ligation of hemorrhoids. Which diet does the nurse expect to be ordered in preparation for this surgery? A) Bland B) Clear liquid C) High-protein D) Low-residue
D) Low-residue
A nurse is caring for a client who had a hypophysectomy. For which complications specific to this surgery should the nurse assess the client for early clinical manifestations? A) Urinary retention B) Respiratory distress C) Bleeding at the suture line D) Increased ICP
D) Increased ICP - Because the pituitary gland is located in the brain, edema after surgery may result in increased ICP. Early signs include decreased visual acuity, papilledema, and unilateral pupillary dilatation.
What must the nurse emphasize to a family when preparing a child with persistent asthma for discharge? A) A cold, dry environment is desirable B) Limits should not be placed on the child's behavior C) The health problem is gone when symptoms subside D) Medications must be continued even when asymptomatic
D) Medications must be continued even when asymptomatic
A pregnant adolescent at 10 weeks' gestation visits the prenatal clinic for the first time. The nutrition interview indicates that her dietary intake consists mainly of soft drinks, candy, French fries, and potato chips. Why does the nurse consider this diet inadequate? A) Caloric content will result in too great a weight gain B) Ingredients in soft drinks and candy can be teratogenic during pregnancy C) Salt in this diet will contribute to the development of gestational hypertension D) Nutritional composition of the diet places her at risk for a low-birth weight infant
D) Nutritional composition of the diet places her at risk for a low-birth weight infant
A nurse administers an IM injection of vitamin K to a newborn. What is the purpose of the injection? A) Maintains the intestinal flora count B) Promotes proliferation of intestinal flora C) Stimulates vitamin K production in the baby D) Provides protection until intestinal flora is established
D) Provides protection until intestinal flora is established
The nurse is assessing a client using the Snellen chart and determines that the client's visual acuity is the same as in a previous examination, which was recorded as 20/100. When the client asks the meaning of this, which information should the nurse provide? A) This visual acuity result is five times worse that of a normal finding. B) This line should be seen clearly when the client wears corrective lenses. C) A client with normal vision can read at 100 feet what this client reads at 20 feet. D) This client can see at 100 feet what a client with normal vision can see at 20 feet.
D) This client can see at 100 feet what a client with normal vision can see at 20 feet. - The interpretation of the client's visual acuity is compared to the Snellen scale of 20/20, which indicates that the letter size on the Snellen chart is seen clearly and read by a client with normal vision at 20 feet. A finding of 20/100 means that this client can read at 20 feet what a person with normal vision can read at 100 feet (C). (A, B, and D) are inaccurate.
The nurse is planning care for a child with Trisomy 21 who is admitted with recurrent upper respiratory infections and chronic constipation. Which intervention should the nurse include in the plan of care? A) Provide a high caloric diet that meets the child's mental age. B) Delay solid food introduction until the child's tongue thrust subsides. C) Maintain regular meal times to minimize frequency of constipation. D) Use a bedside cool-mist vaporizer during naps and night time.
D) Use a bedside cool-mist vaporizer during naps and night time. - A child with Trisomy 21, Down syndrome, typically has an under-developed nasal bone that compromises respiratory expansion and causes a chronic problem of inadequate drainage of nasal mucus. This persistent nasal congestion forces the child to mouth-breathe, which dries the oropharyngeal membranes and increases the susceptibility to upper respiratory tract and ear infections. Using a cool-mist vaporizer (D) moistens the nasal mucous membranes, liquefies, and drains nasal secretions to reduce this medium for infection. Caloric intake is based on the child's development, height, and weight, not mental age (A). The risk for constipation is related to a decreased muscle tone, not serving times (C). Parents may need instruction about introducing solid foods, but (B) is not indicated.
A HCP orders an upper GI series and a barium enema. The client asks, "Why do I have to have barium for these tests?" The nurse's best response is "Barium: A) gives off visible light, illuminating the alimentary tract" B) provides fluorescence, thereby lighting up the alimentary tract" C) dyes the structures of the alimentary tract, making them more visible" D) gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays."
D) gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays."
29. Which client problem is the nurse least likely to encounter? A. Bleeding. B. Pruritus. C. Weight loss. D. Hyperglycemia.
D. Hyperglycemia. D Is the best answer because hypoglycemia, not hyperglycemia, occurs in acute hepatitis. This is due to an inadequate hepatic glycogen reserve. In addition, inadequate carbphydrate intake, prolonged nausea, and vomiting are also contrlbutory factors. A, B, and C do occur. These are problems that are encountered because of A, prolonged prothrombin time; B, jaundice; and C, anorexia.
Compound (open)
If a ________ fracture exists, splint the extremity and cover the wound with a sterile dressing
Muscular pain
Instruct the client who is taking an antilipemic drug to report any unexplained ________ to the HCP immediately
Which medication class helps to prevent human immunodeficiency virus (HIV) incorporating its genetic material into the client's cell? 1 Entry inhibitors 2 Protease inhibitors 3 Integrase inhibitors 4 Reverse transcriptase inhibitors
Integrase inhibitors such as raltegravir and dolutegravir bind with integrase enzymes and prevent HIV from incorporating its genetic material into the host (client's) cell. Entry inhibitors prevent the binding of HIV. Protease inhibitors prevent the protease enzyme from cutting HIV proteins into the proper lengths needed to allow viable virions to assemble. Reverse transcriptase inhibitors inhibit the action of reverse transcriptase
Stoma color
What do you monitor after a colostomy or ileostomy?
Airway
What is the priority for a client with lung or laryngeal cancer?
Sulfonamide
Withhold ________ if a rash is noted
Anti hypertensives, water-soluble vitamins, certain antibiotics, and digoxin
Withhold ________ until after hemodialysis treatment is done
A nurse is teaching a birthing/prenatal class about breast-feeding. Which hormone stimulates the production of milk during lactation? 1 Progesterone 2 Prolactin 3 Inhibin 4 Estrogen
answer 2 Prolactin is the hormone that initiates and produces milk during lactation. Inhibin prevents the secretions of follicle stimulating hormone and gonadotropin releasing hormone. Estrogen and progesterone are the sex hormones produced by the ovaries.
The nurse is assessing a client 12 hours after the client sustained a deep partial-thickness burn on the forearm. What characteristics should the nurse expect to identify when assessing the injured tissue? a. Red and swollen b. Blistered and wet c. Charred and white d. Leathery and black
b. Blistered and wet
A client is experiencing both tingling of the extremities and tetany. What should the nurse anticipate will be prescribed by the health care provider? a. Dialysis b. Calcium supplements c. Mechanical ventilation d. Intravenous fluids with potassium
b. Calcium supplements
A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding is the nurse most likely to identify? a. Problems with cognition b. Difficulty swallowing saliva c. Intention tremors of the hands d. Nonintention tremors of the extremities
b. Difficulty swallowing saliva
After a suprapubic prostatectomy, a client's plan of care will include the prevention of postoperative deep vein thrombosis. The nurse recalls that this can be achieved best by increasing the: a. Coagulability of the blood b. Velocity of the venous return c. Effectiveness of internal respiration d. Oxygen-carrying capacity of the blood
b. Velocity of the venous return
A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. What precautions should the nurse take? a. Put on a gown when entering the room. b. Place the client with another client who has TB. c. Wear a particulate respirator when caring for the client. d. Don a surgical mask with a face shield when entering the room.
c. Wear a particulate respirator when caring for the client.
What should the nurse assess for in the immediate postoperative period after a client has brain surgery? a. Tachycardia b. Constricted pupils c. Elevated diastolic pressure d. Decreased level of consciousness
d. Decreased level of consciousness
The nurse is reviewing the urinalysis reports of four clients with renal disorders. Which client's finding signifies the presence of excessive bilirubin? 1 Client 1 2 Client 2 3 Client 3 4 Client 4
yellow brown to olive green Client 3's urinalysis reports findings of the presence of yellow-brown to olive-green-colored urine which signifies excessive bilirubin. Client 1's urinalysis report findings of the presence of amber-yellow-colored urine signifies a normal finding. Client 2's urinalysis report findings of the presence of dark, smoky-colored urine signifies hematuria. Client 4's urinalysis report findings of orange-red or orange-brown-colored urine indicates the presence of phenazopyridine in the urine.
Bacille Calmette-Guerin vaccine
An individual who has received a ________ will have a positive Tb skin test result and should be evaluated for Tb with a chest x-ray
Chronic gastritis
Anorexia, N/V, belching, heartburn after eating, sour taste in mouth, vitamin B-12 deficiency
376. Routine postoperative intravenous fluids are designed to supply hydration and electrolytes and only limited energy. Because 1 L of a 5% dextrose solution contains 50 grams of sugar, 3 L/day will supply approximately: 1. 400 kilocalories 2. 600 kilocalories 3. 800 kilocalories 4. 1000 kilocalories
Ans: 2 Ans: 2 2. Carbohydrates provide 4 kcal/g; therefore, 3 L x 50 g/L x 4 kcal/g = 600 kcal, only about a third of the basal energy need.
824. A client's right tibia is fractured in an automobile collision, and a cast is applied. For which manifestation related to damage to major blood vessels by the fractured tibia should the nurse assess? 1. Increased blood pressure 2. Prolonged edema in the thigh 3. Increased skin temperature of the foot 4. Prolonged reperfusion of the toes after blanching
Ans: 4 4. Damage to the blood vessels may decrease circulatory perfusion of the toes.
428. A client is diagnosed as having a peptic ulcer. When teaching about peptic ulcers, the nurse instructs the client to report any stools that appear: 1. Frothy 2. Ribbon shaped 3. Pale or clay colored 4. Dark brown or black
Ans: 4 4. Dark brown or black stools (melena) indicate gastrointestinal bleeding.
431. A client who had a gastric resection for cancer of the stomach is admitted to the postanesthesia care unit with a nasogastric tube. The nurse expects to observe: 1. Periodic vomiting 2. Intermittent bouts of diarrhea 3. Gastric distention after 6 hours 4. Bloody drainage for the first 12 hours
Ans: 4 4. Drainage is bright red initially and gradually becomes darker red during the first 24 hours.
A newborn is admitted to the NICU with a myelomeningocele. What is the priority nursing intervention during the first 24 hours? A) Using only disposable diapers B) Place the infant prone or in a side-lying position C) Wash the infant's genital area with an anti infective
B) Place the infant prone or in a side-lying position - Placing the infant prone or in a side-lying position decreases pressure on the sac.
The nurse is planning care for school-aged children at a community care center. Which activity is best for the children? A) Building model airplanes. B) Playing follow-the-leader. C) Stringing large and small beads. D) Playing with Playdough and clay.
B) Playing follow-the-leader. - School-aged children strive for independence and productivity (Erikson's Industry vs. Inferiority) and enjoy individual and group activities related to real-life situations, such as playing follow-the-leader (B). (A) is an individual activity that could contribute to feelings of inferiority and inadequacy if the task is too complex. Although school-aged children enjoy crafts, (C and D) are more appropriate for pre-school children.
A nurse is caring for a postoperative client who has diabetes. WHich is the MOST common cause of DKA that the nurse needs to consider when caring for this client? A) Emotional stress B) Presence of infection C) Increased insulin dose D) Inadequate food intake
B) Presence of infection
A nurse is caring for a male client who is scheduled for dilation of the urethra. Which structure surrounding the male urethra should the nurse include in the teaching when explaining the procedure? A) Epididymis B) Prostate gland C) Seminal vesicle D) Bulbourethral gland
B) Prostate gland
The neonatologist requests a mother to provide breast milk for her 32-week gestational premature newborn. The nurse provides instructions about pumping, storing, and transporting the breast milk. Which additional information should the nurse include to ensure the mother understands the request? A) To promote maternal production with neonatal demand, pump only the volume the newborn takes. B) Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients. C) Pump every 2 to 3 hours, including during the night, to increase breast milk volume. D) A glass of wine prior to pumping reduces anxiety and increases breast milk production.
B) Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients. - Breast milk, rather than formula, provides antibodies and nutrition that is easily digested and readily absorbed by an immature newborn (B). Breast milk can be frozen and used if the mother is unable to provide breast milk every day, so (A) is not necessary. The mother does not have to pump through the night (C). Alcohol is excreted in breast milk and is not safe for the newborn (D).
During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A) Assign an unlicensed assistive personnel to transport the client via a wheelchair. B) Remind the client to walk carefully down the stairs until reaching a lower floor. C) Ask the client to help by assisting a wheelchair-bound client to a nearby elevator. D) Open the closest fire doors so that ambulatory clients can evacuate more rapidly.
B) Remind the client to walk carefully down the stairs until reaching a lower floor. - During evacuation of a unit because of fire, ambulatory clients should be evacuated via the stairway if at all possible and reminded to walk carefully (B). Ambulatory clients do not require the assistance of a wheelchair to be evacuated (A). Elevators (C) should not be used during a fire and fire doors should be kept closed (D) to help contain the fire.
A nurse is caring for a client who has a radioactive implant for cancer of the cervix. What is the priority nursing action? A) Store urine in lead-lined containers B) Restrict visitors to a 10 minute stay C) Wear a lead-lined apron when giving care D) Avoid giving injections in the gluteal muscle
B) Restrict visitors to a 10 minute stay
A person who is hospitalized for alcoholism becomes boisterous and belligerent and verbally threatens the nurse. What is the most appropriate response by the nurse? A) Place the client in restraints B) Sedate and place the client in a controlled environment C) Encourage the client to play Ping Pong with another client D) Set firm limits on the client's behavior and enforce adherence to them
B) Sedate and place the client in a controlled environment
437. A client develops a gallstone that becomes lodged in the common bile duct. The practitioner schedules an endoscopic sphincterotomy. Preoperative teaching includes information that for the procedure the client will: 1. Have a spinal anesthetic 2. Receive an epidural block 3. Have a general anesthetic 4. Receive an intravenous sedative
Ans: 4 4. During the procedure a sedative is administered intravenously as needed to help the client stay calm.
458. A client with ascites is scheduled for a paracentesis. To prepare the client for the abdominal paracentesis the nurse should: 1. Shave the client's abdomen 2. Medicate the client for pain 3. Encourage the client to drink fluids 4. Instruct the client to empty the bladder
Ans: 4 4. Emptying the bladder of urine keeps the bladder in the pelvic area and prevents puncture when the abdominal cavity is entered.
446. A client is to be discharged after a laser laparoscopic cholecystectomy. The nurse evaluates that the discharge instructions are understood when the client states: 1. "I can change the bandages every day." 2. "I should stay on a full liquid diet for 3 days." 3. "I should not clean the surgical sites for a week." 4. "I may have mild shoulder pain for about a week."
Ans: 4 4. Mild shoulder pain is common up to 1 week after surgery because of diaphragmatic irritation secondary to abdominal stretching or residual carbon dioxide that was used to inflate the abdominal cavity during surgery.
857. A client with rheumatoid arthritis asks the nurse about ways to decrease morning stiffness. The nurse should suggest: 1. Wearing loose but warm clothing 2. Planning a short rest break periodically 3. Avoiding excessive physical stress and fatigue 4. Taking a hot tub bath or shower in the morning
Ans: 4 4. Moist heat increases circulation and decreases muscle tension, which help relieve chronic stiffness.
457. A male client with liver dysfunction reports that his gums bleed spontaneously. In addition, the nurse identifies small hemorrhagic lesions on his face. The nurse concludes that the client needs additional vitamin: 1. D 2. E 3. A 4. K
Ans: 4 4. Petechiae are evidence of capillary bleeding; the diseased liver is no longer able to metabolize vitamin K, which is necessary to activate blood clotting factors.
453. A long-term complication that a client must be made aware of after a pancreaticoduodenectomy for cancer of the pancreas is hypoinsulinism. The nurse evaluates that the teaching about hypoinsulinism is understood when the client states, "I should seek medical supervision if I experience: 1. oliguria." 2. anorexia." 3. weight gain." 4. increased thirst."
Ans: 4 4. Polydipsia is characteristic of hypoinsulinism (diabetes mellitus) because excessive urine is excreted related to glycosuria.
418. A nurse assesses for the development of pernicious anemia when a client has a history of: 1. Hemorrhage 2. Diabetes mellitus 3. Unhealthy dietary habits 4. Having had a gastrectomy
Ans: 4 4. Removal of the fundus of the stomach destroys the parietal cells that secrete intrinsic factor (needed to combine with vitamin B12 preliminary to its absorption in the ileum).
395. When teaching a client how to prevent constipation, the nurse evaluates that the dietary teaching is understood when the client states that the preferred breakfast cereal is: 1. Froot Loops 2. Corn Flakes 3. Cap'n Crunch 4. Shredded Wheat
Ans: 4 4. Shredded Wheat contains 5.5 grams of fiber per serving, which is more that the other choices.
A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? A) The dosage is kept at a minimum B) Only a small part of the body is eradicated C) The client's physical condition is not a risk factor D) Nutritional environment of the affected cells is a risk factor
B) Only a small part of the body is eradicated
A nurse is assessing a client with a diagnosis of hypoglycemia. What clinical manifestations support this diagnosis? Select all that apply. A) Thirst B) Palpitations C) Diaphoresis D) Slurred speech E) Hyperventilation
B) Palpitations C) Diaphoresis D) Slurred speech
Which physiologic mechanism explains a drug's increased metabolism that is triggered by a disease process? A) Selectivity response B) Pharmacokinetics C) Pharmacodynamics D) Pharmacotherapeutics
B) Pharmacokinetics - Pharmacokinetics (B) describes the physiologic process of a drug's movement throughout the body and how the drug's interaction is affected by an underlying disease. Selectivity (A), or a selective drug, is defined as a drug that elicits only the response for which it is given. Pharmacodynamics (C) is the impact of drugs on the body. Pharmacotherapeutics (D) is defined as the use of drugs to diagnose, prevent, or treat disease or prevent pregnancy.
377. After abdominal surgery a client is to receive a progressive postsurgical diet. This diet is characterized by progressive alterations in the: 1. Caloric content of food 2. Nutritional value of food 3. Texture and digestibility of food 4. Variety of food and fluids included
Ans: 3. 3. This diet progresses from the one that makes the least metabolic demand on the client (clear liquid) to a regular diet that requires the capability of unimpaired digestion.
853. A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment reflects this complication? 1. Fever and chest pain 2. Positive Homans' sign 3. Loss of sensation in the operative leg 4. Tachycardia and petechiae over the chest
Ans: 4 4 Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin.
812. A client with cancer is scheduled for a bone scan to determine the presence of metastasis. The nurse evaluates that the teaching before the scheduled bone scan is effective when the client states that: 1. "X-rays will be taken to identify where I may have lost calcium from my bones." 2. "Portions of my bone marrow will be removed and examined for cell composition." 3. "A radioactive chemical will be injected into my vein that will destroy cancer cells present in my bones." 4. "A substance of low radioactivity will be injected into my vein and my body inspected by an instrument to detect where it is deposited."
Ans: 4 4. A bone scan maps the uptake of a bone-seeking radioactive isotope; an increased uptake is seen in metastatic bone disease, osteosarcoma, osteomyelitis, and certain fractures.
412. The response after a gastroscopy that indicates a major complication is: 1. Difficulty swallowing 2. Increased GI motility 3. Nausea with vomiting 4. Abdominal distention with pain
Ans: 4 4. Abdominal distention, which may be associated with pain, can indicate perforation, a complication that can lead to peritonitis.
835. A client is awaiting surgery for a herniated lumbar nucleus pulposus. The nurse's teaching should include that the pain will most likely increase if the client: 1. Breathes deeply 2. Lies on the side 3. Flexes the knees 4. Coughs excessively
Ans: 4 4. Coughing raises intervertebral pressure and places strain on the lumbar area, increasing the herniation of the nucleus pulposis.
A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, the nurse expects to identify: a. Hypertension b. Tenacious sputum c. Altered mental status d. Slow rate of breathing
c. Altered mental status
A client with rheumatoid arthritis has been given a prescription for acetylsalicylic acid. The client asks the nurse, "What kind of drug is acetylsalicylic acid?" The nurse recalls that the classification to which this drug belongs is: a. Sedatives b. Hypnotics c. Analgesics d. Antibiotics
c. Analgesics
Two hours after a subtotal gastrectomy, the nurse identifies that the drainage from the client's nasogastric tube is bright red. What should the nurse do first? a. Notify the health care provider. b. Clamp the nasogastric tube for one hour. c. Determine that this is an expected finding. d. Irrigate the nasogastric tube with iced saline.
c. Determine that this is an expected finding.
A client with esophageal cancer is to receive TPN. A right subclavian catheter is inserted. What is the primary reason why the HCP ordered a central line? A) It prevents the development of infection B) There is less chance of this infusion infiltrating C) It is more convenient so clients can use their hands D) The large amount of blood helps to dilate the concentrated solution
D) The large amount of blood helps to dilate the concentrated solution
CSF
Has a presence of concentric rings (Halo sign) when fluid is placed on a white sterile background, such as gauze pad. Also tests positive for glucose when tested using a strip test.
85%
If pulse oximetry is lower than ________, oxygenation to body tissues is compromised
A tuberculin skin test with purified protein derivative (PPD) tuberculin is performed as part of a routine physical examination. When does the nurse instruct the client to make an appointment so the test can be read? 1 1 week 2 12 hours 3 24 to 48 hours 4 48 to 72 hours
It takes 48 to 72 hours for antibodies to respond to the antigen and form an indurated area. The results of tuberculosis skin tests that are not read within this timeframe will not be accurate.
Ventilator alarm controls
Never set ________ to the off position
Mastectomy
No IVs, injections, BP measurements, and no venipunctures should be done in the arm on the side of the _______
Cholinergic
Not given to a client who has a urinary stricture or obstruction
91%
Pulse oximetry reading lower than ________ requires HCP notification
Pregnancy
Question women regarding ________ or the possibility before performing radiography studies
Decreased abdominal pressure
Rapid removal of fluid from the abdominal cavity during paracentesis leads to __________________, which can cause vasodilation and result in shock
Metformin
________ is held 24 hrs before a procedure requiring the administration of an iodine dye, because of the risk of lactic acidosis. And the med is usually not resumed until 48 hrs after procedure or until renal function studies are done
During discharge teaching, a client with an ileal conduit asks how frequently the urine pouch should be emptied. The best reply by the nurse is: a. "To prevent leakage and pulling of the pouch from the skin, it should be emptied every few hours." b. "To prevent skin irritation, it should be emptied every hour if any urine has collected in the bag." c. "To reduce the risk of infection, the system should be opened as little as possible; two times a day is adequate." d. "To reduce the cost of drainage pouches, it should be emptied once the system is switched to a bedside collection bag.
a. "To prevent leakage and pulling of the pouch from the skin, it should be emptied every few hours."
When a client returns from the postanesthesia care unit after a kidney transplant, how often should the nurse measure the client's urinary output? a. 1 hour b. 2 hours c. 15 minutes d. 30 minutes
a. 1 hour
Tests reveal that a client has phosphatic renal calculi. The nurse teaches the client that the diet may include which food item? 1 Chocolate 2 Apples 3 Cheddar cheese 4 Rye bread
answer: 2 Apples are low in phosphate; fresh fruit is low in phosphorus. Chocolate contains more phosphate than apples. Rye bread contains more phosphate than apples. Cheese is made with milk, which contains phosphate and should be avoided. Dairy products are high in phosphorus. Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response.
A client who was recently diagnosed with emphysema develops a malignancy in the right lower lobe of the lung, and a lobectomy is performed. After surgery, the client is receiving oxygen by nasal cannula at 2 L per minute. Blood gas results demonstrate respiratory acidosis. What should be the initial nursing intervention? a. Administer oral fluids. b. Encourage deep breathing. c. Increase the oxygen flow rate. d. Perform nasotracheal suctioning.
b. Encourage deep breathing.
An older client who lives alone was found unconscious on the floor at home. The client was admitted to the hospital with the diagnoses of a fractured hip, kidney failure, and dehydration. In the 24 hours since admission, the client received 1500 mL of intravenous fluid and the serum electrolyte value demonstrates hyponatremia. The nurse concludes that the element that most likely contributed to the hyponatremia is: a. Salt intake b. Fluid intake c. Sodium absorption d. Glomerular filtration
b. Fluid intake
A client receiving morphine is being monitored by the nurse for signs and symptoms of overdose. Which clinical findings support a conclusion of overdose? Select all that apply. a. Polyuria b. Lethargy c. Bradycardia d. Dilated pupils e. Slow respirations
b. Lethargy c. Bradycardia e. Slow respirations
A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information? a. Low purine b. Low calcium c. High phosphorus d. High alkaline ash
b. Low calcium
Several clients are admitted to the emergency department with brain injuries as a result of an automobile collision. The nurse concludes that the client with an injury to which part of the brain will most likely not survive? a. Pons b. Medulla c. Midbrain d. Thalamus
b. Medulla
Before a cholecystectomy vitamin K is prescribed. Which element, formed in the presence of vitamin K, should the nurse determine is the purpose of administering this medication? a. Bilirubin b. Prothrombin c. Thromboplastin d. Cholecystokinin
b. Prothrombin
A nurse is evaluating a client's response to receiving an intermittent gravity flow percutaneous endoscopic gastrostomy (PEG) tube feeding. Which clinical finding indicates that the client is unable to tolerate a continuation of the feeding? a. Passage of flatus b. Rise of formula in the tube c. Rapid inflow of the feeding d. Tenderness of epigastric area
b. Rise of formula in the tube
A client with cirrhosis of the liver and ascites fails to respond to chlorothiazide (Diuril), a thiazide diuretic. Spironolactone (Aldactone) is prescribed in addition to the chlorothiazide. What should the nurse explain to the client about why spironolactone was added to the medication regimen? a. Promotes water excretion b. Stimulates sodium excretion c. Helps prevent potassium loss d. Reduces arterial blood pressure
c. Helps prevent potassium loss
A client with chronic hepatic failure is to be discharged from the hospital. Which diet should the nurse encourage the client to follow based on the health care provider's prescription? a. High-fat b. Low-calorie c. Low-protein d. High-sodium
c. Low-protein
What must the nurse determine before discontinuing airborne precautions for a client with pulmonary tuberculosis? a. Client no longer is infected. b. Tuberculin skin test is negative. c. Sputum is free of acid-fast bacteria. d. Client's temperature has returned to normal.
c. Sputum is free of acid-fast bacteria.
A nurse educates the client about the relationship between the kidneys and blood pressure. Which term should the nurse use to describe the part of the kidney that senses changes in blood pressure? 1 Macula densa 2 Calices 3 Glomerulus 4 Juxtaglomerular cells
correct 1 The macula densa, a part of the distal convoluted tubule, consists of cells that sense changes in the volume and pressure of blood. Calices are cup-like structures, present at the end of each papilla that collect urine. The glomerulus is the initial part of the nephron, which filters blood to make urine. Juxtaglomerular cells secrete renin. Renin is produced when sensing cells in the macula densa sense changes in blood volume and pressure.
Electrolyte and mineral
________ imbalances could cause cardiac electrical instability, that can result in life-threatening dysrhythmias
Pain relief (administer morphine as a priority in managing pain in the client having an MI)
________ increases O2 supply to the myocardium
Thromboembolism
________ is a problem following valve replacement with a mechanical prosthetic valve, and life-time anticoagulant therapy is required
When performing the initial history and physical examination of a client with a tentative diagnosis of peptic ulcer, the nurse expects the client to describe the pain as: 1. Gnawing epigastric pain or boring pain in the back 2. Located in the right shoulder and preceded by nausea 3. Sudden, sharp abdominal pain, increasing in intensity 4. Heartburn and substernal discomfort when lying down
. 1 Classic symptoms of peptic ulcer include gnawing, boring, or dull pain located in the midepigastrium or back; pain is caused by irritability and erosion of the mucosal lining. 2 This type of pain is more characteristic of cholecystitis. 3 This type of pain is more characteristic of the complication of a perforated ulcer. 4 This type of pain is more characteristic of a hiatal hernia.
Which urinary diagnostic test does not require any dietary or activity restrictions for the client before or after the test? 1 Renal scan 2 Concentration test 3 Renal arteriogram 4 Renal biopsy
1 A renal scan does not require any dietary or activity restrictions. A renal biopsy requires bed rest for 24 hours after the procedure. A renal arteriogram requires the client to maintain bed rest with affected leg straight. A concentration test requires the client to fast after a given time in the evening.
A nurse instructs a client with a history of frequent urinary tract infections to drink cranberry juice to: 1. Decrease the urinary pH 2. Exert a bactericidal effect 3. Improve glomerular filtration 4. Relieve the symptoms of dysuria
. 1 Cranberry juice is excreted as hippuric acid, which helps acidify the urine (decrease the pH) and inhibit bacterial growth. 2 Although bacterial growth may be inhibited, bacteria are not destroyed. 3 Glomerular filtration is unaffected by cranberry juice. 4 Cranberry juice acidifies the urine and may increase the burning sensation associated with urination when an infection is present.
While the nurse is at the bedside of a client in acute renal failure, the client states, "My doctor said that I will be getting some insulin. Do I also have diabetes?" The response that best demonstrates an understanding of the use of insulin in acute renal failure is: 1. "No, the insulin will help your body handle the increased potassium level." 2. "Why don't you ask that question when the doctor comes to see you today." 3. "You probably had an elevated blood glucose level, so your doctor is being cautious." 4. "No, but insulin will reduce the toxins in your blood by lowering your metabolic rate."
. 1 Insulin promotes the transfer of potassium into cells, which reduces the circulating blood level of potassium. 2 This response halts communication and is not supportive. 3 Blood glucose levels usually are not elevated in acute renal failure. 4 Insulin will not lower the metabolic rate.
After a transurethral vaporization of the prostate, the client returns to the unit with a urinary retention catheter and a continuous bladder irrigation. What should the nurse do first when the client indicates the need to urinate? 1. Assess that the tubing attached to the collection bag is patent 2. Obtain the client's vital signs before notifying the practitioner 3. Explain that the balloon inflated in the bladder causes this feeling 4. Review the client's intake and output that was documented in the previous shift
. 1 The drainage tubing may be obstructed. Retained fluid raises intravesicular pressure, causing discomfort similar to the urge to void. 2 The client's vital signs are not related to the complaint; the practitioner should be called only if a blocked drainage tube is not corrected. 3 Although this is true, the patency of the gravity system should be ascertained before determining the cause of the complaint. 4 Although this might be done, it is not the priority. Whether urine is draining from the tubing at this point in time is significant.
After surgical implantation of radon seeds for oral cancer, the nurse observes the client for the side effects of the radiation including: 1. Nausea and/or vomiting 2. Hematuria and/or occult blood 3. Hypotension and/or bradycardia 4. Abdominal cramping and/or diarrhea
. 1 The mucosa of the mouth and the vomiting center in the brainstem may be affected, producing nausea and vomiting. 2 These are not side effects of radiation therapy to the oral cavity. 3 These are not side effects of radiation therapy to the oral cavity. 4 These are not expected responses because of the distance between the radon seeds and the intestines.
A client receiving a 1500-calorie diet eats these foods for breakfast: 1 cup of milk (12 grams of carbohydrate, 8 grams of protein, 10 grams of fat); ¾ cup corn flakes (15 grams of carbohydrate, 2 grams of protein); and half of an orange (5 grams of carbohydrate). How many calories has this client ingested? 1. 208 2. 258 3. 416 4. 456
. 2 The client has ingested 258 calories. Carbohydrates and proteins each yield 4 calories per gram, and fat yields 9 calories per gram. The total carbohydrate calories are 32 × 4 = 128. The total protein calories are 10 × 4 = 40. The total fat calories are 10 × 9 = 90; 128 + 40 + 90 = 258 calories. 1 This is an incorrect calculation. 3 This is an incorrect calculation. 4 This is an incorrect calculation.
An older adult client is admitted to the hospital with a diagnosis of chronic kidney disease. The nurse reviews the client's medical record and completes a physical assessment. Which clinical finding is a priority to be communicated to the practitioner? 1. Sodium level 2. Potassium level 3. Creatinine results 4. Elevated blood pressure CLIENT CHART Laboratory Results Sodium 135 mEq/L Potassium 6 mEq/L Hemoglobin 8.5 g/dL Creatinine clearance 20 mL/min Client Interview The client complains of lethargy and fatigue Graphic Sheet Temperature 99° F Pulse 84 Respirations 24 Blood pressure 150/100
. 2 The potassium is increased outside the expected range for an adult, which places the client at risk for a cardiac dysrhythmia; the increased potassium level must be treated immediately because elevated levels can be lethal. 1 A serum sodium of 135 mEq/L is expected because of the electrolyte imbalance and the anemia related to the decreased production of erythropoietin by the kidney in the presence of chronic kidney failure. 3 A creatinine clearance of <20 mL/min is expected with chronic kidney disease; a creatinine clearance level of less than 10 mL/min is reflective of severe kidney impairment. 4 Although these vital signs are increased, they are not as serious a concern as another assessment; fluid overload and hypervolemia associated with chronic kidney disease are reflected in hypertension, tachycardia, and tachypnea and are expected
A client's serum albumin value is 2.8 g/dL. The nurse evaluates that teaching is successful when the client says, "For lunch I am going to have: 1. fruit salad." 2. sliced turkey." 3. spinach salad." 4. clear beef broth."
. 2 This serum albumin value indicates severe depletion of visceral protein stores; the expected range for serum albumin is 3.5 to 5.5 g/dL; white meat turkey (two slices 4 × 2 × ¼ inch) contains approximately 28 grams of protein. 1 A 6-ounce serving of mixed fruit contains approximately 0.5 gram of protein. 3 A 3-ounce serving of spinach salad contains approximately 9 grams of protein. 4 A 4-ounce serving of beef broth contains approximately 2.4 grams of protein.
When planning care for a client with ureteral colic, the goal of preventing future calculi is based on the knowledge that most factors contributing to the development of renal stones can be overcome by: 1. Decreasing serum creatinine 2. Excluding milk products from the diet 3. Drinking 8 to 10 glasses of water daily 4. Excreting 2000 mL of urine per 24 hours
. 3 Increasing fluid intake dilutes the urine, and crystals are less likely to coalesce and form calculi. 1 An elevated serum creatinine has no relationship to the formation of renal calculi. 2 Calcium restriction is necessary only if calculi have a calcium phosphate or calcium oxalate basis. 4 Producing only 2000 mL of urine per 24 hours is inadequate; urine output should be maintained at 3000 to 4000 mL to limit calculus formation.
A client undergoes an abdominal cholecystectomy with common duct exploration. In the immediate postoperative period the nursing action that is the priority for this client is: 1. Irrigating the T-tube frequently 2. Changing the dressing at least twice a day 3. Encouraging coughing and deep breathing 4. Promoting an adequate fluid and food intake
. 3 Self-splinting results in shallow breathing, which does not aerate the lungs adequately, particularly the lower right lobe. 1 The T-tube is never irrigated; it drains by gravity until the edema in the operative area subsides; the tube is then removed by the physician. 2 The dressing is not changed by the nurse in the immediate postoperative period; the client's respiratory status takes priority. 4 The client will be NPO immediately after surgery.
A 52-year-old woman 3 hours into a car trip is injured in an automobile collision and is admitted for observation. Damage to her bladder is evident. The history that indicates an increased risk of bladder rupture is: 1. Multiple bouts of cystitis 2. Familial history of bladder cancer 3. Failure to have voided before starting the trip 4. Drinking two cups of coffee before the accident
. 3 The walls of a full bladder are stretched thinner and are more susceptible to rupture when traumatized. 1 A history of cystitis predisposes the client to developing future bladder infections, not to rupturing the bladder. 2 A family member with bladder cancer might increase the risk of cancer; however, it will not predispose the client to bladder rupture. 4 This will not result in the production of enough urine to expand the bladder if the client voided before starting the trip.
A client who has a hiatal hernia is 5 feet 3 inches tall and weighs 140 pounds, asks the nurse how to prevent esophageal reflux. The nurse's best response is: 1. "Increase your intake of fat with each meal." 2. "Lie down after eating to help your digestion." 3. "Reduce your caloric intake to foster weight reduction." 4. "Drink several glasses of fluid during each of your meals."
. 3 Weight reduction decreases intra-abdominal pressure, thereby decreasing the tendency to reflux into the esophagus. 1 Fats decrease emptying of the stomach, extending the period that reflux can occur; fats should be decreased. 2 This increases the pressure against the diaphragmatic hernia, increasing symptoms. 4 This will increase pressure; fluid should be discouraged with meals.
After a successful kidney transplant for a client with end-stage kidney disease, the nurse anticipates that laboratory studies will demonstrate: 1. Increased specific gravity 2. Correction of hypotension 3. Elevated serum potassium 4. Decreasing serum creatinine
. 4 As the transplanted organ functions, nitrogenous wastes are eliminated, lowering the serum creatinine. 1 As more urine is produced by the transplanted kidney, the specific gravity and concentration of the urine will decrease. 2 With end-stage kidney disease, fluid retention causes hypertension. There should be a correction of hypertension, not hypotension. 3 After the transplant, the serum potassium should correct to within expected limits for an adult
If a client on peritoneal dialysis develops symptoms of severe respiratory difficulty during the infusion of the dialysate solution, the nurse should: 1. Increase the rate of infusion 2. Auscultate the lungs for breath sounds 3. Place the client in a low Fowler's position 4. Drain the fluid from the peritoneal cavity
. 4 Pressure from the fluid may cause upward displacement of the diaphragm; draining the solution reduces intra-abdominal pressure, which allows the thoracic cavity to expand on inspiration. 1 Additional fluid will aggravate the problem. 2 Auscultation is important, but it does not alleviate the problem. 3 The client should be placed in the semi-Fowler's position for peritoneal dialysis; this allows inflow of fluid while not impinging on the thoracic cavity.
A nurse educates the client about the relationship between the kidneys and blood pressure. Which term should the nurse use to describe the part of the kidney that senses changes in blood pressure? 1 Macula densa 2 Calices 3 Glomerulus 4 Juxtaglomerular cells
...1..The macula densa, a part of the distal convoluted tubule, consists of cells that sense changes in the volume and pressure of blood. Calices are cup-like structures, present at the end of each papilla that collect urine. The glomerulus is the initial part of the nephron, which filters blood to make urine. Juxtaglomerular cells secrete renin. Renin is produced when sensing cells in the macula densa sense changes in blood volume and pressure.
A nurse is assessing a client who reports frequency and burning when urinating. The nurse performs percussion to determine if there is tenderness that indicates the presence of an ascending urinary tract infection. Which area should be percussed? 1. Tail of Spence 2. Suprapubic area 3. McBurney's point 4. Costovertebral angle
. 4 The costovertebral angle (angle formed by the lateral and downward curve of the lowest rib and the vertebral column of the spine itself) is percussed to determine if there is tenderness in the area over the kidney; this can be a sign of glomerulonephritis or severe upper urinary tract infection. 1 The tail of Spence extends from the upper outer quadrant of the breast to the axillary area; this is the most common site for tumors associated with cancer of the breast. 2 The suprapubic area is above the symphysis pubis; it is palpated and percussed to assess for bladder distention. 3 McBurney's point is 1 to 2 inches above the anterosuperior spine of the ileum on a line between the ileum and umbilicus; external pressure produces tenderness with acute appendicitis, not a kidney infection.
After a cholecystectomy a client asks whether there are any dietary restrictions that must be followed. The nurse evaluates that the dietary teaching is understood when the client tells a family member: 1. "I should avoid fatty foods for the rest of my life." 2. "I should not eat those foods that upset me before I had surgery." 3. "I need to eat a high-protein diet for several months after surgery." 4. "I probably will be able to tolerate a regular diet after this type of surgery."
. 4 The response is individual, but ultimately most people can eat anything they want. 1 Fats may have to be gradually reintroduced, but most people tolerate them after this surgery. 2 Foods that caused gastric distress before surgery usually are tolerated after surgery. 3 Increased protein is needed only until healing has occurred.
After a surgical procedure for cancer of the pancreas that included the removal of the stomach, the head of the pancreas, the distal end of the duodenum, and the spleen, the postoperative manifestation by the client that requires immediate attention by the nurse is: 1. Jaundice 2. Indigestion 3. Weight loss 4. Hyperglycemia (Nugent 32) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
. 4 When the head of the pancreas is removed, the client has a greatly reduced number of insulin-producing cells and hyperglycemia will occur; immediate treatment is necessary. 1 This is not immediately life threatening and will take time to develop. 2 This is not immediately life threatening and will take time to develop. 3 This is not immediately life threatening and will take time to develop. (Nugent 114) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Medical Diagnosis: Acute viral hepatitis. • Nursing Problems/Diagnosis: - Risk of injury related to biochemical regulatory Impairment. - Impairment of digestion. - Altered nutrition, less than body requirements. - Self-esteem disturbance - Sensory/perceptual alterations related to chemical alterations. • Chief Complaint: Ms. Bee Is a 25-year-old real estate agent. She complains of fatigue, weakness, dark-yellow urine, and day-colored stools. • History of Present Illness: Two weeks prior to Ms. Bee's hospitalization, she felt very fatigued and weak. She complained of uncomfortable joint pains, frequent headaches, poor appetite, and nausea. On the fourth day of Ms. Bee's hospitalization, she developed jaundice, and strongly insisted that her visitors be restricted to her immediate family. • Past History: Healthy young adult. No previous hospitalizations. • Family History: Father, age 48; mother, age 45; both relatively well. • Physical Exam: Neck: Supple; no pain or stiffness on movement; trachea midline. Chest: Symmetric chest expansion; adequate chest excursion. Lungs: Clear on auscultation. Heart: S1 and distinct; regular rhythm; no S3 or S4 Abdomen: Flat, soft; active bowel sounds; tympanic sound in four quadrants; smooth liver edge with tenderness, palpated 3 cm below right costal margin. Extremities: No rashes or irritation; jaundice of skin noted on fourth hospitalization day; range of motion of all extremities adequate, without pain or discomfort on movement; strong hand grasps bilaterally. • Laboratory and X-ray Data: Chest x-ray: Normal. Blood gases: Normal limits. ECG: Normal sinus rhythm.
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Medical Diagnosis: Bleeding duodenal ulcer • Surgical Treatment: Gastrectomy • Nursing Problems/Diagnosis - Altered bowel elimination. - Altered cardiac output. - Altered comfort (pain). - Effective individual management of therapeutic regimen. - Altered nutrition: less than body requirements. - Self-care deficit: medication administration. • Client Complaint: Mr. Earl Williams, the 46-year-old owner of a small business, is admitted to the hospital complaining of vomiting a large amount of bright red blood. • History or Present Illness: History of gastric disorders for the past 2 years. Current episode consisted of several days of consumption of some alcohol; death of brother (cancer of the lungs); inability to sleep, then epigastric pain, nausea, vomiting gastric contents and then vomiting bright red blood. • Past History: Stomach disorders for several years. Weight loss of 6 pounds. Complainong of gnawing, aching, and burning pain, usually relieved by proper diet and antacids. • Family History: One brother died age 48, heart attack; one brother died, cancer of the lungs one sister, living and well. Wife has multiple sclerosis, early stages. Son Is unemployed and had dropped out of high school. Two daughters: one married (18-years-old) and living at home with husband and 2-month-old daughter; the other daughter is in high school and doing well. • Review of Systems: Weight loss. GI history (see History of Present Illness and Past History). No difficulty in breathing or palpitations. • Physical Exam: Vital signs: BP: 112/60. P: 92. R: 18. Skln pale. Acute pain. Breath sounds clear. Abdomen: complains of burning pain In mid-epigastric area. • Laboratory and X-ray Data: GI series shows abnormality of tissue In the duodenal region. Endoscopy: positive for duodenal ulcer. Stool: positive for occult blood. Hgb: 12g. Hct: 30%
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Musculoskeletal - from Saunders printed book
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Which statement regarding erythropoietin is true? 1 An erythropoietin deficiency is associated with renal failure. 2 Erythropoietin is released only when there is adequate blood flow. 3 An erythropoietin deficiency causes diabetes. 4 Erythropoietin is released by the pancreas.
...1 correct Erythropoietin is produced by the kidneys; its deficiency occurs in renal failure. Erythropoietin is released by the kidneys, not the pancreas. Erythropoietin deficiency causes anemia. Erythropoietin is secreted in response to hypoxia, which results in decreased oxygenated blood flow to the tissues.
A client with ascites has a paracentesis, and 1500 mL of fluid is removed. For which immediate response is it most important for the nurse to monitor? 1 Respiratory congestion 2 Increase in temperature 3 Rapid, thready pulse 4 Decreased peristalsis
...3 Fluid shifts from the intravascular compartment into the abdominal cavity, causing hypovolemia. A rapid, thready pulse [1] [2], which is indicative of shock, is a compensatory response to this shift. Decreased peristalsis is not likely to occur in the immediate period. After a paracentesis, intravascular fluid shifts into the abdominal cavity, not into the lungs. Increase in temperature is not the priority; body temperature usually is not affected immediately; an infection will take several days
The nurse is performing an assessment of a client's reproductive system. Which action should the nurse take? 1 Maintain friendly demeanor with the client during assessment 2 Ask about sexual practices at the beginning of assessment 3 Ask about menstrual history at the beginning of assessment 4 Maintain gender-specific terms while questioning during assessment
...3 It is necessary to gather health information as part of an assessment of the reproductive system. The nurse should always start the questioning with minimally sensitive information such as menstrual history. This will help the client adjust gradually. The nurse should maintain a professional demeanor while assessing or taking a reproductive health history. Sensitive information, such as client's sexual practices, should be asked after basic and less-sensitive topics. The nurse should make use of gender-neutral terms while questioning the client regarding their sexual partners.
A client arrives at a health clinic reporting hematuria, frequency, urgency, and pain on urination. Which diagnosis will the nurse most likely observe written in the client's medical record? 1 Pyelonephritis 2 Nephrotic syndrome 3 Cystitis 4 Chronic glomerulonephritis
...3...Cystitis is an inflammation of the bladder that causes frequency and urgency of urination, pain on micturition, and hematuria. Chronic glomerulonephritis is a disease of the kidney that is associated with manifestations of systemic circulatory overload. Nephrotic syndrome is a condition of increased glomerular permeability characterized by severe proteinuria. Pyelonephritis is a diffuse, pyogenic infection of the pelvis and parenchyma of the kidney that causes flank pain, chills, fever, and weakness.
Which drug prescribed to a client with a urinary tract infection (UTI) turns urine reddish-orange in color? 1 Nitrofurantoin 2 Ciprofloxacin 3 Phenazopyridine 4 Amoxicillin
...3...Phenazopyridine is a topical anesthetic that is used to treat pain or burning sensation associated with urination. It also imparts a characteristic orange or red color to urine. Amoxicillin is a penicillin form that could cause pseudomembranous colitis as a complication; it is not associated with reddish-orange colored urine. Ciprofloxacin is a quinolone antibiotic used for treating UTIs and can cause serious cardiac dysrhythmias and sunburns. It is not, however, responsible for reddish-orange colored urine. Nitrofurantoin is an antimicrobial medication prescribed for UTIs. This drug may affect the kidneys but is not associated with reddish-orange colored urine.
What is the function of the structure labeled in the given figure? 3204932528 1 Holds the fetus 2 Secretes ovum 3 Serves as entry to the sperm 4 Massages the ovaries
...4...The structure labeled in the figure represents the fallopian tubes, fingerlike projections that massage the ovaries to facilitate ovum extraction. The ovaries produce ovum. The uterus accommodates the fetus. The cervix serves as an entry to the sperm and is also involved in expulsion of menses.
Tests reveal that a client has phosphatic renal calculi. The nurse teaches the client that the diet may include which food item? 1 Chocolate 2 Apples 3 Cheddar cheese 4 Rye bread Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response.
...Apples are low in phosphate; fresh fruit is low in phosphorus. Chocolate contains more phosphate than apples. Rye bread contains more phosphate than apples. Cheese is made with milk, which contains phosphate and should be avoided. Dairy products are high in phosphorus.
A nurse is caring for a client with a diagnosis of cancer of the prostate. The nurse should teach the client that which serum level will be monitored throughout the course of the disease? 1 Albumin 2 Prostate-specific antigen (PSA) 3 Blood urea nitrogen (BUN) 4 Creatinine
.2..The PSA is an indication of cancer of the prostate; the higher the level, the greater the tumor burden. Albumin is a protein that is an indicator of nutritional and fluid status. Increased creatinine or BUN levels may be caused by impaired renal function as a result of blockage by an enlarged prostate but do not indicate that metastasis has occurred.
835. A client is being discharged to home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client states that he or she should: 1. Avoid getting the cast wet. 2. Cover the casted leg with warm blankets. 3. Use the fingertips to lift and move the leg. 4. Use a padded coat hanger end to scratch under the cast.
1 Rationale: A plaster cast must remain dry to keep its strength. The cast should be handled with the palms of the hands, not the fingertips, until fully dry. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast; the client may use a hair dryer on the cool setting to relieve an itch.
A client is transferred to the postanesthesia care unit after undergoing a pyelolithotomy. The client's urinary output is 50 mL/hr. What should the nurse do? 1 Record the output as an expected finding. 2 Milk the client's nephrostomy tube. 3 Encourage the client to drink oral fluids. 4 Notify the primary healthcare provider.
1 An output of 50 mL/hr is adequate; when urine output drops below 20 to 30 mL/hr, it may indicate renal failure, and the primary healthcare provider should be notified. Encouraging the client to drink oral fluids is contraindicated; the client probably still will be under the influence of anesthesia, and the gag reflex may be depressed. Milking the client's nephrostomy tube is unnecessary because the output is adequate.
A client is diagnosed as having invasive cancer of the bladder, and brachytherapy is scheduled. What should the nurse expect the client to demonstrate that indicates success of this therapy? 1 Shrinkage of the tumor on scanning 2 Increase in pulse strength 3 Increase in the quantity of white blood cells (WBCs) 4 Decrease in urine output
1 Brachytherapy, in which isotope seeds are implanted in the tumor, interferes with cell multiplication, which should control the growth and metastasis of cancerous tumors. Radiation affects healthy as well as abnormal cells; urinary output will increase with successful therapy. With brachytherapy of the bladder, increase in pulse strength is not a sign of success. Bone marrow sites may be affected by radiation, resulting in a reduction of WBCs.
Which urinalysis finding indicates a urinary tract infection? 1 Presence of leukoesterase 2 Presence of crystals 3 Presence of ketones 4 Presence of bilirubin
1 Leukoesterases are released by white blood cells as a response to an infection or inflammation. Therefore, the presence of this chemical in urine indicates a urinary tract infection. The presence of crystals in the urine indicates that the specimen had been allowed to stand. Presence of bilirubin in the urine indicates anorexia nervosa, diabetic ketoacidosis, and prolonged fasting. The presence of ketones indicates diabetic ketoacidosis.
Which diagnostic procedure helps in the detection of uropathologic features in a client who has a urinary pouch or ileal conduit? 1 Loopogram 2 Cystogram 3 Computed tomography urogram 4 Urethrogram
1 Loopogram helps in the detection of uropathologic features in a client who has a urinary pouch or ileal conduit. Cystogram helps to visualize the bladder and evaluates vesicoureteral reflux. A computed tomography (CT) urogram provides excellent visualization of kidneys and kidney size can be evaluated. When urethral trauma is suspected, an urethrogram is done before catheterization.
A client is diagnosed with condyloma acuminatum. Which finding in the client supports the diagnosis? 1 Moist, fleshy projections on the penis 2 Pus-filled ulcers on the penis 3 Swollen penis with tight foreskin 4 Macules on the penis
1 Moist, fleshy projections on the penis with single or multiple projections is a clinical manifestation of condyloma acuminatum. Macules on the penis or scrotum are clinical manifestations of penile erythema. Chancroid is manifested by pus-filled ulcers on the penis. A swollen penis with tight foreskin is a clinical manifestation of paraphimosis
A nurse is caring for an older bedridden male client who is incontinent of urine. Which action should the nurse take first? 1 Offer the urinal regularly. 2 Insert an indwelling urinary catheter. 3 Apply incontinence pants. 4 Restrict fluid intake.
1 Offering the urinal is the first step. Retraining the bladder includes a routine pattern of attempts to void, which may increase bladder muscle tone and produce a conditioned response. Restricting fluid intake can result in dehydration and a urinary tract infection in an older client. Applying incontinence pants does not address the cause of the incontinence; also it promotes skin breakdown and can lower self-esteem. Inserting an indwelling urinary catheter increases the risk of a urinary tract infection. Also, it requires a primary healthcare provider's prescription.
When assessing a client's abdomen, the nurse palpates the area directly above the umbilicus. This area is known as the: 1. Iliac area 2. Epigastric area 3. Hypogastric area 4. Suprasternal area
2 The stomach is located within the sternal angle, known as the epigastric area. 1 This is in the area of the iliac bones. 3 This is the lowest middle abdominal area. 4 This is the area above the sternum.
A client with a history of chronic kidney disease is hospitalized. Which assessment findings will alert the nurse to kidney insufficiency? 1 Edema and pruritus 2 Facial flushing 3 Diminished force and caliber of stream 4 Dribbling after voiding and dysuria
1 The accumulation of metabolic wastes in the blood (uremia) can cause pruritus; edema results from fluid overload caused by impaired urine production. Pallor, not flushing, occurs with chronic kidney disease as a result of anemia. Dribbling after voiding is a urinary pattern that is not caused by chronic kidney disease; this may occur with prostate problems. Diminished force and caliber of stream occur with an enlarged prostate, not kidney disease.
Which part of the kidney produces the hormone bradykinin? 1 Juxtaglomerular cells of the arterioles 2 Kidney tissues 3 Kidney parenchyma 4 Renin-producing granular cells
1 The juxtaglomerular cells of the arterioles produce the hormone bradykinin, which increases blood flow and vascular permeability. The kidney tissues produce prostaglandins that regulate internal blood flow by vasodilation or vasoconstriction. The kidney parenchyma produces erythropoietin that stimulates the bone marrow to make red blood cells. The renin-producing granular cells produce the renin hormone that raises blood pressure as a result of angiotensin and aldosterone secretion.
Thiamine (Vitamin B1) and niacin (Vitamin B3) are prescribed for a client with alcoholism. Which body function maintained by these vitamins should the nurse include in a teaching plan? A) Neuronal activity B) Bowel elimination C) Efficient circulation D) Prothrombin development
A) Neuronal activity
A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. A priority nursing action during the first 48 hours after the client's admission is to: 1. Monitor the client's vital signs 2. Increase the client's fluid intake 3. Improve the client's nutritional status 4. Determine the client's reasons for drinking
1 A client's vital signs, especially the pulse and temperature, will increase before the client demonstrates any of the more severe symptoms of withdrawal from alcohol. 2 Increasing intake is contraindicated initially because it may cause cerebral edema. 3 Improving nutritional status becomes a priority after the problems of the withdrawal period have subsided. 4 Determining the client's reasons for drinking is not a priority until after the detoxification process.
During a health symposium a nurse teaches the group how to prevent food poisoning. The nurse evaluates that the teaching is understood when one of the participants states: 1. "Meats and cream-based foods need to be refrigerated." 2. "Once most food is cooked it does not need to be refrigerated." 3. "Poultry should be stuffed and then refrigerated before cooking." 4. "Cooked food should be cooled before being put into the refrigerator."
1 A cold environment limits growth of microorganisms. 2 All food should be refrigerated before and after it is cooked to limit the growth of microorganisms. 3 This promotes the growth of microorganisms because the stuffing will still be warm for a period before the refrigerator's cold environment cools the center of the bird. It is advocated that poultry not be stuffed. If it is stuffed, it should be done immediately before cooking. 4 This promotes the growth of microorganisms because microorganisms thrive in warm, moist environments.
After sustaining multiple internal injuries in an automobile collision, the nurse identifies that the client's blood pressure suddenly drops to 80/60 mm Hg. What most likely has caused this drop in blood pressure? 1. Reduction in the circulating blood volume 2. Diminished vasomotor stimulation to the arterial wall 3. Vasodilation resulting from diminished vasoconstrictor tone 4. Cardiac decompensation resulting from electrolyte imbalance (Nugent 20) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 A decreased intravascular volume results in hypovolemia and hypotension, which is evidenced by a decreased blood pressure and a decreased pulse pressure. 2 Vasomotor stimulation to the arterial walls is increased with shock. 3 This is a description of neurogenic shock, which is unlikely in this situation. 4 Although electrolyte imbalances can precipitate cardiac decompensation, cardiogenic shock is unlikely in this situation. (Nugent 101) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
The nurse expects that the most definitive test to confirm a diagnosis of multiple myeloma is: 1. Bone marrow biopsy 2. Serum test for hypercalcemia 3. Urine test for Bence-Jones protein 4. X-ray films of the ribs, spine, and skull (Nugent 19) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 A definite confirmation of multiple myeloma can only be made through a bone marrow biopsy; this is a plasma cell malignancy with widespread bone destruction. 2 Although calcium is lost from bone tissue and hypercalcemia results, this is not a confirmation of the disease. 3 Although this protein is found in the urine, it does not confirm the disease. 4 X-ray films will show the characteristic "punched-out" areas caused by the increased number of plasma cells, which contributes to the making of the diagnosis. The definitive diagnosis is made on biopsy. (Nugent 99) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Three hours after a subtotal gastrectomy, a client who has a nasogastric tube to continuous low suction and IV fluids complains of nausea and abdominal pain. The client's abdomen appears distended and there are no bowel sounds. The nurse should first: 1. Instill air into the tube 2. Give the prn pain medication 3. Check bowel movements for blood 4. Notify the surgeon of absent bowel sounds
1 Abdominal distention, nausea, and abdominal pain can be signs of nasogastric tube blockage. Instilling 30 mL of air may reestablish patency. 2 Although opioids usually are ordered postoperatively, they tend to decrease peristalsis and may increase abdominal distention and nausea. 3 There will be no stools for several days. 4 Bowel sounds are not expected for several days after stomach or intestinal surgery.
A client is diagnosed with cancer of the stomach and is scheduled for a partial gastrectomy. Preoperative preparation for this client should include an explanation about the postoperative: 1. Gastric suction 2. Oxygen therapy 3. Fluid restriction 4. Urinary catheter
1 After gastric surgery a nasogastric tube is in place for drainage of blood and gastric secretions. 2 Oxygen is not required unless the client experiences a complication necessitating its administration. 3 The average client is given about 3500 mL of fluid by IV to meet fluid needs and replace gastric losses. 4 This may or may not be necessary.
Because of chronic crampy pain, diarrhea, and cachexia, a young adult is to receive total parenteral nutrition (TPN) via a central line. Before preparing a client for the insertion of the catheter, the nurse is aware that a: 1. Parenteral solution may be administered intermittently 2. Fluoroscopy must be done before the catheter is inserted 3. Jugular vein is the most commonly used catheter insertion site 4. Client will experience a moderate amount of pain during the procedure
1 Although the central venous catheter remains in situ, total parenteral nutrition does not have to infuse continuously. Continuous versus intermittent administration depends on the practitioner's order. 2 Placement of the tube after the procedure is verified by x-ray, not fluoroscopy. 3 The subclavian veins are used most often; the jugular vein is too close to hair-growing areas, which increases the possibility of sepsis, and neck movements may interfere with maintaining placement of the catheter. 4 Although a feeling of pressure may be experienced, it is not a painful procedure.
A client with achalasia is to have bougienage to dilate the lower esophagus and cardiac sphincter. After the procedure the nurse assesses the client for esophageal perforation, which is indicated by: 1. Tachycardia and abdominal pain 2. Faintness and feelings of fullness 3. Diaphoresis and cardiac palpitations 4. Increased blood pressure and urinary output
1 An increased heart rate is related to an autonomic nervous system response; pain is related to the trauma of the perforation and possibly gastric reflux. 2 These are signs of dumping syndrome. 3 These are signs of dumping syndrome. 4 An increased blood pressure may occur, but an increased urinary output has no relationship to esophageal perforation.
A client is transferred to the postanesthesia care unit after undergoing a pyelolithotomy. The client's urinary output is 50 mL/hr. The nurse should: 1. Record the findings 2. Notify the practitioner 3. Milk the client's nephrostomy tube 4. Encourage the client to drink oral fluids
1 An output of 50 mL/hr is adequate; when urine output drops below 30 mL/hr, it may indicate renal failure and the practitioner should be notified. 2 This is unnecessary because the output is adequate. 3 This is unnecessary because the output is adequate. 4 This is contraindicated; the client probably will still be under the influence of anesthesia and the gag reflex may be depressed.
A male client is diagnosed as having phosphatic calculi. The nurse teaches the client that his diet may include: 1. Apples 2. Chocolate 3. Rye bread 4. Cheddar cheese
1 Apples are low in phosphate. 2 Chocolate contains more phosphate than apples. 3 Rye bread contains more phosphate than apples. 4 Cheese is made with milk, which contains phosphate and should be avoided.
A client with multiple myeloma, who is receiving chemotherapy, has a temperature that has risen 3 degrees during a 6-hour period and is now 102.2° F. The nurse should: 1. Administer the prescribed antipyretic and notify the practitioner 2. Obtain the other vital signs and recheck the temperature in 1 hour 3. Assess the amount and color of urine and obtain a specimen for a urinalysis 4. Note the consistency of respiratory secretions and obtain a specimen for culture (Nugent 19) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Because an elevated temperature increases metabolic demands, the pyrexia must be treated immediately. The practitioner should be notified because this client is immunodeficient from both the disease and the chemotherapy. A search for the cause of the pyrexia can then be initiated. 2 More vigorous intervention is necessary. This client has a disease in which the immunoglobulins are ineffective and the therapy further suppresses the immune system. 3 This is not the immediate priority, although it is important because the cause of the pyrexia must be determined. Also the increased amount of calcium and urates in the urine can cause renal complications if dehydration occurs. 4 This is not the priority, although important because respiratory tract infections are a common occurrence in clients with multiple myeloma. (Nugent 99) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client has cholelithiasis with possible obstruction of the common bile duct. Before the scheduled cholecystectomy, nutritional deficiencies and excesses should be corrected. A nutritional assessment is conducted to determine whether the client: 1. Is deficient in vitamins A, D, and K 2. Eats adequate amounts of dietary fiber 3. Consumes excessive amounts of protein 4. Has excessive levels of potassium and folic acid
1 Bile promotes the absorption of the fat-soluble vitamins. An obstruction of the common bile duct limits the flow of bile to the duodenum and thus the absorption of these fat-soluable vitamins. 2 Dietary fiber is not relevant to the situation. 3 Although adequate dietary protein is desirable for wound healing, it is unrelated to cholelithiasis. 4 Elevated potassium and folic acid are not related to cholelithiasis.
When providing care for a client in the first 24 hours after a thyroidectomy, the nurse includes: 1. Checking the back and sides of the operative site 2. Supporting the head during mild range-of-motion exercises 3. Encouraging the client to ventilate feelings about the surgery 4. Advising the client that regular activities can be resumed immediately (Nugent 30) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Bleeding may occur, and blood will pool in the back of the neck because the blood will flow via gravity. 2 ROM exercises will increase pain and put tension on the suture line. 3 Talking should be avoided in the immediate postoperative period except to assess for a change in pitch or tone, which may indicate laryngeal nerve damage. 4 Activity should be gradually resumed, and frequent rest periods encouraged. (Nugent 112) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A nurse explains to a client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because it is: 1. More accurate 2. Easier to perform 3. Done by the client 4. Not influenced by drugs (Nugent 31) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Blood glucose testing is a more direct and accurate measure; urine testing provides an indirect measure that can be influenced by kidney function and the amount of time the urine is retained in the bladder. 2 Whereas blood and urine testing is relatively simple, testing the blood involves additional knowledge. 3 Both procedures can be done by the client. 4 This is not a factor. Although some urine tests are influenced by drugs, there are methods to test urine to bypass this effect. (Nugent 113) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
When teaching a community health class the nurse informs the group that the person at highest risk of developing prostate cancer is a: 1. 55-year-old black male 2. 45-year-old white male 3. 55-year-old Asian male 4. 45-year-old Hispanic male
1 Cancer of the prostate is rare before age 50 but increases with each decade; black men develop cancer of the prostate twice as often and at an earlier age than white men. 2 White men develop prostatic cancer half as often as black men, but more commonly than Asian or Hispanic men. 3 This group of men has a lower incidence of prostatic cancer and lower mortality rate than white and black men. 4 This group of men has a lower incidence of prostatic cancer and lower mortality rate than white and black men.
A client is admitted with cellulitis of the left leg and a temperature of 103° F. The practitioner prescribes IV antibiotics. Before instituting this therapy, the nurse should: 1. Determine whether the client has allergies 2. Apply a warm, moist dressing over the area 3. Measure the amount of swelling in the client's leg 4. Obtain the results of the culture and sensitivity tests (Nugent 20) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Drug hypersensitivity and anaphylaxis are most common with antimicrobial agents. 2 This is a dependent function; it is not crucial to starting antibiotic therapy. 3 This is an important assessment, but it is not crucial to starting antibiotic therapy. 4 Withholding treatment until culture results are available may extend the infection. (Nugent 100) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
When preparing a client for discharge after a thyroidectomy, the nurse teaches the signs of hypothyroidism. The nurse evaluates that the client understands the teaching when the client says, "I should call my physician if I develop: 1. dry hair and an intolerance to cold." 2. muscle cramping and sluggishness." 3. fatigue and an increased pulse rate." 4. tachycardia and an increase in weight." (Nugent 30) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Dry, sparse hair and cold intolerance are characteristic responses to low serum thyroxine. 2 Muscle cramping is associated with hypocalcemia. 3 Low thyroxine levels reduce the metabolic rate, resulting in fatigue, but do not increase the pulse rate. 4 Low thyroxine levels reduce the metabolic rate, resulting in weight gain and bradycardia, not tachycardia. (Nugent 112) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client is scheduled for a transurethral prostatectomy. He is concerned about the operation's effect on his sexual ability. The nurse should reply that he may: 1. Experience retrograde ejaculations 2. Have prolonged erections afterward 3. Be permanently impotent after the operation 4. Develop a diminishing sex drive after the surgery
1 Ejection of semen into the bladder instead of the urethra is common after a transurethral prostatectomy. 2 This surgery will not cause prolonged erections. 3 Impotence is not usual with this approach; it may occur with the retroperitoneal approach. 4 This surgery should not interfere with the libido.
A client visits the clinic because of concerns about insomnia and recent weight loss. A tentative diagnosis of hyperthyroidism is made. In addition to these changes, the nurse further assesses this client for: 1. Fatigue 2. Dry skin 3. Anorexia 4. Bradycardia (Nugent 29) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Excessive metabolic activity associated with hyperthyroidism causes fatigue. 2 Warm, moist skin is expected because of increased peripheral perfusion associated with increased metabolism. 3 Increased appetite is expected because of the increased metabolism associated with hyperthyroidism. 4 Tachycardia is expected because of the increased metabolism associated with hyperthyroidism. (Nugent 111) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A home health care nurse visits a 40-year-old housewife who is receiving hemodialysis. When reviewing the diet with the client, the nurse encourages her to include: 1. Rice 2. Potatoes 3. Canned salmon 4. Barbecued beef
1 Foods high in carbohydrates and low in protein, sodium, and potassium are encouraged for these clients. 2 This is high in potassium, which is restricted. 3 This is high in protein and sodium, which usually are restricted. 4 This is high in protein, sodium, and potassium, which usually are restricted.
A client has surgery to repair a bladder laceration. The routine nursing intervention that takes priority in the postoperative care of this client is: 1. Repositioning frequently 2. Giving lower back care 3 times daily 3. Implementing range-of-motion exercises 4. Placing 3 side rails in the elevated position
1 Frequent position changes are important to ensure efficient urinary drainage; gravity promotes flow, which prevents obstruction. 2 Back care is necessary but is not a priority. 3 ROM is of minimal importance because the client will be able to move without limitation. 4 Raising three side rails is routine care, particularly if the client is sedated; positioning to promote urinary drainage takes priority. Clinical Area: Medical-Surgical Nursing; Client Needs: Reduction of Risk Potential; Cognitive Level: Application; Nursing Process: Planning
A client is diagnosed as having hepatitis A. The information from the admitting data that most likely is linked to hepatitis A is the client's history of working: 1. For a local plumber 2. In a hemodialysis unit of a hospital 3. As a dishwasher at a local restaurant 4. With occupational arsenic compounds
1 Hepatitis A is primarily spread via a fecal-oral route; sewage-polluted water may harbor the virus. 2 Hepatitis types B, C, and D are more often spread via the bloodborne route; using disposable equipment and proper handling of syringes decreases the risk of spreading the virus. 3 This does not increase the risk of developing the disease, but will increase the risk of an infected individual spreading the disease to others. 4 Exposure to arsenic or carbon tetrachloride can cause toxic hepatitis, which is not communicable.
An obese client with type 2 diabetes asks about the intake of alcohol or special "dietetic" food in the diet. The nurse teaches the client that: 1. Alcohol can be used, with its calories counted in the diet 2. Unlimited amounts of sugar substitutes can be used as desired 3. Alcohol should not be used in cooking because it adds too many calories 4. Special "dietetic" foods are needed because many regular foods cannot be used (Nugent 32) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 In the overweight individual with type 2 diabetes, occasional alcohol can be ingested with caloric substitution for equivalent fat exchanges in the diet because it is metabolized like fat. 2 Moderation is vital; these may not be used in unlimited quantities and they must be accounted for in the dietary calculations. 3 Alcohol can be used as long as it is accounted for in the diet. 4 This is untrue; regular foods can be used in the diet of individuals with diabetes. (Nugent 114) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
When assessing a female client with Graves' disease (hyperthyroidism) the nurse expects to identify a history of: 1. Diaphoresis 2. Menorrhagia 3. Dry, brittle hair 4. Sensitivity to cold (Nugent 29-30) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Increased basal metabolic rate, increased circulation, and vasodilation result in warm, moist skin. 2 This problem is associated with hypothyroidism. 3 This problem is associated with hypothyroidism. 4 This problem is associated with hypothyroidism. (Nugent 111) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client who had a lithotripsy for a renal calculus is to be discharged from the hospital. The nurse who is providing home care instructions should include: 1. Drinking at least 3 L of fluid daily for 4 weeks 2. Removing organ meats from the diet for 6 weeks 3. Increasing the intake of dairy products for 5 days 4. Restricting movement for 3 days before resuming usual activities
1 Increasing fluid intake aids in the passage of fragments of the calculus that remain after the lithotripsy. 2 Organ meats are high in purine, an amino acid, which is a causative factor in the formation of uric acid crystals; they should be avoided by people with gout. 3 Calcium is the major component of the most common type of calculus; the intake of dairy products, which are high in calcium, should be limited. 4 Early ambulation is encouraged to aid in the passage of fragments of the calculus that remain after a lithotripsy.
After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for: 1. Monthly injections of vitamin B12 2. Regular daily use of a stool softener 3. Weekly injections of iron dextran (Imferon) 4. Daily replacement therapy of pancreatic enzymes
1 Intrinsic factor is lost with removal of the stomach, and vitamin B12 is needed to maintain the hemoglobin level once the client is stabilized; injections are given monthly for life. 2 Adequate diet, fluid intake, and exercise should prevent constipation. 3 This is not a routine expectation. 4 This surgery does not affect pancreatic enzymes.
A client with end-stage kidney disease is to begin continuous ambulatory peritoneal dialysis (CAPD). When assessing the client before the institution of CAPD, the nurse should be alert for the presence of: 1. Client motivation 2. Cardiac problems 3. Emotional lability 4. Pulmonary problems
1 Lack of motivation is the most serious impediment to successful CAPD. 2 This is not a contraindication to CAPD. 3 This is not a contraindication to CAPD. 4 This is not a contraindication to CAPD.
The nurse teaches a client to irrigate a new sigmoid colostomy when the: 1. Stool starts to become formed 2. Client can lie on the side comfortably 3. Abdominal incision is closed and contamination is no longer a danger 4. Perineal wound heals and the client can sit comfortably on the commode
1 Once stool is formed, peristalsis needs to be stimulated to promote the passage of stool. 2 The sitting, not side-lying, position is the position of choice for a colostomy irrigation because it facilitates evacuation of the bowel via gravity. 3 Contamination is avoided because fecal elimination flows through the sleeve of the colostomy appliance directly into the commode. 4 The perineal wound may take weeks to heal, and irrigations must be started when the stool is formed.
Late in the postoperative period after resection of an aldosterone-secreting adenoma, the nurse expects the client's blood pressure to: 1. Gradually return to near normal levels 2. Rise quickly above the preoperative level 3. Fluctuate greatly during this entire period 4. Drop very low, then increase rapidly to normal levels (Nugent 29) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Once the excessive secretion of aldosterone is stopped, the blood pressure gradually drops to a near normal level. 2 The blood pressure drops gradually; it does not rise. 3 Blood pressure will fluctuate if the hypervolemia is overcorrected; this is not expected. 4 The blood pressure drops gradually in response to decreasing serum corticosteroid levels; a rapid drop immediately after surgery may indicate hemorrhage. (Nugent 110) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
When a client returns from the postanesthesia care unit after a kidney transplant, the nurse should plan to measure the client's urinary output every: 1. 1 hour 2. 2 hours 3. 3 hours 4. 15 minutes
1 Output is critical when assessing kidney function. The urinary output should be monitored every 30 to 60 minutes; decreasing urinary output is a sign of rejection. 2 This is too infrequent to monitor output immediately after a transplant. It is essential to monitor output more frequently to evaluate whether the new kidney is working or whether it is being rejected. 3 This is too infrequent to monitor output immediately after a transplant. It is essential to monitor output more frequently to evaluate whether the new kidney is working or whether it is being rejected. 4 It is not necessary to monitor urinary output this frequently.
A 50-year-old man is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature of 101°F. He reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, the primary nursing concern for this client is: 1. Acute pain 2. Inadequate nutrition 3. Electrolyte imbalance 4. Disturbed self-concept
1 Pain with pancreatitis usually is severe and is the major symptom; it occurs because of the autodigestive process in the pancreas and peritoneal irritation. 2 Although clients with this medical diagnosis are often malnourished, addressing the client's pain takes priority. 3 There are not enough data for this conclusion; additional data such as skin turgor, serum electrolytes, and I&O are needed to identify whether the client has a fluid and electrolyte imbalance. 4 There are no data to support the presence of a disturbed selfconcept.
A client with cholelithiasis is scheduled for a lithotripsy. Preoperative teaching should include the information that: 1. Opioids will be available for postoperative pain 2. Fever is a common response to this intervention 3. Heart palpitations often occur after the procedure 4. Anesthetics are not necessary during the procedure
1 Painful biliary colic may occur in the postoperative period as a result of the passage of pulverized fragments of the calculi; this may occur 3 or more days after the lithotripsy. 2 Fever may indicate pancreatitis, which is a rare occurrence. 3 The delivery of shock waves during the procedure is synchronized with the heartbeat to avoid initiation of dysrhythmias. 4 Light sedation may be used to keep the client comfortable and as still as possible.
A practitioner orders three stool specimens for occult blood for a client who complains of blood-streaked stools and a 10-pound weight loss in 1 month. To ensure valid test results, the nurse should instruct the client to: 1. Avoid eating red meat before testing 2. Test the specimen while it is still warm 3. Discard the day's first stool and use the next three stools 4. Take three specimens from different sections of the fecal sample
1 Red meat can react with reagents used in the test to cause false-positive results. 2 This may apply for testing for ova and parasites, not for occult blood. 3 If the correct procedure is followed, discarding the first specimen is unnecessary. 4 Random stool testing can be done but must be on three different bowel movements during the screening period.
A client with an aldosterone-secreting adenoma is scheduled for surgery to remove the tumor. The client wonders what will happen if surgery is canceled. The nurse bases a response on the fact that: 1. Heart and kidney damage may occur if the tumor is not removed 2. Surgery will prevent the tumor from metastasizing to other organs 3. Chemotherapy is as reliable as surgery to treat adenomas of this type 4. Radiation therapy or surgery can be just as effective if the tumor is small (Nugent 29) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Renal and cardiac complications will occur if hypertension is not arrested. 2 An aldosteronoma is a benign tumor; metastasis is not possible. 3 Drugs are not used; the tumor must be removed. 4 This is not true; the tumor must be removed by surgical means. (Nugent 110) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A 49-year-old female is admitted to the hospital with a possible diagnosis of Addison's disease. What is an important nursing responsibility during a 24-hour urine collection for the client suspected of having Addison's disease? 1. Keep the client quiet and reduce stress 2. Assess the client for signs and symptoms of edema 3. Monitor the client for an elevation in blood pressure 4. Restrict the client's fluid intake during the day of the test (Nugent 29) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Stress and activity increase the secretion of ACTH and adrenocortical hormones, elevating the urine values for the byproducts of these hormones, thus invalidating the test results. 2 Clients with Addison's disease are chronically dehydrated and do not have edema. 3 Because of fluid deficits, the client will be hypovolemic and the blood pressure will be decreased. 4 Adequate fluid intake is necessary for urine production; Addison's disease involves salt wasting and dehydration, which necessitates an increased fluid intake, not a restriction of fluid intake. (Nugent 111) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
The laboratory results of a client following chemotherapy for cancer indicate bone marrow suppression. The nurse should encourage the client to: 1. Use an electric razor when shaving 2. Drink citrus juices frequently for nourishment 3. Increase activity level by ambulating frequently 4. Sleep with the head of the bed slightly elevated (Nugent 19) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 Suppression of bone marrow increases bleeding susceptibility associated with decreased platelets. 2 This will not affect the bone marrow. Citrus juices should be avoided by the client receiving chemotherapy because of the side effects of stomatitis. 3 With bone marrow suppression there is a decrease in red blood cells; rest should be encouraged. 4 With bone marrow suppression the red blood cells are decreased in number and there is a decreased oxygen-carrying capacity of the blood. This position will not increase the number of red blood cells. (Nugent 98-99) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Blood screening tests of the immune system of a client with AIDS indicates: 1. A decrease in CD4 T cells 2. An increase in thymic hormones 3. An increase in immunoglobulin E 4. A decrease in the serum level of glucose-6-phosphate dehydrogenase (Nugent 18) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 The HIV infects helper T-cell lymphocytes; therefore, 300 or fewer CD4 T cells per cubic millimeter of blood or CD4 cells accounting for less than 20% of lymphocytes is suggestive of AIDS. 2 The thymic hormones necessary for T-cell growth are decreased. 3 This finding is associated with allergies and parasitic infections. 4 This finding is associated with drug induced hemolytic anemia and hemolytic disease of the newborn. (Nugent 97-98) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A practitioner tells a client that an increase in vitamin E and beta-carotene is important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are: 1. Spinach and mangoes 2. Fish and peanut butter 3. Oranges and grapefruits 4. Carrots and sweet potatoes
1 The antioxidants vitamin E and beta-carotene, which help inhibit oxidation and therefore tissue breakdown, are found in these foods. 2 These are excellent sources of vitamin E, not beta-carotene. 3 These are excellent sources of vitamin C, not vitamin E and beta-carotene. 4 These are excellent sources of beta-carotene, not vitamin E.
A client with a long history of alcohol abuse is admitted to the hospital with ascites, jaundice, and confusion. A diagnosis of hepatic cirrhosis is made. A nursing priority is to: 1. Institute safety measures 2. Monitor respiratory status 3. Measure abdominal girth daily 4. Test stool specimens for blood
1 The high ammonia levels contribute to deterioration of mental function and then to hepatic encephalopathy and hepatic coma; safety is the priority. 2 Although the client may have dyspnea as a result of ascites, it is not life threatening; safety is the priority. 3 Although this is done to monitor ascites, it is not the priority for a confused client; safety is the priority. 4 This is not the priority; providing for client safety is the priority.
A client with malignant hot nodules of the thyroid gland has a thyroidectomy. Immediately after the thyroidectomy, the nurse's priority action for this client is to: 1. Place in low-Fowler's position to limit edema of the neck 2. Monitor intake and output strictly to assess for fluid overload 3. Encourage coughing and deep breathing to prevent atelectasis 4. Assess level of consciousness to determine recovery from anesthesia (Nugent 30) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 The inflammatory response and trauma of surgery may cause edema; elevating the head facilitates drainage preventing compression of the trachea. 2 Although this is an important assessment for any postoperative client, it is not the priority for this client. 3 Although deep breathing should be encouraged, coughing this early in the postoperative period is too traumatic to the operative site. 4 Although this is an important assessment for any postoperative client, it is not the priority for this client. (Nugent 112) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client has a body mass index (BMI) of 35 and verbalizes the need to lose weight. The nurse encourages the client to lose weight safely by: 1. Decreasing portion size and fat intake 2. Increasing protein and vegetable intake 3. Decreasing carbohydrate and fat intake 4. Increasing fruits and limiting fluid intake
1 The most effective and safest method for achieving weight loss is to decrease caloric intake. This is best accomplished by maintaining a balance of nutrients while decreasing portion size and fat intake. A gram of fat is 9 calories, whereas a gram of protein and a gram of carbohydrate are each 4 calories. 2 Increasing protein intake can increase fat intake because animal protein also contains fat. 3 Although decreasing carbohydrate and fat intake will promote weight loss, the diet may result in an imbalance of nutrients, which may jeopardize the client's health. 4 Fruits are important in any diet, and if a balance of nutrients is to be maintained, fruit intake may need to be increased or decreased depending on the client's eating habits; water intake should not be limited in a weight loss diet; 6 to 8 glasses a day is recommended to enhance weight loss.
A client with cirrhosis of the liver and malnutrition begins to develop slurred speech, confusion, drowsiness, and tremors. With these signs and symptoms, the diet should be limited to: 1. 20 grams of protein, 2000 calories 2. 80 grams of protein, 1000 calories 3. 100 grams of protein, 2500 calories 4. 150 grams of protein, 1200 calories
1 The signs and symptoms indicate hepatic coma; protein is reduced according to tolerance, and calories are increased to prevent tissue catabolism. 2 This represents a high-protein diet, which is contraindicated in impending hepatic coma. 3 This represents a high-protein diet, which is contraindicated in impending hepatic coma. 4 This represents a high-protein diet, which is contraindicated in impending hepatic coma.
A client with extensive gastric carcinoma is admitted to the hospital for an esophagojejunostomy. What information should the nurse include in the teaching plan when preparing this client for surgery? 1. Chest tube will be in place immediately after surgery 2. Liquids by mouth may be permitted the evening after surgery 3. Complete bed rest may be necessary for two days after surgery 4. Trendelenburg's position will be used on the first day after surgery
1 The thoracic cavity usually is entered for a complete resection, necessitating a chest tube. 2 Fluids are contraindicated until the suture line has healed and nasogastric suction is no longer being used. 3 The client should ambulate early to minimize the hazards of immobility. 4 There is no physiological necessity for this position.
The characteristics that alert the nurse that a client is at increased risk of developing gallbladder disease is a female: 1. Older than the age of 40, obese 2. Younger than the age of 40, history of high fat intake 3. Older than the age of 40, low serum cholesterol level 4. Younger than the age of 40, family history of gallstones
1 These characteristics are well-established risk factors for gallbladder disease (3 Fs - female, fat, and forty). 2 Although these clients usually are older than the age of 40, a high-fat intake does not predispose one to cholecystitis. 3 The age is correct, but these clients have an increase in serum cholesterol. 4 Although there is an increased risk with a family history of gallstones, these clients usually are older than the age of 40.
A male client who has had recurring renal calculi has a ureterolithotomy. Before discharge the nurse discusses the need to avoid urinary tract infections (UTIs). The nurse evaluates that the signs and symptoms of infection are understood when the client says he will report: 1. Urgency or frequency of urination 2. The inability to maintain an erection 3. Pain radiating to the external genitalia 4. An increase in alkalinity or acidity of urine
1 These occur with a urinary tract infection because of bladder irritability; burning on urination and fever are additional signs of a UTI. 2 This is not related to a UTI. 3 This is a symptom of a urinary calculus, not infection. 4 This is not a sign of a UTI; this may be caused by altering the diet to include foods that form acid ash or alkaline ash.
A client with newly diagnosed diabetes indicates a hatred for asparagus, broccoli, and mushrooms. When reviewing the exchange list with the client, the nurse evaluates that the teaching about the exchange list is understood when the client states, "Instead of these foods I can eat: 1. string beans, beets, or carrots." 2. corn, lima beans, or dried peas." 3. baked beans, potatoes, or parsnips." 4. corn muffins, corn chips, or pretzels." (Nugent 32) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 These vegetables are in the vegetable exchange, as are asparagus, broccoli, and mushrooms. 2 These are starchy vegetables and are listed as bread exchanges. 3 These are starchy vegetables and are listed as bread exchanges. 4 These foods are from the bread exchange list. (Nugent 114) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially this causes: 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis (Nugent 21) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
1 This occurs during the progressive stage of shock as a result of accumulated lactic acid. 2 Metabolic alkalosis cannot occur with the buildup of lactic acid. 3 Eventually this can result from decreased respiratory function in late shock, further compounding metabolic acidosis. 4 This may occur as a result of hyperventilation during early shock. (Nugent 101) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
When preparing a client for a liver biopsy, the nurse explains that during the test the client will be placed: 1. In the supine position, with the right arm raised behind the head 2. On the right side, with the left arm stretched up and over the head 3. On the left side, with the right arm extended out in front across the bed 4. In the prone position, with both elbows flexed and the hands resting on the pillow
1 This position exposes the right intercostal space, making the large right lobe of the liver accessible. 2 This position will not provide accessibility to the liver; the small left lobe is not anatomically near the left chest wall. 3 In this position the liver will fall away from the chest wall and be less accessible. 4 This will not provide accessibility to the liver.
Resuscitation bag
A ________ should be available at the bedside for all clients receiving BiPAP ventilation
A client who has had a transurethral prostatectomy (TURP) experiences dribbling after the indwelling catheter is removed. To address this problem, the nurse should state: 1. "Increase your fluid intake and urinate at regular intervals." 2. "I know you're worried, but it will go away in a few days." 3. "Limit your fluid intake and urinate when you first feel the urge." 4. "The catheter will have to be reinserted until your bladder regains its tone."
1 This will improve bladder tone, which should alleviate dribbling. 2 This identifies feelings but does not actively help the client solve the problem. 3 These interventions do not increase bladder tone; fluids should be increased and the time between voidings should be increased gradually. 4 Continuous bladder decompression will reduce bladder tone; reduced bladder tone will persist when the indwelling catheter is removed until bladder tone improves.
A client is cautioned to avoid vitamin D toxicity while increasing protein intake. The nurse evaluates that dietary teaching is understood when the client states, "I must increase my intake of: 1. tofu products." 2. eggnog with fruit." 3. powdered whole milk." 4. cottage cheese custard."
1 Tofu products increase protein without increasing vitamin D because, unlike milk products, tofu does not contain vitamin D. 2 Eggnog contains milk, which has vitamin D, and should be avoided. 3 This contains vitamin D and should be avoided. 4 This contains milk, which has vitamin D, and should be avoided.
A client who is diagnosed with a duodenal ulcer asks, "Now that I have an ulcer, what comes next?" The nurse's best response is: 1. "Most peptic ulcers heal with medical treatment." 2. "Clients with peptic ulcers have pain while eating." 3. "Early surgery is advisable, especially after the first attack." 4. "If ulcers are untreated, cancer of the stomach can develop."
1 Treatment with medications, rest, diet, and stress reduction relieves symptoms, heals the ulcer, and prevents complications and recurrence. 2 Pain occurs 30 minutes to 1 hour after a meal. 3 Surgery may be done after multiple recurrences and for treating complications. 4 Perforation, pyloric obstruction, and hemorrhage, not cancer, are major complications.
After abdominal surgery a client returns to the unit with a nasogastric tube to decompression. The practitioner orders an antiemetic every 6 hours prn for nausea. When the client complains of nausea, the first action by the nurse is to: 1. Check for placement of the tube 2. Administer the ordered antiemetic 3. Irrigate the tube with normal saline 4. Notify the practitioner of the problem
1 With a nasogastric tube for decompression in place, nausea may indicate tube displacement or obstruction. Checking placement can determine whether it is in the stomach; once placement is verified, then fluid can be instilled to ensure patency. 2 The antiemetic may relieve the discomfort, but will not determine the cause. 3 If the tube is displaced it may be in the trachea or bronchi and instillation of fluid will cause respiratory impairment before placement is confirmed. 4 The nurse should always assess a situation carefully before notifying the practitioner.
Which parts of the nephron are the sites for the regulation of water balance? Select all that apply. 1 Loop of Henle 2 Descending limb (DL) 3 Proximal convoluted tubule (PCT) 4 Bowman capsule (BC) 5 Glomerulus
1, 2 A loop of Henle is a part of a nephron that continues from the proximal convoluted tubule (PCT). It is permeable to water, sodium chloride, and urea and is a site for the regulation of water balance. The descending limb (DL) continues from the loop of Henle. It is permeable to water, sodium chloride, and urea and is a site for the regulation of water balance. The glomerulus is a site of glomerular filtration. The Bowman capsule (BC) is a site of the collection of glomerular filtrate. The proximal convoluted tubule (PCT) is a site for the reabsorption of sodium, chloride, glucose, water, amino acids, potassium, and calcium.
845. A nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Select all instructions that the nurse would include on the list. 1. Keep the cast and extremity elevated. 2. The cast needs to be kept clean and dry. 3. Allow the wet cast 24 to 72 hours to dry. 4. Tingling and numbness in the extremity are expected. 5. Use a hair dryer set on a warm to hot setting to dry the cast. 6. Use a soft padded object that will fit under the cast to scratch the skin under the cast.
1, 2, 3 Rationale: A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity should be elevated to reduce edema if prescribed. A wet cast is handled with the palms of the hand until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat cannot be used on a plaster cast because the cast heats up and burns the skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment, such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The physician is notified immediately if circulatory impairment occurs.
854. In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? Select all that apply. 1. Symptom control during periods of emotional stress 2. Normal white blood cell, platelet, and neutrophil counts 3. Radiological findings that show no progression of joint degeneration 4. An increased range of motion in the affected joints 3 months into therapy 5. Inflammation and irritation at the injection site 3 days after the injection is given 6. A low-grade temperature on rising in the morning that remains throughout the day
1, 2, 3, 4 Rationale: Because emotional stress frequently exacerbates the symptoms of rheumatoid arthritis, the absence of symptoms is a positive finding. DMARDs are given to slow the progression of joint degeneration. In addition, the improvement in the range of motion after 3 months of therapy with normal blood work is a positive finding. Temperature elevation and inflammation and irritation at the medication injection site could indicate signs of infection.
What are the general manifestations associated with clients who have urinary system disorders? Select all that apply. 1 Nausea and vomiting 2 Facial edema 3 Excessive thirst 4 Elevated blood pressure 5 Stress incontinence
1,3,4 The general manifestations associated with urinary system disorders include excessive thirst, nausea and vomiting, and elevated blood pressure. The specific manifestations associated with urinary system disorders include facial edema and stress incontinence.
388. A practitioner orders three stool specimens for occult blood for a client who complains of blood-streaked stools and a 10-pound weight loss in 1 month. To ensure valid test results, the nurse should instruct the client to: 1. Avoid eating red meat before testing 2. Test the specimen while it is still warm 3. Discard the day's first stool and use the next three stools 4. Take three specimens from different sections of the fecal sample
1. Red meat can react with reagents used in the test to cause false-positive results.
A client is diagnosed with condyloma acuminatum. Which finding in the client supports the diagnosis? 1 Moist, fleshy projections on the penis 2 Pus-filled ulcers on the penis 3 Swollen penis with tight foreskin 4 Macules on the penis
1...Moist, fleshy projections on the penis with single or multiple projections is a clinical manifestation of condyloma acuminatum. Macules on the penis or scrotum are clinical manifestations of penile erythema. Chancroid is manifested by pus-filled ulcers on the penis. A swollen penis with tight foreskin is a clinical manifestation of paraphimosis.
148. Which area should the nurse examine to look for jaundice in a person with a dark complexion? A. Nailbeds. B. Palms of hands. C. Hard palate. D. Soles of feet.
148. C. Hard palate Jaundice, in persons of various skin colors, can be readily viewed by examining the hard palate of the mouth with the aid of a flashlight. A is incorrect since some persons have naturally yellow, discolored nailbeds or very dark nailbeds, which prevents observation of color change. B and D are incorrect because the do not represent the best site for observing jaundice in dark-skinned persons. Some people have a yellow coloration to their skin because of ethnic background or sun exposure. Others may have such dark skin that jaundice is not clearly visible in these areas.
831. A nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which of the following findings? 1. Inflammation 2. Serous drainage 3. Pain at a pin site 4. Purulent drainage
2 Rationale: A small amount of serous oozing is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported to the physician.
848. Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be used with caution in which of the following disorders? 1. Myxedema 2. Renal failure 3. Hypothyroidism 4. Diabetes mellitus
2 Rationale: Colchicine is used with caution in older clients, debilitated clients, and clients with cardiac, renal, or gastrointestinal disease. The disorders in options 1, 3, and 4 are not concerns with administration of this medication.
837. A nurse has given a client instructions about crutch safety. The nurse determines that the client needs reinforcement of information if the client states: 1. That he or she will not use someone else's crutches 2. That crutch tips will not slip even when wet 3. The need to have spare crutches and tips available 4. That crutch tips should be inspected periodically for wear
2 Rationale: Crutch tips should remain dry. Water could cause the client to slip by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed.
836. A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse's response is based on the understanding that this could most likely result in: 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates
2 Rationale: Crutches are measured so that the tops are two to three fingerwidths from the axillae. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus.
844. A nurse is caring for a client with a diagnosis of gout. Which of the following laboratory values would the nurse expect to note in the client? 1. Calcium level of 9.0 mg/dL 2. Uric acid level of 8.6 mg/dL 3. Potassium level of 4.1 mEq/L 4. Phosphorus level of 3.1 mg/dL
2 Rationale: In addition to the presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia, with a uric acid level higher than 8 mg/dL; a normal value ranges from 2.5 to 8 mg/dL. Options 1, 3, and 4 indicate normal laboratory values. Additionally, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis.
842. A client is complaining of low back pain that radiates down the left posterior thigh. The nurse further assesses the client to see if the pain is worsened or aggravated by: 1. Bed rest 2. Bending or lifting 3. Ibuprofen (Motrin) 4. Application of heat
2 Rationale: Low back pain that radiates into one leg (sciatica) is consistent with herniated lumbar disk. The nurse assesses the client to see whether the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the leg straight up while supine (straight leg-raising test).
A male client reports dysuria, nocturia, and difficulty starting the urinary stream. A cystoscopy and biopsy of the prostate gland have been scheduled. After the procedure the client reports an inability to void. Which action should the nurse take? 1 Insert a urinary retention catheter. 2 Palpate above the pubic symphysis. 3 Assure the client that this is expected. 4 Limit oral fluids until the client voids.
2 A full bladder is palpable with urinary retention and distention, which are common problems after a cystoscopy because of urethral edema. More conservative nursing methods, such as running water or placing a warm cloth over the perineum, should be attempted to precipitate voiding; catheterization carries a risk of infection and is used as the last resort. Fluids dilute the urine and reduce the chance of infection after cystoscopy and should not be limited. Although urinary retention can occur, it is not expected; the nurse must assess the extent of bladder distention and discomfort.
A client has a permanent colostomy. During the first 24 hours there is no drainage from the colostomy. How should the nurse interpret this finding? 1 Effective functioning of the nasogastric tube is causing this. 2 Absence of intestinal peristalsis is causing this. 3 Edema after the surgery is causing this. 4 Decrease in fluid intake before surgery is causing this.
2 Absence of peristalsis is caused by manipulation of abdominal contents and the depressant effects of anesthetics and analgesics. Edema will not interfere with peristalsis; edema may cause peristalsis to be less effective, but some output will result. An absence of fiber has a greater effect on decreasing peristalsis than does decreasing fluids. A nasogastric tube decompresses the stomach; it does not cause cessation of peristalsis.
A nurse is assessing the urine of a client with a urinary tract infection. For which characteristic should the nurse assess each specimen of urine? 1 Viscosity 2 Clarity 3 Specific gravity 4 Glucose level Cloudy urine usually indicates drainage associated with infection. Viscosity is a characteristic that is not measurable in urine. Urinary glucose levels are not affected by urinary tract infections. Specific gravity yields information related to fluid balance.
2 Cloudy urine usually indicates drainage associated with infection. Viscosity is a characteristic that is not measurable in urine. Urinary glucose levels are not affected by urinary tract infections. Specific gravity yields information related to fluid balance.
A nurse is concerned about the public health implications of gonorrhea diagnosed in a 16-year-old adolescent. Which should be of most concern to the nurse? 1 Interviewing the client's parents 2 Finding the client's sexual contacts 3 Instructing the client about birth control measures 4 Determining the reasons for the client's promiscuity
2 Gonorrhea is a highly contagious disease transmitted through sexual intercourse. The incubation period varies, but symptoms usually occur 2 to 10 days after contact. Early effective treatment prevents complications such as sterility. The parents may be unaware that their child has gonorrhea. Most birth control measures do not protect against the transmission of sexually transmitted infections. Contracting venereal infection is not necessarily indicative of promiscuity.
A client is admitted to the hospital from the emergency department with a diagnosis of urolithiasis. The nurse reviews the client's clinical record and performs an admission assessment. Which is the priority nursing action? 1 Collect a urine specimen for culture and sensitivity. 2 Administer the prescribed morphine. 3 Strain the client's urine. 4 Place the client in the high-Fowler position.
2 Pain relief is the priority. Clients report that ureteral colic is excruciatingly painful. Once pain is under control and the client is comfortable, other medical and nursing interventions can be implemented. Although straining all urine is required, pain relief is the priority. Once the client is medicated for pain, the urine that was set aside can be strained. The high-Fowler position is not necessary. The client can be assisted to assume a position of comfort. The urine was sent for a culture and sensitivity in the emergency department.
The registered nurse is preparing to assess a client's renal system. Which statement by the nurse indicates effective technique? 1 "I must first palpate the client if a tumor is suspected." 2 "I must first auscultate the client and then proceed to percussion and palpation." 3 "I must first listen for normal pulse at the client's wrist region." 4 "I must first examine tender abdominal areas and then proceed to nontender areas."
2 Palpation and percussion can cause an increase in normal bowel sounds and hide abdominal vascular sounds. Therefore it is wise to perform auscultation prior to percussion and palpation during clinical assessment of the renal system. Palpation should be avoided if a client is suspected of having a tumor because it could harm the client. It is more important as part of clinical assessment of the renal system to listen for bruit by auscultating over the renal artery. Bruit indicates renal artery stenosis. The nontender areas should be examined prior to tender areas to avoid confusion regarding radiating pain from the tender area being percussed.
A nurse is notified that the latest potassium level for a client in acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action should the nurse take first? 1 Call the laboratory to repeat the test. 2 Take vital signs and notify the primary healthcare provider. 3 Obtain an electrocardiogram (ECG) strip and obtain an antiarrhythmic medication. 4 Alert the cardiac arrest team.
2 Vital signs monitor the cardiopulmonary status; the primary healthcare provider must treat this hyperkalemia [1] [2] to prevent cardiac dysrhythmias. The cardiac arrest team responds to a cardiac arrest; there is no sign of arrest in this client. A repeat laboratory test will take time and probably reaffirm the original results; the client needs medical attention. Although obtaining an ECG strip is appropriate, obtaining an antiarrhythmic is premature; vital signs and medical attention is needed first.
During a yearly physical examination a complete blood count (CBC) is performed to determine a client's hematologic status. It is composed of several tests, one of which is the level of: 1. Blood glucose 2. Hemoglobin (Hb) 3. C-reactive protein 4. Blood urea nitrogen (BUN) (Nugent 17-18) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 A complete blood count (CBC) includes red blood cell (RBC) count and RBC indices, white blood cell (WBC) count and WBC differential count, hemoglobin (Hb), hematocrit (Hct), and platelet count. 1 A blood glucose level is not part of a CBC. 3 The C-reactive protein level is not part of a CBC. 4 Blood urea nitrogen (BUN) is not part of a CBC. (Nugent 97) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client with Hodgkin's disease enters a remission period and remains symptom-free for 6 months when a relapse occurs. The client is diagnosed at stage IV. The therapy option the nurse expects to be implemented at this time is: 1. Radiation therapy 2. Combination chemotherapy 3. Radiation with chemotherapy 4. Surgical removal of the affected nodes (Nugent 18) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 A protocol consisting of three or four chemotherapeutic agents that attack the dividing cells at various phases of development is the therapy of choice at this stage; alternating courses of different protocols generally are used. 1 Radiation, alone or in combination with chemotherapy, is used in stages IA, IB, IIA, IIB, and IIIA. 3 This is recommended for use in stage IIIA. 4 This is not a therapy for Hodgkin's disease at any stage. The nodes may be removed for biopsy or irradiated as part of therapy. (Nugent 98) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
In the early postoperative period after a transurethral resection of the prostate, the most common complication the nurse should monitor for is: 1. Sepsis 2. Hemorrhage 3. Leakage around the catheter 4. Urinary retention with overflow
2 After transurethral surgery, hemorrhage can occur because of venous oozing and bleeding from many small arteries in the area. 1 Sepsis is unusual and occurs later in the postoperative course. 3 Leaking around the catheter is not a major complication. 4 Urinary retention is unlikely with an indwelling catheter in place.
A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis? 1. Blood glucose 2. Serum amylase 3. Serum bilirubin level 4. White blood cell count
2 Amylase concentration is increased in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed; this distinguishes pancreatitis from other acute abdominal problems. 1 An elevated blood glucose level is not indicative of pancreatitis, but rather diabetes mellitus; however, hyperglycemia and glycosuria may occur in some people with acute pancreatitis if the islets of Langerhans are affected. 3 This occurs in other disease processes, such as cholecystitis. 4 This is not specific to pancreatitis; white blood cells are elevated in other disease processes.
When discussing future meal plans with a client who has a hiatal hernia, the nurse asks what beverages the client usually enjoys. The beverage that should be included in the diet when the client is discharged is: 1. Ginger ale 2. Apple juice 3. Orange juice 4. Cola beverages
2 Apple juice is not irritating to the gastric mucosa. 1 Carbonated beverages distend the stomach and promote regurgitation. 3 The acidity of orange juice aggravates the disorder. 4 Most colas should be avoided because they contain caffeine, which causes increased acidity and aggravates the disorder; also they are carbonated, which distends the stomach and promotes regurgitation.
Immediately after a subtotal gastrectomy a client is brought to the postanesthesia care unit. The nurse identifies small blood clots in the gastric drainage. The nurse should: 1. Clamp the tube 2. Consider this an expected event 3. Instill the tube with iced normal saline 4. Notify the client's surgeon of this finding
2 As a result of the trauma of surgery, some bleeding can be expected for 4 to 5 hours. 1 Clamping the tube will cause increased pressure on the gastric sutures from a buildup of gas and fluid. 3 Iced saline rarely is used because it causes vasoconstriction, local ischemia, and a reduction in body temperature. 4 This is not necessary; this is an expected occurrence.
A young woman is admitted to the oncology unit with a diagnosis of Hodgkin's disease. Staging is done and the client's spleen is found to be grossly involved, and it is surgically removed. A complication specifically related to a splenectomy for which the nurse should monitor the client is: 1. Pulmonary embolism 2. Inadequate lung aeration 3. Hypoactive bowel sounds 4. Postoperative hemorrhage (Nugent 18) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 Because of the location of the spleen, postoperative pain will cause splinting and shallow breathing and underaeration of the lung's left lower lobe. 1 This is true of any abdominal surgery and is not specific to a splenectomy. 3 This is true of any abdominal surgery and is not specific to a splenectomy. 4 This is true of any abdominal surgery and is not specific to a splenectomy. (Nugent 98) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
When assessing for hemorrhage after a client has a total hip replacement, the most important nursing action is to: 1. Measure the girth of the thigh 2. Examine the bedding under the client 3. Check the vital signs every four hours 4. Observe for ecchymosis at the operative site (Nugent 20) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 Because of the recumbent position, drainage may flow by gravity under the client and not be noticed unless the bedding is examined. 1 This assessment is inaccurate when there is a dressing in place. 3 In the immediate postoperative period, vital signs should be taken more frequently than every 4 hours; in addition, observation of the site is a more reliable indicator of hemorrhage. 4 Dressings impede an accurate assessment of the site for ecchymosis. (Nugent 100) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Immediately after esophageal surgery the priority nursing assessment concerns the client's: 1. Incision 2. Respirations 3. Level of pain 4. Nasogastric tube
2 Because of the trauma of surgery and the proximity of the esophagus to the trachea, respiratory assessments become the priority. 1 Although this is important, an adequate airway is the priority. 3 Although this is important, an adequate airway is the priority. 4 Although this is important, an adequate airway is the priority
After a suprapubic prostatectomy, a client's plan of care must include the prevention of postoperative deep vein thrombosis. This is best achieved by increasing the: 1. Coagulability of the blood 2. Velocity of the venous return 3. Effectiveness of internal respiration 4. Oxygen-carrying capacity of the blood
2 Because venous stasis is the major predisposing factor of pulmonary emboli, venous flow velocity should be increased through activity. 1 Increasing the coagulability of the blood can lead to the development of deep vein thrombosis. 3 This will not affect the prevention of deep vein thrombosis. 4 This will not affect the prevention of deep vein thrombosis.
After receiving 75 mL of packed red blood cells, the client complains of chills and low back pain. The nurse suspects a hemolytic transfusion reaction and stops the infusion. The blood bag and a urine specimen are sent to the laboratory. The reason for sending a urine specimen to the laboratory is to test for: 1. Specific gravity 2. Free hemoglobin 3. Carboxyhemoglobin 4. Disseminated intravascular coagulation (Nugent 20) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 Blood incompatibility causes lysis of red blood cells with the result that hemoglobin is freed into the circulation; if a sufficient (100 mL or more) amount of incompatible blood is transfused, permanent renal damage can occur. Chills and low back pain indicate kidney involvement. 1 Specific gravity need not be determined. 3 Carboxyhemoglobin need not be determined. 4 Disseminated intravascular coagulation (DIC) is an intravascular clotting disorder that does not occur with a transfusion reaction. (Nugent 100) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
When assessing a client who had abdominal surgery, the nurse determines that peristalsis has returned when the client first: 1. Passes flatus 2. Has bowel sounds 3. Tolerates clear liquids 4. Has a bowel movement
2 Bowel sounds are the result of peristaltic movements that propel intestinal contents through the alimentary tract, causing characteristic sounds. 1 Bowel sounds will be heard before flatus is passed. 3 Liquids should not be given until bowel sounds have returned. 4 Peristalsis will return before the client has a bowel movement.
A female client is admitted to the hospital with severe renal colic caused by a ureteral calculus. Later that evening the client's urinary output is much less than her intake. When it is confirmed that her bladder is not distended, the nurse should suspect the development of: 1. Oliguria 2. Hydroureter 3. Renal shutdown 4. Urethral obstruction
2 Calculi may obstruct the flow of urine to the bladder, allowing the urine to distend the ureter, causing hydroureter. 1 There is insufficient information to come to this conclusion even though output is less than intake; oliguria is present when the output is between 100 and 500 mL in a 24-hour period. 3 Calculi do not cause renal shutdown directly; they may obstruct the urinary tract and cause damage indirectly as a result of pressure from urine buildup. 4 If the urethra is obstructed, the bladder will be distended.
Routine postoperative intravenous fluids are designed to supply hydration and electrolytes and only limited energy. Because 1 L of a 5% dextrose solution contains 50 grams of sugar, 3 L/day will supply approximately: 1. 400 kilocalories 2. 600 kilocalories 3. 800 kilocalories 4. 1000 kilocalories
2 Carbohydrates provide 4 kcal/g; therefore, 3 L × 50 g/L × 4 kcal/g = 600 kcal, only about a third of the basal energy need. 1 This is less than the kilocalories provided by the ordered IV fluid. 3 This is more than the kilocalories provided by the ordered IV fluid. 4 This is more than the kilocalories provided by the ordered IV fluid.
A client complains of urinary problems. Cholinergic medications are prescribed. Which condition is treated with cholinergic medications? 1. Kidney stones 2. Flaccid bladder 3. Spastic bladder 4. Urinary tract infections
2 Cholinergics intensify and prolong the action of acetylcholine, which increases the tone in the genitourinary tract, preventing urinary retention. 1 Cholinergics will not prevent renal calculi. 3 Anticholinergics are prescribed for the frequency and urgency associated with a spastic bladder. 4 Preventing urinary tract infections is a secondary gain because cholinergics help prevent urinary retention that can lead to a urinary tract infection, but this is not the primary purpose for administering these drugs.
A client with jaundice associated with hepatitis expresses concern over the change in skin color. The nurse explains that this color change is a result of: 1. Stimulation of the liver to produce an excess quantity of bile pigments 2. Inability of the liver to remove normal amounts of bilirubin from the blood 3. Increased destruction of red blood cells during the acute phase of the disease 4. Decreased prothrombin levels, leading to multiple sites of intradermal bleeding
2 Damage to liver cells affects the ability to facilitate removal of bilirubin from the blood, with resulting deposition in the skin and sclera. 1 With hepatitis, the liver does not secrete excess bile. 3 Destruction of red blood cells does not increase in hepatitis. 4 Decreased prothrombin levels cause spontaneous bleeding, not jaundice.
A 40-year-old client is admitted with biliary cancer. The associated jaundice gets progressively worse. The nurse is most concerned about the potential complication of: 1. Pruritus 2. Bleeding 3. Flatulence 4. Hypokalemia
2 Obstruction of bile flow impairs absorption of vitamin K, a fat-soluable vitamin; prothrombin is not produced and the clotting process is prolonged. 1 Although deposition of bile salts in the skin may lead to pruritus, this is not life threatening. 3 Although there may be an increase in flatulence with biliary disease, it is not life threatening. 4 Obstructive jaundice does not affect potassium levels.
A client has been receiving hemodialysis for several months. The nurse considers that bleeding into the GI tract is of particular significance to a client with chronic kidney disease because: 1. Hypovolemia can compromise kidney function 2. Blood is digested thereby increasing the kidneys' protein load 3. Clotting problems in kidney disease make diagnosis of the bleeding site difficult 4. Usual signs of blood loss will not be manifested in the client with kidney failure
2 Digested blood is protein which will increase the BUN. 1 Kidney function already is compromised; dialysis performs the function of the kidneys. 3 Although clients with chronic kidney disease have problems with bleeding, this does not interfere with identifying the site of bleeding. 4 Chronic kidney disease does not affect the signs of GI blood loss, hemorrhage, or shock
The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HIV). The discussion reveals that there is no risk of exposure to HIV when an individual: 1. Has intercourse with just the spouse 2. Makes a donation of a pint of whole blood 3. Uses a condom each time there is sexual intercourse 4. Limits sexual contact to those without HIV antibodies (Nugent 18) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 Equipment used in blood donation is disposable; the donor does not come into contact with anyone else's blood. 1 The risk depends on the spouse's prior behavior. 3 Although condoms do offer protection, they are subject to failure because of condom rupture or improper use; risks of infection are present with any sexual contact. 4 An individual may be infected before testing positive for the antibodies; the individual can still transmit the virus. (Nugent 97) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A 45-year-old client develops acute glomerulonephritis after a recent streptococcal infection. Which sign or symptom should the nurse expect the client to report? 1. Nocturia 2. Mild headache 3. Increased appetite 4. Recent weight loss
2 Headaches occur because of the retention of fluid and hypertension. 1 The client will experience oliguria, not nocturia. 3 The client will develop anorexia related to elevated toxic substances in the blood. 4 The client will have a weight gain because of the retention of fluid.
A client with chronic kidney disease is on a restricted protein diet and is taught about high-biologic-value protein foods. An understanding of the rationale for this diet is demonstrated when the client states that high-biologic-value protein foods are: 1. Needed to promote weight gain 2. Necessary to prevent muscle wasting 3. Used to increase urea blood products 4. Responsible for controlling hypertension
2 High-biologic-value (HBV) protein contains essential amino acids needed by the body for tissue building and repair; HBV proteins limit the extent of nitrogenous wastes. 1 A high-calorie diet provides for weight gain. 3 The purpose of a diet for a client with chronic kidney disease is to decrease, not increase, nitrogenous wastes. 4 This is not the purpose of HBV proteins; sodium restriction decreases blood pressure.
A client with an ileal conduit is being prepared for discharge. Before discharge the nurse instructs the client to: 1. Abstain from beer and alcohol consumption 2. Maintain fluid intake of at least two liters daily 3. Notify the practitioner if the stoma size decreases 4. Avoid getting soap and water on the peristomal skin
2 High-fluid intake flushes the ileal conduit and prevents infection and obstruction caused by mucus or uric acid crystals. 1 Alcohol is not contraindicated with an ileal conduit. 3 This is expected; as edema decreases, the stoma will become smaller. 4 Soap and water on the peristomal area help prevent irritation from waste products.
A client receiving chemotherapy and a steroid has a white blood cell count of 12,000/mm3 and a red blood cell count of 4.5 million/mm3. What is the priority instruction that the nurse should teach the client is? 1. Omit the daily dose of prednisone 2. Avoid large crowds and persons with infections 3. Shave with an electric rather than a safety razor 4. Increase the intake of high-protein foods and red meats (Nugent 18-19) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 Moderate leukopenia increases the risk of infection; the client should be taught protective measures. 1 Leukopenia is a side effect of cyclophosphamide (Cytoxan), not prednisone. 3 The platelet count is not given, so bleeding precautions are not indicated. 4 These are measures to correct anemia; protection from infection takes priority. (Nugent 98) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
After multiple bee stings a client has an anaphylactic reaction. The nurse determines that the symptoms the client is experiencing are caused by: 1. Respiratory depression and cardiac arrest 2. Bronchial constriction and decreased peripheral resistance 3. Decreased cardiac output and dilation of major blood vessels 4. Constriction of capillaries and decreased peripheral circulation (Nugent 20) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 Hypersensitivity to a foreign substance can cause an anaphylactic reaction; histamine is released, causing bronchial constriction, increased capillary permeability, and dilation of arterioles; this decreased peripheral resistance is associated with hypotension and inadequate circulation to major organs. 1 These are the problems that result from bronchial constriction and vascular collapse. 3 Dilation of arterioles occurs. 4 Arterioles dilate, capillary permeability increases, and eventually vascular collapse occurs. (Nugent 100) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Immediately after a subtotal thyroidectomy the nurse plans to assess a female client for unilateral injury of the laryngeal nerve every 30 to 60 minutes by: 1. Checking the throat for edema 2. Asking her to state her name out loud 3. Eliciting spasms of her facial muscles 4. Palpating the neck for seepage of blood (Nugent 30) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 If the laryngeal nerve is damaged during surgery, the client will be hoarse and have difficulty speaking. 1 This does not indicate injury to the laryngeal nerve; this is part of the assessment for a compromised airway. 3 Eliciting the Chvostek sign assesses for hypocalcemia resulting from inadvertent removal of the parathyroid glands. 4 This assesses for bleeding and possible hemorrhage, not laryngeal nerve injury. (Nugent 112) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
The nurse is caring for a client with acute renal failure. The most serious complication for this client is: 1. Anemia 2. Infection 3. Weight loss 4. Platelet dysfunction
2 Infection is responsible for one third of the traumatic or surgically induced deaths of clients with acute renal failure, as well as for medically induced acute renal failure. Resistance is reduced in clients with kidneys that fail because of decreased phagocytosis, which makes them susceptible to microorganisms. 1 Anemia occurs often with acute renal failure, but it is not the most serious complication and should be treated in relation to the client's adaptations; erythropoietin and iron supplements usually are prescribed. 3 Weight loss is not life threatening. 4 Platelet dysfunction occurs because of decreased cell surface adhesiveness, but it is not as serious as an infection.
Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of bloody drainage from the client's nasogastric tube. The nurse should: 1. Clamp the tube and call the surgeon immediately 2. Report the characteristics of drainage to the surgeon 3. Instill 30 mL of iced normal saline into the nasogastric tube 4. Continue to monitor the drainage and record the observations
2 Large amounts of blood or excessive bloody drainage 12 hours postoperatively must be reported immediately because the client is hemorrhaging. 1 Clamping the tube is contraindicated; accumulation of secretions causes pressure on the suture line, preventing further observation of drainage. 3 This must be ordered by the practitioner; 50 to 100 mL of normal saline at room temperature instilled every 30 to 50 minutes is the usual therapy to prevent lowering the core body temperature. 4 This is an unsafe intervention at this time; the surgeon should be notified
A client with colitis inquires as to whether surgery will eventually be necessary. When teaching about the disease and its treatment, the nurse should emphasize that: 1. Medical treatment for colitis is curative; surgery is not required 2. Surgery for colitis is considered only as a last resort for most clients 3. Surgery for colitis is done early in the course of the disorder for most clients 4. Medical treatment is all that will be needed if the client can acquire some emotional stability
2 Medical treatment is directed toward reducing motility of the inflamed bowel, restoring nutrition, and preventing and treating infection; surgery is used selectively for those who are acutely ill or have excessive exacerbations. 1 This is untrue; medical treatment is symptomatic, not curative. 3 It is usually performed as a last resort. 4 Although there is an emotional component, the physiological adaptations determine whether surgery is necessary.
A client is suspected of having a gastric peptic ulcer. When obtaining a history from this client, the nurse expects the reported pain to: 1. Intensify when the client vomits 2. Occur one to three hours after meals 3. Increase when the client eats fatty foods 4. Begin in the epigastrium, radiating across the abdomen
2 Pain occurs after the stomach empties with a gastric peptic ulcer; ingesting food stimulates gastric secretions, which later act on the gastric mucosa of the empty stomach, causing the gnawing pain. 1 Vomiting temporarily alleviates pain because acid secretions are eliminated from the body. 3 There is no intolerance of fats; eating generally alleviates gastric peptic pain. 4 Gastric pain is sharply localized in the epigastrium; it can radiate across the abdomen if a gastric peptic ulcer perforates.
A client has emergency surgery for a ruptured appendix. After determining that the client is manifesting signs and symptoms of shock, the nurse should: 1. Prepare for a blood transfusion 2. Notify the practitioner immediately 3. Elevate the head of the bed thirty degrees 4. Increase the liter flow of oxygen being administered (Nugent 21) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 Peritonitis and shock are potentially life-threatening complications following abdominal surgery; prompt, rigorous treatment is necessary. 1 Fluids, not blood, are needed to expand and maintain the circulating blood volume. 3 The head of the bed should be flat to increase tissue perfusion and oxygenation to the vital organs. 4 The practitioner should be notified; the client is already receiving oxygen and the problem still exists. (Nugent 101) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
In addition to Pneumocystis jiroveci, a client with AIDS also has an ulcer 4 cm in diameter on the leg. Considering the client's total health status, the most critical concern is: 1. Skin integrity 2. Gas exchange 3. Social isolation 4. Nutritional status (Nugent 18) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 Pneumocystis jiroveci, now believed to be a fungus, causes pneumonia in immunosuppressed hosts; it can cause death in 60% of the clients. The client's respiratory status is the priority. 1 Although this is a concern, the client's respiratory status is the priority. 3 Although this is a concern, the client's respiratory status is the priority. 4 Although this is a concern, the client's respiratory status is the priority. (Nugent 98) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
The serum potassium level of a client who has diabetic ketoacidosis is 5.4 mEq/L. When monitoring the ECG tracing, the nurse expects to observe: 1. Abnormal P waves and depressed T waves 2. Peaked T waves and widened QRS complexes 3. Abnormal Q waves and prolonged ST segments 4. Peaked P waves and an increased number of T waves (Nugent 32) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 Potassium is the principal intracellular cation, and during ketoacidosis it moves out of cells into the extracellular compartment to replace potassium lost as a result of glucose-induced osmotic diuresis; overstimulation of the cardiac muscle results. 1 P waves are abnormal because the PR interval may be prolonged and the P wave may be lost; however, the T wave is peaked, not depressed. The T wave is depressed in hypokalemia. 3 Initially, the QT segment is short, and as the potassium level rises, the QRS complex widens. The ST segment becomes depressed. 4 The PR interval is prolonged, and the P wave may be lost. QRS complexes and thus T waves become irregular, and the rate does not necessarily change. (Nugent 114) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Diet instruction for a client who is being treated with continuous ambulatory peritoneal dialysis (CAPD) for chronic glomerulonephritis includes the need for: 1. Low-calorie foods 2. High-quality protein 3. Increased fluid intake 4. Foods rich in potassium
2 Proteins eaten should be high quality to replace those lost during dialysis. 1 A high-calorie diet is encouraged. 3 Usually there is a modest restriction of fluids when the client is on dialysis. 4 Usually there is a restriction of high-potassium foods when the client is on dialysis.
The laboratory values of a client with renal calculi reveal a serum calcium within expected limits and an elevated serum purine. The nurse concludes that the stone is probably composed of: 1. Cystine 2. Uric acid 3. Calcium oxalate 4. Magnesium ammonium phosphate
2 Purines are precursors of uric acid, which crystallizes. 1 Cystine stones are caused by a rare hereditary defect resulting in inadequate renal tubular reabsorption of cystine (inborn error of cystine metabolism). 3 Serum purine will not be elevated if the stone is composed of calcium oxalate. 4 A struvite stone is sometimes called a magnesium ammonium phosphate stone and is precipitated by recurrent urinary tract infections with coliform bacteria.
After revision of the pancreas because of cancer, total parenteral nutrition is instituted via a central venous infusion route. During the fourth hour of the infusion the client complains of nausea, fatigue, and a headache. The hourly urine output is twice the amount of the previous hour. The nurse should call the practitioner and: 1. Stop the infusion while covering the insertion site 2. Slow the infusion and check the serum glucose level 3. Prepare the client for immediate surgery for possible bowel obstruction 4. Increase fluids via a peripheral intravenous route and give analgesics for the headache
2 Rapid administration can cause glucose overload, leading to osmotic diuresis and dehydration; slowing the infusion decreases the possibility of glucose overload. 1 Stopping the flow will jeopardize the central line; this site is commonly covered by a transparent dressing to allow for assessment of the site. 3 Signs of bowel obstruction are not present. 4 The client's headache should disappear with oral fluid replacement; analgesics are not indicated.
A 62-year-old woman who has been on hemodialysis for several weeks asks the nurse what substances are being removed by the dialysis. The nurse informs the client that one of the substances passing through the membrane is: 1. RBCs 2. Sodium 3. Glucose 4. Bacteria
2 Sodium is an electrolyte that passes through the semipermeable membrane during hemodialysis. 1 These do not pass through the semipermeable membrane during hemodialysis. 3 This does not pass through the semipermeable membrane during hemodialysis. 4 These do not pass through the semipermeable membrane during hemodialysis.
A client has an exacerbation of systemic lupus erythematosus. The dosage of steroid medication is increased, and a home health care nurse is to provide health teaching. To reduce the frequency of exacerbations, the nurse teaches the client: 1. Basic principles of hygiene 2. Techniques to reduce stress 3. Measures to improve nutrition 4. Signs of an impending exacerbation (Nugent 19-20) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 Systemic lupus erythematosus is an autoimmune disorder and physical and emotional stresses have been identified as contributing factors to the occurrence of exacerbations. 1 Although this should be done, inadequate hygiene is not known to produce exacerbations. 3 Although this should be done, nutritional status is not significantly correlated to exacerbations. 4 Knowledge of the symptoms will not decrease the occurrence of exacerbations. (Nugent 100) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A male client with a history of chronic kidney disease is hospitalized. The nurse assesses the client for signs of related kidney insufficiency, which include: 1. Facial flushing 2. Edema and pruritus 3. Dribbling after voiding 4. Diminished force and caliber of stream
2 The accumulation of metabolic wastes in the blood (uremia) can cause pruritus; edema results from fluid overload caused by impaired urine production. 1 Pallor occurs with chronic kidney disease as a result of anemia. 3 This is a urinary pattern that is not caused by chronic kidney disease; this may occur after prostate surgery. 4 These occur with an enlarged prostate, not kidney disease.
When a nurse plans to teach a client with type 1 diabetes about the use of an insulin pump, it is of major importance that the client understand that the: 1. Insulin pump's needle should be changed every day 2. Pump is an attempt to mimic the way a healthy pancreas works 3. Pump will be implanted in a subcutaneous pocket near the abdomen 4. Insulin pump's advantage is that it requires glucose monitoring once a day (Nugent 32) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 The basal infusion rate mimics the low rate of insulin secretion during fasting, and the bolus before meals mimics the high output after meals. 1 The subcutaneous needle may be left in place for as long as 3 days. 3 Most insulin pumps are external to the body and access the body via a subcutaneous needle. 4 Blood glucose monitoring is done a minimum of 4 times a day. (Nugent 115) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
The wife of a client who has had a resection of an aldosterone-secreting tumor of an adrenal gland says, "I hope this is the end of the problem and that my husband will be back to work soon." Based on an understanding of the health problem, the nurse should: 1. Caution the wife about high expectations because the outcome for this problem is variable 2. Explain that surgery will effect a cure because the remaining adrenal gland will meet the body's needs 3. Advise the wife to investigate other occupational alternatives for her husband if he plans to return to work 4. Tell her that although her husband will require hormone supplements for the rest of his life, he should be able to work (Nugent 29) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 The body has two adrenal glands; an aldosteronoma is a unilateral tumor. 1 The prognosis usually is excellent; this is unnecessarily alarming. 3 This is unnecessary; the prognosis usually is excellent. 4 Hormones are not necessary; there is another adrenal gland that will secrete an adequate amount of hormones. (Nugent 110) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
After surgery for creation of an ileostomy, a client is to be discharged. Before discharge, the primary nursing intervention is to: 1. Coax the client into caring for the ileostomy alone 2. Evaluate the client's ability to care for the ileostomy 3. Ensure the client understands the dietary limitations that must be followed 4. Have the client change the dry sterile dressing on the incision without assistance
2 The client's feelings, knowledge, and skills concerning the ileostomy must be assessed before discharge. 1 People should not be pressured into performing self-care before they are physically and emotionally ready. 3 The diet is not limited; however, the client should be encouraged to eat a high-protein diet or a regular diet with supplemental protein; a high-fluid intake should be maintained. 4 Often the client no longer needs a dressing on the incision at the time of discharge; a collection pouch is used over the stoma.
When performing a peritoneal dialysis procedure, the nurse should: 1. Place the client in a side-lying position 2. Warm dialysate solution slightly before instillation 3. Infuse the dialysate solution slowly over several hours 4. Withhold the routine medications until after the procedure
2 The infusion should be warmed to body temperature to lessen abdominal discomfort and promote dilation of peritoneal vessels. 1 The side-lying position may restrict fluid inflow and prevent maximum urea clearance; the client should be placed in the semi-Fowler position. 3 The infusion of dialysate solution should take approximately 5 to 10 minutes. 4 Routine medications should not interfere with the infusion of dialysate solution.
An acute, life-threatening complication for which a nurse should assess a client in the early postoperative period after a radical nephrectomy for cancer of the kidney is: 1. Sepsis 2. Hemorrhage 3. Renal failure 4. Paralytic ileus
2 The kidney, an extremely vascular organ, receives a large percentage of the blood flow, and hemorrhage from the operative site can occur. 1 This may occur later in the postoperative period. 3 This may occur later in the postoperative period. 4 This can occur, but it is not life threatening.
An 80-year-old male client had surgery for a strangulated hernia. One hour after surgery his blood pressure drops from 134/80 to 114/76. Assessment reveals that he does not have postoperative bleeding. The nurse should: 1. Turn him onto his left side 2. Encourage him to move his legs 3. Call the practitioner immediately 4. Administer his prescribed pain medication
2 The lowered blood pressure may be caused by pooling of blood in peripheral vessels; moving the legs will aid venous return. 1 This will not increase the blood pressure; this intervention is used for pregnant women to move the gravid uterus off the vena cava, which increases placental perfusion. 3 This eventually may be done after performing the initial interventions and evaluating results. 4 Opioid analgesics may decrease the blood pressure further.
A client has recently been diagnosed with type 1 diabetes. A glucose tolerance test is ordered. The order reads, "Administer glucose 1g/kg." The client weighs 240 pounds. How much glucose should the nurse administer? 1. 100 grams 2. 109 grams 3. 115 grams 4. 118 grams (Nugent 31) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 The nurse must administer 109 grams of glucose. Solve the problem using ratio and proportion. 2.2 pounds equals 1 kilogram. 2402.2=x12.2=240x=109grams 1 This is an incorrect calculation. 3 This is an incorrect calculation. 4 This is an incorrect calculation. (Nugent 113) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A nurse evaluates that a client with diabetes understands the teaching about the treatment of hypoglycemia when the client says, "If I become hypoglycemic I should initially eat: 1. fruit juice and a lollipop." 2. sugar and a slice of bread." 3. chocolate candy and a banana." 4. peanut butter crackers and a glass of milk." (Nugent 33) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 The suggested treatment of hypoglycemia in a conscious client is a simple sugar (such as two packets of sugar), followed by a complex carbohydrate (such as a slice of bread), and finally a protein (such as milk); the simple sugar elevates the blood glucose level rapidly; the complex carbohydrates and protein produce a more sustained response. 1 These are fast-acting sugars, and neither of them will provide a sustained response. 3 The fat content of chocolate candy decreases the rate of absorption of glucose. 4 Neither of these is a fast-acting sugar; peanut butter crackers and milk can be used to maintain the glucose level after it is raised. (Nugent 115) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
On the second day after an abdominoperineal resection, the nurse anticipates that the colostomy stoma will appear: 1. Dry, pale pink, and flush with the skin 2. Moist, red, and raised above the skin surface 3. Dry, purple, and depressed below the skin surface 4. Moist, pink, flush with the skin, and painful when touched
2 The surface of a stoma is mucous membrane and should be dark pink to red, moist, and shiny; the stoma usually is raised beyond the skin surface. 1 The stoma should be moist, not dry; pale pink indicates a low hemoglobin level; although some stomas can be flush with the skin, a raised stoma is more common. 3 The stoma should be moist, not dry; purple indicates compromised circulation; a depressed stoma is retracted and unexpected. 4 Although the stoma should be moist and dark pink to red, it should not be painful; although some stomas can be flush with the skin, a raised stoma is more common.
A client is diagnosed with hyperthyroidism and surgery is scheduled because the client refuses ablation therapy. While awaiting the surgical date, the nurse plans to instruct the client to: 1. Consciously attempt to calm down 2. Eliminate coffee, tea, and cola from the diet 3. Keep the home warm and use an extra blanket at night 4. Schedule activities during the day to overcome lethargy (Nugent 30) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 These beverages contain caffeine, which may increase thyroid activity. 1 Hyperactivity is a physiological response; it is not under conscious control. 3 The increased metabolic rate associated with hyperthyroidism will make the client feel warm; a cool environment is needed. 4 Hyperactivity is a problem, and the client should be encouraged to rest. (Nugent 111-112) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client with AIDS and Cryptococcus pneumonia frequently is incontinent of feces and urine and produces copious sputum. When providing care for this client, the nurse's priority is to: 1. Wear goggles when suctioning the client's airway 2. Use gown, mask, and gloves when bathing the client 3. Use gloves to administer oral medications to the client 4. Wear a gown when assisting the client with the bedpan (Nugent 18) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 These items prevent contact with feces, sputum, or other body fluids during intimate body care. 1 Goggles alone are inadequate because the client is producing copious sputum. 3 Gloves are not necessary because touching body fluids when giving oral medication is not likely. 4 Gloves are necessary when assisting the client with a bedpan because the nurse may be exposed to the client's excreta. (Nugent 98) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A female college freshman visits the health center because she feels nervous, irritable, and extremely tired. She complains that, although she eats large amounts of food, she has frequent bouts of diarrhea and is losing weight. The nurse observes a fine hand tremor, an exaggerated reaction to external stimuli, and a wide-eyed expression. What laboratory tests may be ordered to determine the cause of these signs and symptoms? 1. PTT and PT 2. T3, T4, and TSH 3. VDRL and CBC 4. ACTH, ADH and CRF (Nugent 29) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 These tests provide a measure of thyroid hormone production; an increase is associated with the client's signs and symptoms. 1 Prothrombin time (PT) and partial thromboplastin time (PTT) assess blood coagulation. 3 The VDRL test is for syphilis; the CBC assesses the hematopoietic system. 4 Adrenocorticotropic hormone (ACTH) stimulates the synthesis and secretion of adrenal cortical hormones. Antidiuretic hormone (ADH) increases water reabsorption by the kidney. Corticotropin-releasing factor (CRF) triggers the release of ACTH. (Nugent 111) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
The diet ordered for a client permits 190 grams of carbohydrates, 90 grams of fat, and 100 grams of protein. The nurse calculates that this diet contains approximately how many calories? 1. 920 calories 2. 1970 calories 3. 2470 calories 4. 2970 calories
2 This diet contains approximately 1970 calories. There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein. 1 This is an incorrect calculation; this is too few calories. 3 This is an incorrect calculation; this is too many calories. 4 This is an incorrect calculation; this is too many calories.
The practitioner orders daily fasting blood glucose levels for a client with diabetes mellitus. The goal of treatment is that the client will have glucose levels within the range of: 1. 40 to 65 mg/dL of blood 2. 70 to 105 mg/dL of blood 3. 110 to 145 mg/dL of blood 4. 150 to 175 mg/dL of blood (Nugent 31) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
2 This is the expected range for blood glucose. 1 This range is indicative of hypoglycemia. 3 This range is indicative of hyperglycemia. 4 This range is indicative of hyperglycemia. (Nugent 113) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A 64-year-old client diagnosed with cancer of the bladder is scheduled for a total cystectomy and the formation of an ileal conduit. When assessing the client 8 hours after surgery, the nurse identifies all of the following findings. Which finding should be promptly reported? 1. Edematous stoma 2. Dusky-colored stoma 3. Absence of bowel sounds 4. Pink-tinged urinary drainage
2 This may denote a compromised blood supply to the stoma and impending necrosis. 1 This is expected in the early postoperative period after this surgery. 3 This is expected in the early postoperative period after this surgery. 4 Pink-tinged urine may be present in the immediate postoperative period.
The home health care nurse is teaching about peritoneal dialysis to a client who has just started the procedure. The client is informed that if drainage of dialysate from the peritoneal cavity ceases before the required amount has drained out, the client should: 1. Drink a glass of water 2. Turn from side to side 3. Deep breathe and cough 4. Periodically rotate and reposition the catheter
2 Turning from side to side will change the position of the catheter, thereby freeing the drainage holes, which may be obstructed. 1 Taking fluids into the gastrointestinal tract does not influence drainage of dialysate from the peritoneal cavity. 3 This improves pulmonary ventilation but does not improve flow of dialysate from the catheter. 4 The position of the catheter should be changed by the practitioner.
When caring for a client who had abdominal intestinal surgery, it is important for the nurse to consider that: 1. Rectal intubation will relieve vomiting 2. Air swallowing causes gastric distention 3. Preoperative enemas prevent a postoperative ileus 4. Clear liquids a day after surgery stimulate peristalsis
2 When anxious, in pain, or performing deep-breathing exercises, it is common for air to be swallowed, which can cause gastric distention. 1 A rectal tube does not relieve nausea and vomiting; it facilitates expulsion of gas and some secretions trapped in the large intestines because of lack of peristalsis. 3 Preoperative enemas are not given to prevent paralytic ileus postoperatively; they are given to cleanse the lower gastrointestinal tract, decreasing the possibility of peritoneal contamination. 4 Liquids are not given until some peristalsis has returned as evidenced by the presence of bowel sounds.
What are the functions of antidiuretic hormone (ADH)? Select all that apply. 1 Promoting the reabsorption of sodium in the distal convoluted tubule (DCT) 2 Increasing tubular permeability to water 3 Increasing arteriole constriction 4 Controlling calcium balance 5 Stimulating the bone marrow to make red blood cells
2, 3 Antidiuretic hormone (ADH), also known as vasopressin, is a hormone released from the posterior pituitary gland. ADH increases arteriole constriction and tubular permeability to water. Calcium balance is controlled by blood levels of calcitonin and the parathyroid hormone (PTH). Erythropoietin stimulates the bone marrow to make red blood cells. Aldosterone promotes the reabsorption of sodium in the distal convoluted tubule (DCT).
A nurse is caring for a client with a ureteral calculus. Which are the most important nursing actions? Select all that apply. 1 Limiting fluid intake at night 2 Administering the prescribed analgesic 3 Monitoring intake and output 4 Recording the client's blood pressure 5 Straining the urine at each voiding
2, 3, 5 A urinary calculus may obstruct urine flow, which will be reflected in a decreased output; obstruction may result in hydronephrosis [1] [2]. Urine is strained to determine whether any calculi or calcium gravel is passed. Reduction of pain is a priority. A calculus obstructing a ureter causes flank pain that extends toward the abdomen, scrotum and testes, or vulva; the pain begins suddenly and is severe (renal colic). Fluids should be encouraged to promote dilute urine and facilitate passage of the calculi. Recording the blood pressure is not critical.
A client is diagnosed with calcium oxalate renal calculi. Which foods should the nurse teach the client to avoid? Select all that apply. 1 Liver 2 Spinach 3 Rhubarb 4 Milk 5 Tea
2, 3, 5 Tea, rhubarb, and spinach are high in calcium oxalate. Limiting oxalate-rich foods limits oxalate absorption and the formation of calcium oxalate calculi. Milk is an acceptable calcium-rich protein and is avoided in calcium stones but not with oxalate stones. Liver is a purine-rich food that may be eaten. Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit you to identify areas that need further review. Also it will help you to see how correct your guessing can be.
To prevent bleeding after a suprapubic prostatectomy, the client should be instructed to avoid straining on defecation. Which foods should the nurse encourage the client to eat to help prevent constipation during the recovery period? Select all that apply. 1 Scrambled eggs 2 Green peas 3 Milk 4 Apples 5 Oatmeal
2, 4, 5 Apples, oatmeal, and green peas are high in fiber, which helps prevent constipation. Milk and milk products can be constipating; they do not contain bulk. Scrambled eggs contain little dietary fiber and do not prevent constipation.
Famotidine 20 mg IVBP is prescribed for a client with a duodenal ulcer. The medication is diluted in 50 mL of 5% dextrose and is to infuse over 15 minutes. At what rate should the infusion control device be set. Record your answer using a whole number.
200 mL/hr
853. A nurse is administering an intravenous dose of methocarbamol (Robaxin) to a client with multiple sclerosis. For which of the following adverse effects would the nurse monitor? 1. Tachycardia 2. Rapid pulse 3. Bradycardia 4. Hypertension
3 Rationale: Intravenous administration of methocarbamol can cause hypotension and bradycardia. The nurse needs to monitor for these side effects. Options 1, 2, and 4 are not a concern with administration of this medication.
832. A nurse is assessing the casted extremity of a client. The nurse would assess for which of the following signs and symptoms indicative of infection? 1. Dependent edema 2. Diminished distal pulse 3. Presence of a "hot spot" on the cast 4. Coolness and pallor of the extremity
3 Rationale: Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The physician should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished arterial pulse, and edema.
A nurse is caring for a client with end-stage renal disease. Which clinical indicators of end-stage renal disease should the nurse expect? Select all that apply. A) Polyuria B) Jaundice C) Azotemia D) HTN E) Polycythemia
C) Azotemia E) Polycythemia
A client has glomerulonephritis. To prevent future attacks of glomerulonephritis, the nurse planning discharge teaching includes which instruction? 1 "Avoid situations that involve physical activity." 2 "Restrict fluid intake." 3 "Seek early treatment for respiratory infections." 4 "Take showers instead of bubble baths."
3 A common cause of glomerulonephritis is a streptococcal infection. This infection initiates an antibody formation that damages the glomeruli. Any fluid restriction is moderated as the client improves; fluid is allowed to prevent urinary stasis. The alkalinity of bubble baths is linked to urinary tract infections, not glomerulonephritis. Moderate activity is helpful in preventing urinary stasis, which can precipitate urinary infection.
A client who has been told she needs a hysterectomy for cervical cancer is upset about being unable to have a third child. Which action should the nurse take next? 1 Emphasize that she does have two children already. 2 Encourage her to focus on her own recovery. 3 Ensure that other treatment options for her will be explored. 4 Evaluate her willingness to pursue adoption.
3 Although a hysterectomy may be performed, conservative management may include cervical conization [1] [2] [3] and laser treatment that do not preclude future pregnancies; clients have a right to be informed by their primary healthcare provider of all treatment options. Willingness to pursue adoption currently is not the issue for this client. Encouraging her to focus on her own recovery and emphasizing that she does have two children already negate the client's feelings.
The nurse is teaching a client receiving peritoneal dialysis about the reason dialysis solution is warmed before it is instilled into the peritoneal cavity. Which information will the nurse share with the client? 1 Because it adds extra warmth to the body because metabolic processes are disturbed 2 Because it helps prevent cardiac dysrhythmias by speeding up removal of excess potassium 3 Because it encourages removal of serum urea by preventing constriction of peritoneal blood vessels 4 Because it forces potassium back into the cells, thereby decreasing serum levels
3 Encouraging the removal of serum urea by preventing constriction of peritoneal blood vessels promotes vasodilation so that urea, a large-molecular substance, is shifted from the body into the dialyzing solution. Heat does not affect the shift of potassium into the cells. The removal of metabolic wastes is affected in kidney failure, not the metabolic processes. Heating dialysis solution does not affect cardiac dysrhythmias.
Which hormone is released in response to low serum levels of calcium? 1 Atrial natriuretic peptide 2 Renin 3 Parathyroid hormone 4 Erythropoietin
3 If serum calcium levels decline, the parathyroid gland releases parathyroid hormone to maintain calcium homeostasis. Renin is a hormone released in response to decreased renal perfusion; this hormone is responsible for regulating blood pressure. Erythropoietin is released by the kidneys in response to poor blood flow to the kidneys; it stimulates the production of red blood cells. Atrial natriuretic peptide is produced by the right atrium of the heart in response to increased blood volume. This hormone then acts on the kidneys to promote sodium excretion, which decreases the blood volume.
The nurse is preparing a client who is on metformin therapy and is scheduled to undergo renal computed tomography with contrast dye. What does the nurse anticipate the primary healthcare provider to inform the client regarding the procedure? 1 "Discontinue metformin a half-day prior to procedure." 2 "Discontinue metformin 7 days following the procedure." 3 "Discontinue metformin 1 day prior to procedure." 4 "Discontinue metformin 3 days following the procedure."
3 Metformin can react with the iodinated contrast dye that is given for a renal computed tomography (CT) and cause lactic acidosis. Therefore the nurse anticipates an instruction that the client should discontinue the metformin 1 day before the procedure. Stopping the metformin a half-day before the renal CT may not reduce the risk of lactic acidosis. The client is advised to discontinue the metformin for at least 48 hours after the procedure. It is not necessary to discontinue metformin for 3 to 7 days after a renal CT with contrast media.
The nurse prepares a client for a Papanicolaou test (Pap test). What should the nurse instruct the client before conducting the test? 1 Douche the vagina with soap 2 Empty the bladder 3 Avoid sexual intercourse for at least 24 hours before the test 4 Avoid scheduling a Pap test to be performed during menses
3 The Papanicolaou test is a cytological study used to detect precancerous and cancerous cells within the cervix. The nurse should advise the client to avoid sexual intercourse at least 24 hours before the test to prevent test misinterpretations. A client undergoing a pelvic examination should empty her bladder immediately before the test. Douching the vagina with soap or applying deodorants may lead to false test results. The Papanicolaou test should be scheduled between the client's menstrual periods so that the menstrual flow does not interfere with laboratory analysis.
Which vascular component of the client's nephron delivers arterial blood from the glomerulus into the peritubular capillaries or the vasa recta? 1 Afferent arteriole 2 Interlobular artery 3 Efferent arteriole 4 Arcuate artery
3 The efferent arteriole is the vascular component of the nephron that delivers arterial blood from the glomerulus into the peritubular capillaries or the vasa recta. The arcuate artery is a curved artery of the renal system that surrounds the renal pyramids. The afferent arteriole is the vascular component of the nephron that delivers arterial blood from the branches of the renal artery into the glomerulus. The interlobular artery feeds the lobes of the kidney.
The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis results. Which urinary finding should the nurse conclude needs to be reported to the primary healthcare provider? 1 Acidic pH 2 Glucose negative 3 Presence of large proteins 4 Bacteria negative
3 The glomeruli are not permeable to large proteins such as albumin or red blood cells (RBCs), and it is abnormal if albumin or RBCs are identified in the urine; their presence should be reported. The urine can be acidic; normal pH is 4.0 to 8.0. Glucose and bacteria should be negative; these are normal findings.
The nurse is preparing a blood transfusion for a client with renal failure. Why does anemia often complicate renal failure? 1 Increase in blood pressure 2 Decrease in serum sodium concentration 3 Decrease in erythropoietin 4 Increase in serum phosphate levels
3 The hormone erythropoietin, produced by the kidneys, stimulates the bone marrow to produce red blood cells. In renal failure there is a deficiency of erythropoietin that often results in the client developing anemia. Therefore the nurse is instructed to administer blood. In renal failure, increased blood pressure is due to impairment of renal vasodilator factors and is not treated by administration of blood. Phosphate is retained in the body during renal failure, causing binding of calcium leading to done demineralization, not anemia. Increase in urinary sodium concentration and decrease in serum sodium concentration trigger the release of renin from the juxtaglomerular cells.
A nurse is performing peritoneal dialysis for a client. Which action should the nurse take? 1 Withhold the routine medications until after the procedure. 2 Infuse the dialysate solution slowly over several hours. 3 Warm the dialysate solution slightly before instillation. 4 Place the client in a side-lying position.
3 The infusion should be warmed to body temperature to decrease abdominal discomfort and promote dilation of peritoneal vessels. The side-lying position may restrict fluid inflow and prevent maximum urea clearance; the client should be placed in the semi-Fowler position. The infusion of dialysate solution should take approximately 10 to 20 minutes. Routine medications should not interfere with the infusion of dialysate solution.
A client has a surgical creation of a colostomy for cancer of the rectum. When comparing the procedures of a colostomy irrigation and an enema, the nursing intervention that is unique to a colostomy irrigation is: 1. Positioning the client for evacuation of the bowel 2. Lubricating the catheter tip with a water-soluble jelly 3. Instilling the irrigating solution using a cone-shaped tip catheter 4. Clearing the tubing of air before insertion of the irrigating solution
3 A cone-shaped tip controls the depth of insertion of the catheter, which prevents perforation of the bowel and limits leakage of water from the stoma during fluid insertion. 1 In both procedures the client should be positioned for evacuation of the bowel, which allows gravity to facilitate bowel evacuation. 2 In both procedures the catheter tip should be lubricated with a water-soluble jelly, which limits trauma to the intestinal mucosa. 4 In both procedures the tubing should be clear of air to facilitate the tolerance of a larger volume of irrigating solution.
A client who had a suprapubic prostatectomy for cancer of the prostate returns to the postanesthesia care unit with a continuous bladder irrigation. The purpose of this irrigation is to: 1. Stimulate continuous formation of urine 2. Facilitate the measurement of urinary output 3. Prevent the development of clots in the bladder 4. Provide continuous pressure on the prostatic fossa
3 A continuous flushing of the bladder dilutes the bloody urine and empties the bladder, preventing clots. 1 Fluid instilled into the bladder does not affect kidney function. 2 Urinary output can be measured regardless of the amount of fluid instilled. 4 The urinary retention catheter is not designed to exert pressure on the prostatic fossa.
The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response is based on the principle that bed rest: 1. Prevents the further aggregation of platelets 2. Enhances the peripheral circulation in the deep vessels 3. Decreases the potential for further dislodgment of emboli 4. Maximizes the amount of blood available to damaged tissues (Nugent 20) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 Activity may encourage the dislodgment of more microemboli. 1 Bed rest may enhance platelet aggregation and the formation of thrombi because of venous stasis. 2 Venous stasis, rather than enhanced circulation, is supported by bed rest. 4 Bed rest supports venous stasis rather than the circulation of blood to damaged tissues. (Nugent 100) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client who has had a subtotal thyroidectomy does not understand how hypothyroidism can develop when the problem was initially hyperthyroidism. The nurse bases a response on the fact that: 1. Hypothyroidism is a gradual slowing of the body's function 2. There will be a decrease in pituitary thyroid-stimulating hormone 3. There may not be enough thyroid tissue to supply adequate thyroid hormone 4. Atrophy of tissue remaining after surgery reduces secretion of thyroid hormones (Nugent 30-31) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 After a subtotal thyroidectomy the thyroxine output may be inadequate to maintain an appropriate metabolic rate. 1 Hypothyroidism is a decrease in thyroid functioning, not a slowing of the entire body's functions. 2 In hypothyroidism the level of thyroid-stimulating hormone (TSH) from the pituitary is usually increased. 4 Atrophy of the remaining thyroid tissue does not occur. (Nugent 112-113) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client is diagnosed with chronic pancreatitis. When providing dietary teaching it is most important that the nurse instruct the client to: 1. Eat a low-fat, low-protein diet 2. Avoid foods high in carbohydrates 3. Avoid ingesting alcoholic beverages 4. Eat a bland diet of six small meals a day
3 Alcohol increases pancreatic secretions, which cause pancreatic cell destruction. 1 Although the diet should be low in fat, it should be high in protein; also it should be high in carbohydrates. 2 The client should be consuming 4,000 to 6,000 calories a day to maintain weight and promote tissue repair. 4 A bland diet is not necessary, but large, heavy meals should be avoided.
A client with uremic syndrome has the potential to develop many complications. Which complication should the nurse anticipate? 1. Hypotension 2. Hypokalemia 3. Flapping hand tremors 4. Elevated hematocrit values
3 An elevation in uremic waste products causes irritation of the nerves, resulting in flapping hand tremors (asterixis, "liver flap"). 1 Hypertension results from kidney failure because of sodium and water retention. 2 The diseased kidney is unable to excrete potassium ions, resulting in hyperkalemia, not hypokalemia. 4 The hematocrit value will be low because of a decreased production of erythropoietin, a hormone synthesized in the kidney; erythropoietin regulates the production of erythrocytes.
A nurse is obtaining a health history from a client with the diagnosis of renal calculi. Which factor in the client's history most likely contributed to the development of renal calculi? 1. High-cholesterol diet 2. Excessive exercise program 3. Excess ingestion of antacids 4. Frequent consumption of alcohol
3 An excessive use of antacids may result in hypercalciuria; most calculi contain calcium combined with phosphate or other substances. 1 Cholesterol is unrelated to the formation of renal calculi; cholesterol stones in the gallbladder are the result of increased cholesterol synthesis in the liver. 2 Immobility with the associated demineralization of bone, not exercise, contributes to the formation of renal calculi. 4 Alcohol intake is unrelated to renal calculi formation.
A 79-year-old client is admitted to the hospital with painful abdominal spasms and severe diarrhea of 2 days' duration. The order of physical skills the nurse should follow when performing an admitting examination of this client should be "inspection" followed by: 1. Percussion, palpation, auscultation 2. Percussion, palpation, auscultation 3. Auscultation, palpation, percussion 4. Auscultation, percussion, palpation
3 Auscultation must be performed before palpation and percussion because they may influence intestinal peristalsis resulting in inaccurate results. Palpation is performed before percussion because percussion will have a greater impact on peristalsis. 1 Percussion or palpation performed before auscultation may result in an inaccurate assessment of bowel sounds. 2 Percussion or palpation performed before auscultation may result in an inaccurate assessment of bowel sounds. 4 Although auscultation is performed before percussion or palpation, palpation should precede percussion when assessing the abdomen.
The laboratory values of a client with cancer of the esophagus show a hemoglobin of 7 g/dL, hematocrit of 25%, and RBC count of 2.5 million/mm3. The outcome that takes priority at this time is, "The client will: 1. be free of injury." 2. remain pain free." 3. demonstrate improved nutrition." 4. maintain an effective airway clearance."
3 Based on the presented data, improving nutritional status is the priority at this time. The decreased hemoglobin and hematocrit levels and RBC count may be a result of malnutrition; also cancer of the esophagus can cause dysphagia and anorexia. 1 Although maintaining the client's safety is a goal, it is not as high a priority as another concern based on the data provided in the question. 2 Data given do not relate to the presence of pain. 4 Data given do not relate to airway obstruction.
After a bilateral herniorrhaphy the nurse should assess a male client for the development of: 1. Hydrocele 2. Paralytic ileus 3. Urinary retention 4. Thrombophlebitis
3 Because of pain and the proximity of the operative site to the lower urinary tract, urinary retention is common after this surgery. 1 Hydrocele is not a complication of a herniorrhaphy. 2 The abdomen was not entered; there should be no interference with peristalsis. 4 Thrombophlebitis should not occur because early ambulation is permitted.
A client who has had right upper quadrant pain for several months now experiences clay-colored stools and visits the local clinic. Based on the reported history and elevated liver enzymes, a needle biopsy of the liver is scheduled. The nurse explains that: 1. The procedure is painless because general anesthesia is used 2. Disfiguring scars are minimal because a small incision is made 3. Lying on the right side after the procedure is required because it will decrease the risk of hemorrhage 4. A light meal should be eaten 2 hours before the procedure because it stimulates gastrointestinal secretions
3 Because of the vascularity of the liver, compression of the needle insertion site limits the risk of hemorrhage; also it decreases the risk of bile leakage. 1 The procedure is performed under local anesthesia and some discomfort may be felt during instillation of the anesthetic as well as when the needle enters the liver. 2 There is no scarring because a surgical incision is not necessary for a needle biopsy. 4 The client is kept NPO for at least 6 hours before the procedure to prevent nausea and vomiting.
The nurse evaluates that the teaching regarding the use of vitamin B12 injections to treat pernicious anemia is understood when a client states, "I must take the drug: 1. when feeling fatigued." 2. until my symptoms subside." 3. monthly, for the rest of my life." 4. during exacerbations of anemia." (Nugent 18) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 Because the intrinsic factor does not return to gastric secretions even with therapy, B12 injections will be required monthly for the remainder of the client's life. 1 B12 injections must be taken for the rest of the client's life. 2 B12 injections must be taken for the rest of the client's life. 4 Intramuscular injections of B12 must be taken monthly for the rest of the client's life. (Nugent 98) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A male client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. When obtaining this client's history, the nurse gives priority to the client's statement that: 1. His pain increases after meals 2. He experiences nausea frequently 3. His stools have a black appearance 4. He recently joined Alcoholics Anonymous
3 Black (tarry) stools indicate upper GI bleeding; digestive enzymes act on the blood resulting in tarry stools. Hemorrhage can occur if erosion extends to blood vessels. 1 Investigation of bleeding takes priority; later the nurse should help to identify irritating foods that are to be avoided. 2 Nausea is a common symptom of gastritis, but is not life threatening. 4 Attempts to control alcoholism should be supported but this is a long-term goal; assessment of bleeding takes priority.
When obtaining a health history from a client with probable acute lymphoblastic leukemia (ALL), the clinical manifestation the nurse expects to be present is: 1. Alopecia 2. Insomnia 3. Ecchymosis 4. Splenomegaly (Nugent 19) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 Bleeding tendencies occur because of bone marrow suppression and rapidly proliferating leukocytes. 1 There is no change in hair growth in the absence of chemotherapy. 2 The client will more likely be sleeping excessively. 4 Splenomegaly occurs with chronic lymphoblastic leukemia (CLL) and chronic myelogenous leukemia (CML), not acute lymphoblastic leukemia (ALL). (Nugent 99) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client who is in hypovolemic shock has a hematocrit value of 25%. The nurse anticipates that the practitioner will order: 1. Ringer's lactate 2. Serum albumin 3. Blood replacement 4. High molecular dextran (Nugent 21) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 Blood replacement is needed to increase the oxygen-carrying capacity of the blood; the expected hematocrit for women is 37% to 47% and for men is 42% to 52%. 1 Ringer's lactate does not increase the oxygen-carrying capacity of the blood. 2 Serum albumin helps maintain volume but does not affect the hematocrit level. 4 Although dextran does expand blood volume, it decreases the hematocrit because it does not replace red blood cells. (Nugent 101) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A-negative blood. Blood can be used from relatives whose blood is: 1. Type O positive 2. Type AB positive 3. Type A or O negative 4. Type A or AB negative (Nugent 17) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 Both A- and O-negative blood are compatible with the client's blood. A-negative is the same as the client's blood type and preferred; in an emergency, type O-negative blood also may be given. 1 Although type O blood may be used, it will have to be Rh negative; Rh-positive blood is incompatible with the client's blood and will cause hemolysis. 2 Type AB-positive blood is incompatible with the client's blood and will cause hemolysis. 4 Type A-negative blood is compatible with the client's blood but type AB-negative is incompatible and will cause hemolysis. (Nugent 96-97) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
The nurse evaluates that dietary teaching for a client with a colostomy is effective when the client states, "It is important that I eat: 1. food low in fiber so that there is less stool." 2. bland foods so that my intestines do not become irritated." 3. everything I ate before the operation and avoid foods that cause gas." 4. soft foods that are more easily digested and absorbed by my large intestine."
3 Clients with a colostomy can eat a regular diet; only gas-forming foods that cause distention and discomfort should be avoided. 1 The amount of stool does not have to be limited; therefore, a low-residue diet is not necessary. 2 The affected tissue has been removed and healthy mucosal tissue lines the intestine and forms the stoma; therefore, bland foods are not necessary. 4 Nutrients are absorbed by the small, not the large, intestine; a regular diet usually is easily digested and absorbed.
A client has decided to become a vegan and wishes to plan a diet to ensure adequate protein quality. To provide guidance, the nurse instructs this client to: 1. Add milk to grains to provide complete proteins 2. Use eggs and plant foods to provide essential amino acids 3. Plan a careful mixture of plant proteins to provide a balance of amino acids 4. Add cheese to grains and beans to increase the quality of the protein consumed
3 Complementary mixtures of essential amino acids in plant proteins provide complete dietary protein equivalents. 1 A vegan does not consume flesh, milk, milk products, or eggs. 2 A vegan does not consume flesh, milk, milk products, or eggs. 4 A vegan does not consume flesh, milk, milk products, or eggs.
When teaching a community health class about the signs of colorectal cancer, the nurse stresses that the most common complaint of persons with colorectal cancer is: 1. Rectal bleeding 2. Abdominal pain 3. Change in bowel habits 4. Decrease in diameter of stools
3 Constipation, diarrhea, and/or constipation alternating with diarrhea are the most common signs of colorectal cancer. 1 This is the second most common complaint that results from destruction of the epithelial lining of the intestine. 2 Pain is reported as a symptom in less than 25% of clients; also it is a late sign after other organs are invaded. 4 This is a later sign that becomes evident when the lumen of the intestine narrows as a result of the enlarging mass.
A client with colitis has a hemicolectomy performed. After surgery the nurse identifies that, in addition to having vomited 300 mL of dark green viscous fluid, the client has increasing abdominal distention and absent bowel sounds. Immediate care should be directed toward: 1. Replacing fluid losses 2. Decreasing the vomiting 3. Decompressing the bowel 4. Restoring electrolyte balance
3 Decompression removes collected secretions behind the nonfunctioning bowel segment (paralytic ileus), thus reducing pressure on the suture line and allowing healing. 1 Although this is important, the primary concern is decompression of the bowel; the amount of fluid removed will direct fluid and electrolyte replacement therapy. 2 Vomiting will subside as the bowel is decompressed. 4 Although this is important, the primary concern is decompression of the bowel; the amount of fluid removed will direct fluid and electrolyte replacement therapy.
A nurse is reviewing preoperative instructions with a client who is scheduled for orthopedic surgery at 8 o'clock the next morning. The nurse advises the client to: 1. Have dinner and then nothing by mouth after 6 pm 2. Drink full liquids tonight and clear liquids in the morning 3. Consume a light evening meal and no food or fluid after midnight 4. Eat lunch the day before surgery and then not drink or eat anything until after surgery
3 Eating a light meal and eliminating food and fluids after midnight limit complications during and after surgery, which include aspiration, nausea, dehydration, and possible ileus. 1 A large meal the evening before surgery may not clear before peristalsis is slowed by anesthesia, resulting in abdominal distention and discomfort after surgery. 2 Clear liquids in the morning can cause nausea, vomiting, and aspiration. 4 Fluids should not be withheld for more than 8 hours, to prevent dehydration. Not eating or drinking anything after lunch is an excessive amount of time to restrict food and fluids before surgery the next morning.
A client with carcinoma of the colon is scheduled for an abdominoperineal resection. Preparation of this client several days before surgery should include: 1. Medications to promote diuresis 2. Restriction of fluids to one L daily 3. Antibiotics to reduce intestinal bacteria 4. Abdominal exercises to facilitate recovery
3 Except in an emergency, the client receives an intestinal antibiotic for several days preoperatively to reduce the amount of intestinal bacteria. 1 Diuretics are not necessary unless prescribed for a preexisting problem. 2 Fluids usually are restricted after midnight on the day of surgery, not for days before surgery. 4 Abdominal exercises are not part of the surgical preparation.
A client newly diagnosed as having type 1 diabetes is taught to exercise on a regular basis primarily because exercise has been shown to: 1. Decrease insulin sensitivity 2. Stimulate glucagon production 3. Improve the cellular uptake of glucose 4. Reduce metabolic requirements for glucose (Nugent 31) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 Exercise increases the metabolic rate, and glucose is needed for cellular metabolism; therefore, excess glucose is consumed during exercise. 1 Regular vigorous exercise increases cell sensitivity to insulin. 2 Glucagon action raises blood glucose but does not affect cell uptake or utilization of glucose. 4 Cellular requirements for glucose increase with exercise. (Nugent 113) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client is admitted to the hospital with the diagnosis of acute salmonellosis. The nurse expects that the client will receive: 1. Opioids 2. Antacids 3. Electrolytes 4. Antidiarrheals
3 Fluids of dextrose and normal saline and electrolytes are administered to prevent profound dehydration caused by an excessive loss of water and electrolytes through diarrheal output. 1 These are not used when there is a possibility of bacterial infection because slowed peristalsis decreases excretion of the salmonella organism. 2 Salmonellosis is an infection, not a condition caused by hyperacidity. 4 These are not used when there is a possibility of bacterial infection because slowed peristalsis decreases excretion of the salmonella organism
A client with cancer of the tongue has radon seeds implanted. The plan of care states that the client is to receive meticulous oral hygiene. This plan can best be implemented by: 1. Offering a firm-bristled toothbrush 2. Providing an antiseptic mouthwash 3. Using a gentle spray of normal saline 4. Swabbing the mouth with a moistened gauze square
3 Gentle sprays are effective in cleaning the mouth and teeth without disturbing the sensitive tissues or radon seeds. 1 This can dislodge the radon seeds and be traumatic to the compromised oral mucosa. 2 An antiseptic mouthwash is an astringent that is too harsh for the sensitive oral mucosa. 4 This can dislodge the radon seeds and be traumatic to the compromised oral mucosa.
A client is instructed to avoid straining on defecation postoperatively. The nurse evaluates that the related teaching is understood when the client states, "I must increase my intake of: 1. ripe bananas." 2. milk products." 3. green vegetables." 4. creamed potatoes."
3 Green vegetables contain fiber, which promotes defecation. 1 These have a constipating effect, which results in straining at stool. 2 These have a constipating effect, which results in straining at stool. 4 These have a constipating effect, which results in straining at stool.
A client is admitted to the hospital with a ureteral calculus. What clinical findings should the nurse expect when the client voids? 1. Urgency and pain 2. Foul odor and dark urine 3. Hematuria with sharp pain 4. Frequency with small amounts of urine
3 Hematuria and pain may result from damage to the ureteral lining as the calculus moves down the urinary tract; the urine may become cloudy or pink tinged. 1 Although severe pain may be present, urgency is not associated with renal calculi; urgency may be associated with an enlarged prostate, cystitis, or other genitourinary problems. 2 The odor of urine is not foul with this condition; the color of urine is not dark with this condition, although it may be cloudy, pink, or red from hematuria. 4 Frequency may occur when the calculus reaches the bladder.
The practitioner orders contact precautions for a client with hepatitis A. What specific interventions are required for contact precautions? 1. Private room and the door must be kept closed 2. Persons entering the room must wear a gown, a mask, and gloves 3. Gown and gloves must be worn when handling articles contaminated by urine or feces 4. Gowns and gloves must be worn only when handling the client's soiled linen, dishes, or utensils
3 Hepatitis A is transmitted via the fecal-oral route; contact precautions must be used when there are articles that have potential fecal and/or urine contamination. 1 Neither a private room nor a closed door is required; these are necessary only for respiratory (airborne) precautions. 2 Hepatitis A is not transmitted via the airborne route and therefore a mask is not necessary; a gown and gloves are required only when handling articles that may be contaminated. 4 This is too limited; a gown and gloves also should be worn when handling other fecally contaminated articles, such as a bedpan or rectal thermometer.
When discussing the therapeutic regimen of vitamin B12 for pernicious anemia with a client, the nurse explains that: 1. Weekly Z-track injections provide needed control 2. Daily intramuscular injections are required for control 3. Intramuscular injections once a month will maintain control 4. Oral tablets of vitamin B12 taken daily will provide symptom control (Nugent 18) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 IM injections bypass the vitamin B12 absorption defect (lack of intrinsic factor, the transport carrier component of gastric juices). A monthly dose is usually sufficient because it is stored in active body tissues such as the liver, kidney, heart, muscles, blood, and bone marrow. 1 The Z-track method need not be used as it is for iron dextran injections. 2 Because it is stored and only slowly depleted, injections once a month usually are sufficient. 4 Vitamin B12 cannot be taken by mouth because of the lack of intrinsic factor. (Nugent 98) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
When discussing a scheduled liver biopsy with a client, the nurse explains that for several hours after the biopsy the client will have to remain in: 1. The left side-lying position with the head of the bed elevated 2. A high Fowler's position with both arms supported on several pillows 3. The right side-lying position with pillows placed under the costal margin 4. Any comfortable recumbent position as long as the client remains immobile
3 In this position the liver capsule at the entry site is compressed against the chest wall and escape of blood and/or bile is impeded. 1 This is unsafe because pressure will not be applied to the puncture site and the client can bleed from the insertion site. 2 This is unsafe because pressure will not be applied to the puncture site and the client can bleed from the insertion site. 4 This is unsafe because pressure will not be applied to the puncture site and the client can bleed from the insertion site.
While hospitalized, a client with diabetes is observed picking at calluses on the feet. The nurse should immediately: 1. Warn the client of the danger of infection 2. Suggest that the client wear white cotton socks 3. Teach the client the importance of effective foot care 4. Check the client's shoes for their fit in the area of the calluses (Nugent 32) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 Inadequate foot care can lead to skin breakdown, poor healing, and subsequent infection. 1 This can increase anxiety and reduce the client's ability to learn. 2 This is only one aspect of effective foot care; synthetic fibers that wick moisture are preferred. 4 Although important, this is not comprehensive foot care. (Nugent 114) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A 25-year-old physical fitness instructor is feeling increasingly tired and seeks medical care. Type 1 diabetes is diagnosed. The nurse explains that the increased fatigue is the result of: 1. Increased metabolism at the cellular level 2. Increased glucose absorption from the intestine 3. Decreased production of insulin by the pancreas 4. Decreased glucose secretion into the renal tubules (Nugent 31) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 Insulin facilitates transport of glucose across the cell membrane to meet metabolic needs and prevent fatigue. 1 With diabetes there is decreased cellular metabolism because of the decrease in glucose entering the cells. 2 Glucose is not absorbed from the intestinal tract by the cells; fatigue is caused by decreased, not increased, cellular levels of glucose. 4 Filtration and excretion of glucose by the kidneys do not regulate energy levels; if insulin production is adequate, glucose does not spill into the urine. (Nugent 113) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
To help prevent a cycle of recurring urinary tract infections, the nurse should plan to instruct a female client to: 1. Increase the daily intake of citrus juice 2. Douche frequently with alkaline agents 3. Urinate as soon as possible after intercourse 4. Cleanse from the vaginal orifice to the urethra
3 Intercourse may cause urethral inflammation, increasing the risk of infection; voiding clears the urinary meatus and urethra of microorganisms. 1 Most fruit juices, with the exception of cranberry juice, cause alkaline urine, which promotes bacterial growth. 2 Douching is no longer recommended because it alters the vaginal flora. 4 Perineal care should be accomplished with wipes from the urinary meatus toward the rectum to help prevent microorganisms from the vaginal or rectal areas from reaching the urinary meatus.
During the early postoperative period after a subtotal thyroidectomy, the concern that has the priority is: 1. Hemorrhage 2. Thyrotoxic crisis 3. Airway obstruction 4. Hypocalcemic tetany (Nugent 30) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 Maintaining airway patency is always the priority to permit gas exchange necessary to maintain life. 1 Although important, it does not exceed patency of the airway in priority. 2 Although important, it does not exceed patency of the airway in priority. 4 Although important, it does not exceed patency of the airway in priority. (Nugent 112) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
During a laparoscopic cholecystectomy on an obese client, the surgeon encounters difficulty because of the presence of adhesions as a result of the client's having had a previous surgery. An abdominal cholecystectomy is performed. After surgery the nurse plans to alleviate tension on the surgical wound by: 1. Limiting deep breathing 2. Maintaining T-tube patency 3. Maintaining nasogastric tube patency 4. Encouraging the right side-lying position
3 Maintaining nasogastric tube patency ensures gastric decompression, thus preventing abdominal distension, which places tension on the incision. 1 Deep breathing should be encouraged to prevent respiratory complications. 2 Maintaining T-tube patency only ensures a portal of exit for bile drainage; the tube is not irrigated and an obstruction will lead to jaundice rather than tension on the surgical wound. 4 The right-side-lying position after a cholecystectomy can increase, not decrease, tension in the operative area.
A nurse evaluates that a client with chronic kidney disease understands an adequate source of high-biologic-value protein when the food the client selects from the menu is: 1. Apple juice 2. Raw carrots 3. Cottage cheese 4. Whole wheat bread
3 One cup of cottage cheese contains approximately 225 calories, 27 grams of protein, 9 grams of fat, 30 mg of cholesterol, and 6 grams of carbohydrate; proteins of high biologic value (HBV) contain optimal levels of the amino acids essential for life. 1 Apple juice is a source of vitamins A and C, not protein. 2 Raw carrots are a carbohydrate source and contain beta-carotene. 4 Whole wheat bread is a source of carbohydrates and fiber.
A client with a history of gastrointestinal varices develops severe hematemesis, and the practitioner inserts a Sengstaken-Blakemore tube. The nurse understands that this tube is a: 1. Single-lumen tube for gastric lavage 2. Double-lumen tube for intestinal decompression 3. Triple-lumen tube used to compress the esophagus 4. Multi-lumen tube for gastric and intestinal decompression
3 One lumen inflates the esophageal balloon, the second inflates the gastric balloon, and the third decompresses the stomach. 1 It is a triple-, not single-lumen tube. 2 It is a triple-, not double-lumen tube; the stomach, not the intestine, is decompressed. 4 The stomach, but not the intestine, is decompressed.
A client is admitted for repair of bilateral inguinal hernias. Before surgery the nurse assesses the client for signs that strangulation of the intestine may have occurred. What is an early sign of strangulation? 1. Increased flatus 2. Projectile vomiting 3. Sharp abdominal pain 4. Decreased bowel sounds
3 Pain is wavelike, colicky, and sharp because of obstruction and localized bowel ischemia. 1 Flatus is impeded by strangulation. 2 Vomiting is persistent, not projectile. 4 This is not an early sign of obstruction; decreased bowel sounds occur after gas and fluid accumulate.
A Schilling test is ordered for a client who is suspected of having pernicious anemia. The nurse considers that the primary purpose of the Schilling test is to determine the client's ability to: 1. Store vitamin B12 2. Digest vitamin B12 3. Absorb vitamin B12 4. Produce vitamin B12 (Nugent 18) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 Pernicious anemia is caused by the inability to absorb vitamin B12 resulting from a lack of intrinsic factor in gastric juices; for the Schilling test, radioactive vitamin B12 is administered and its absorption and excretion can be ascertained. 1 This is not measured by this test. 2 This is not measured by this test. 4 Vitamin B12 is not produced in the body. (Nugent 98) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
When obtaining the history of a 24-year-old graduate student recently diagnosed with type 1 diabetes, the nurse expects to identify the presence of: 1. Edema 2. Anorexia 3. Weight loss 4. Hypoglycemic episodes (Nugent 31) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 Protein and lipid catabolism occur because carbohydrates cannot be used by the cells; this results in weight loss and muscle wasting. 1 Dehydration, not edema, is more likely to occur because of the polyuria associated with hyperglycemia. 2 Polyphagia, not anorexia, occurs with diabetes as the client attempts to meet metabolic needs. 4 Hyperglycemia, not hypoglycemia, is present in both type 1 and type 2 diabetes. (Nugent 113) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A traveling salesman develops gastric bleeding and is hospitalized. An important etiologic clue for the nurse to explore while taking this client's history is: 1. Any recent foreign travel 2. The client's usual dietary pattern 3. The medications that the client is taking 4. Any change in the status of family relationships
3 Some medications, such as aspirin, NSAIDs, and prednisone, irritate the stomach lining and may cause bleeding with prolonged use. 1 Travel to foreign countries may be related to intestinal irritation, causing diarrhea and intestinal bleeding, not gastric bleeding. 2 This is not the cause of gastric bleeding; it is important to ascertain dietary habits when teaching about diet therapy. 4 Although stress may play a part, the use of some medications has a more direct relationship.
Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop a stress ulcer (Curling's). Stress ulcers usually are evidenced by: 1. Unexplained shock 2. Melena for several days 3. Sudden massive hemorrhage 4. Gradual drop in the hematocrit value
3 Stress ulcers are asymptomatic until they produce massive hematemesis and rectal bleeding. 1 Shock is the outcome of massive hemorrhage; it is not unexplained because the sudden gastrointestinal bleeding will be identified. 2 Sudden massive bleeding occurs, not the slow oozing that causes melena. 4 A gradual drop in the hematocrit value indicates slow blood loss.
A client with acute glomerulonephritis complains of thirst. What should the nurse offer the client? 1. Ginger ale 2. Milk shake 3. Hard candy 4. Cup of broth
3 Sucking on a hard candy will relieve thirst and increase carbohydrates, but does not supply extra fluid. 1 Carbonated beverages contain sodium and provide additional fluid, which must be restricted. 2 A milkshake contains both fluid and protein, which must be restricted. 4 Broth contains sodium, which increases fluid retention.
A practitioner orders a high-calorie, high-protein diet for a client who is a heavy smoker. In light of the history of smoking, the nurse encourages the client to eat foods high in: 1. Niacin 2. Thiamine 3. Vitamin C 4. Vitamin B12
3 The RDA requirement of vitamin C for an adult male is 90 mg; smoking accelerates oxidation of tissue vitamin C, so smokers need an additional 35 mg/day. 1 Niacin is not oxidized more rapidly in the smoker. 2 Thiamine is not oxidized more rapidly in the smoker. 4 Vitamin B12 is not oxidized more rapidly in the smoker.
Four hours after surgery the blood glucose level of a client who has type 1 diabetes is elevated. The nurse can expect to: 1. Administer an oral hypoglycemic 2. Institute urine glucose monitoring 3. Give supplemental doses of regular insulin 4. Decrease the rate of the intravenous infusion (Nugent 32) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 The blood glucose level needs to be reduced; regular insulin begins to act in 30 to 60 minutes. 1 The client has type 1, not type 2, diabetes, and an oral hypoglycemic will not be effective. 2 Blood glucose levels are far more accurate than urine glucose levels. 4 The rate may be increased because polyuria often accompanies hyperglycemia. (Nugent 114) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Polycythemia is frequently associated with chronic obstructive pulmonary disease (COPD). When assessing for this complication, the nurse should monitor for: 1. Pallor and cyanosis 2. Dyspnea on exertion 3. Elevated hemoglobin 4. Decreased hematocrit (Nugent 17) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 The body attempts to compensate for decreased oxygen to tissues by increasing the number of blood cells, the oxygen-carrying component of the blood. 1 With polycythemia, the skin, especially the face, appears flushed, not pale. 2 This is not specific to polycythemia; there is more than one cause of dyspnea on exertion. 4 The hematocrit is increased with polycythemia. (Nugent 96) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client with type 1 diabetes of long duration takes Novolin 70/30 (combination of Novolin N 70% and Novolin R 30%) every morning. At noon, before eating lunch, the client is admitted to the emergency department with an acute myocardial infarction. Two hours later the client's serum glucose level drops to 30 mg/dL, and insulin coma is diagnosed. The nurse concludes that the reason for the development of acute hypoglycemia in this client is that: 1. Glycogenolysis increased when lunch was not eaten after taking Novolin N insulin 2. The stress brought on by the chest pain increases the use of serum glucose available to the client 3. Glucose levels that are controlled by insulin drop more quickly than those controlled by oral antidiabetics 4. The client's body became sensitive to the prescribed dose of insulin after long use causing blood glucose levels to drop erratically (Nugent 32-33) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 The dose of exogenous insulin causes a rapid drop in the blood glucose level, especially if food is not eaten. 1 This leads to hyperglycemia. 2 Stress usually contributes to hyperglycemia because of glycogenolysis and gluconeogenesis. 4 The use of insulin over long periods does not build tolerance to insulin or cause blood glucose levels to fluctuate dramatically. (Nugent 115) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client who has cancer of the sigmoid colon is to have an abdominoperineal resection with a permanent colostomy. Before surgery a low-residue diet is ordered. The nurse explains that this is necessary to: 1. Limit production of flatus in the intestine 2. Prevent irritation of the intestinal mucosa 3. Reduce the amount of stool in the large bowel 4. Lower the bacterial count in the gastrointestinal tract
3 This diet is low in fiber; after digestion and absorption there is only a small amount of residue to be eliminated. 1 This diet does not promote peristalsis; the products of digestion remain in the intestine longer, and flatus is increased. 2 Although a low-residue diet is less irritating, this is not the primary reason for its use before surgery. 4 Antimicrobials, such as neomycin, are given to do this.
On admission, the bloodwork of a young adult with leukemia indicates elevated blood urea nitrogen (BUN) and uric acid levels. The nurse determines that these laboratory results may be related to: 1. Lymphadenopathy 2. Thrombocytopenia 3. Hypermetabolic status 4. Hepatic encephalopathy (Nugent 19) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 The hypermetabolic state associated with leukemia causes more urea and uric acid (end products of metabolism) to be produced and to accumulate in the blood. 1 Enlarged lymph nodes will not increase blood urea and uric acid. 2 Thrombocytopenia causes a decrease in platelets, which causes bleeding. 4 Hepatic encephalopathy is associated with liver disease, not leukemia. (Nugent 99) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client demonstrates signs and symptoms of a transfusion reaction. The nurse immediately stops the infusion and next: 1. Obtains blood pressure in both arms 2. Sends a urine specimen to the laboratory 3. Hangs a bag of normal saline with new tubing 4. Monitors the intake and output every fifteen minutes (Nugent 17) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 The tubing must be replaced to avoid infusing the blood left in the original tubing; the normal saline infusion will maintain an open line for any further IV treatment. 1 All vital signs should be taken eventually; blood pressure may be taken on either arm, not necessarily both. 2 A urine sample is collected after the blood transfusion is stopped, the tubing replaced, and a bag of normal saline hung. The specimen will be analyzed to determine kidney function. 4 Although the intake, and especially the output, should be monitored to assess kidney function, this is not the priority. (Nugent 97) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
When a client develops steatorrhea, the nurse documents this stool as: 1. Dry and rock-hard 2. Clay colored and pasty 3. Bulky and foul smelling 4. Black and blood-streaked
3 These characteristics describe steatorrhea, which results from impaired fat digestion. 1 This is descriptive of stools resulting from constipation. 2 This is descriptive of acholic stools occurring with biliary obstruction resulting from an absence of urobilin. 4 This is descriptive of upper and lower gastrointestinal bleeding
A client who had a prostatectomy complains of painful bladder spasms. To limit these spasms the nurse should: 1. Administer the client's ordered opioid every 4 hours 2. Irrigate the indwelling catheter with 60 mL of isotonic solution 3. Encourage the client to avoid contracting his muscles as if he were voiding 4. Advance the urinary catheter to relieve the pressure against the prostatic fossa
3 This action causes the bladder muscle to contract, initiating painful bladder spasms. 1 Although opioids may dull the pain, they may not limit muscle spasms. 2 Instillation of fluid may be irritating and can precipitate bladder spasms. 4 Advancing or manipulating the catheter may precipitate bladder spasms.
After abdominal surgery a client is to receive a progressive postsurgical diet. This diet is characterized by progressive alterations in the: 1. Caloric content of food 2. Nutritional value of food 3. Texture and digestibility of food 4. Variety of food and fluids included
3 This diet progresses from the one that makes the least metabolic demand on the client (clear liquid) to a regular diet that requires the capability of unimpaired digestion. 1 The caloric content is not the focus in a progressive postsurgical diet. 2 Initially a progressive diet has little nutritional value; the focus is to rest the gastrointestinal tract immediately after surgery. 4 Initially a limited variety of fluids is presented to rest the gastrointestinal tract; food is not included until later.
Twenty-four hours after a penile implant the client's scrotum is edematous and painful. The nurse should: 1. Assist the client with a sitz bath 2. Apply warm soaks to the scrotum 3. Elevate the scrotum using a soft support 4. Prepare for an incision and drainage procedure
3 This increases lymphatic drainage, reducing edema and pain. 1 This increases circulation to the area, intensifying edema and pain in this client. 2 This increases circulation to the area, intensifying edema and pain in this client. 4 This is not indicated; scrotal swelling is caused by the trauma of surgery, not infection.
A 64-year-old client is suspected of having carcinoma of the liver, and a liver biopsy is scheduled. A liver biopsy may be contraindicated in certain situations. Therefore, for what should the nurse assess the client? 1. Confusion and disorientation 2. Presence of any infectious disease 3. Prothrombin time of less than 40% of normal 4. Inclusion of foods high in vitamins E and K in the client's diet
3 This indicates that the client has a deficiency in clotting, which should be corrected before the biopsy to prevent hemorrhage. 1 Confusion and disorientation are not a contraindication for a liver biopsy; if present, the client may need support and the examiner may need assistance, but the biopsy can be done. 2 A biopsy is not contraindicated in the presence of an infectious disease. 4 Vitamin K is needed for the production of prothrombin; however, this does not guarantee clotting activity; vitamin E is not involved in clotting.
A client with type 1 diabetes is placed on an insulin pump. The most appropriate short-term goal when teaching this client to control the diabetes is: "The client will: 1. adhere to the medical regimen." 2. remain normoglycemic for 3 weeks." 3. demonstrate the correct use of the administration equipment." 4. list 3 self-care activities that are necessary to control the diabetes." (Nugent 32) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 This is a short-term goal, client oriented, necessary for the client to control the diabetes, and measurable when the client performs a return demonstration for the nurse. 1 This is not a short-term goal. 2 This is measurable, but it is a long-term goal. 4 Although this is measurable and a short-term goal, it is not the one with the greatest priority when a client has an insulin pump that must be mastered before discharge. (Nugent 114-115) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
The nurse expects the diagnostic studies of a client with Cushing's syndrome to indicate: 1. Moderately increased serum potassium levels 2. Increased numbers of eosinophils in the blood 3. High levels of 17-ketosteroids in a 24-hour urine test 4. Normal to low levels of adrenocorticotropic hormone (ACTH) (Nugent 29) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 This is a urinary metabolite of steroid hormones that are excreted in large amounts in hyperaldosteronism. 1 With aldosterone hypersecretion, sodium is retained and potassium is excreted, resulting in hypernatremia and hypokalemia. 2 With Cushing's syndrome, the eosinophil count is decreased, not increased. 4 ACTH levels usually are high in Cushing's syndrome. (Nugent 110-111) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client returns from surgery with a permanent colostomy. During the first 24 hours the colostomy does not drain. What does the nurse determine is the probable cause of this response? 1. Intestinal edema after surgery 2. Presurgical decrease in fluid intake 3. Absence of gastrointestinal motility 4. Effective functioning of nasogastric suction
3 This is caused by intestinal manipulation and the depressive effects of anesthesia and analgesics. 1 Edema will not totally interfere with peristalsis; there should be some output. 2 A presurgical decrease in fluid intake will not influence gastric motility 24 hours later. 4 A nasogastric tube decompresses the stomach; it does not directly influence intestinal motility at this time.
One month after abdominal surgery a client is readmitted to the hospital with recurrent abdominal pain and fever. The medical diagnosis is fistula formation with peritonitis. The nurse should maintain the client in the: 1. Supine position 2. Right Sims position 3. Semi-Fowler's position 4. Most comfortable position
3 This position promotes localization of purulent material and inflammation and prevents an ascending infection. 1 The risk of an ascending infection may be increased in this position because it allows fluid in the abdominal cavity to bathe the entire peritoneum. 2 The risk of an ascending infection may be increased in this position because it allows fluid in the abdominal cavity to bathe the entire peritoneum. 4 The client may choose a position that increases the risk of an ascending infection.
A client who has bone pain of insidious onset is suspected of having multiple myeloma. The nurse expects that one of the diagnostic findings specific for multiple myeloma is: 1. Occult blood in the stool 2. Low serum calcium levels 3. Bence Jones protein in the urine 4. Positive bacterial culture of sputum (Nugent 19) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 This protein (globulin) results from tumor cell metabolites. It is present in clients with multiple myeloma. 1 This is not specific for the diagnosis of multiple myeloma; it is a late complication of multiple myeloma related to coagulation defects. 2 Hypercalcemia, not hypocalcemia, occurs with multiple myeloma because of bone erosion. 4 Multiple myeloma is not caused by a bacterial infection. (Nugent 99) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client is scheduled to have a thyroidectomy for cancer of the thyroid. Preoperative instructions for the postoperative period include teaching the client to: 1. Cough and deep breathe every two hours 2. Perform range-of-motion exercises of the head and neck 3. Support the head with the hands when changing position 4. Apply gentle pressure against the incision when swallowing (Nugent 30) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 This relieves tension on the incision and limits the risk of dehiscence. 1 Coughing should be avoided during the early postoperative period to prevent trauma to the operative site. 2 This should be avoided until advised by the practitioner, usually after initial healing of the incision occurs. 4 Pressure against the operative area is not necessary to promote the integrity of the incision, and it may act to inhibit swallowing. (Nugent 111) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A nurse is notified that the latest potassium level for a client in acute renal failure is 6.2 mEq. What is most important for the nurse to do? 1. Alert the cardiac arrest team 2. Call the laboratory to repeat the test 3. Take vital signs and notify the practitioner 4. Obtain an ECG strip and have lidocaine available
3 Vital signs monitor the cardiopulmonary status; the practitioner must treat this hyperkalemia to prevent cardiac dysrhythmias. 1 The cardiac arrest team responds to a cardiac arrest; there is no sign of arrest in this client. 2 A repeat laboratory test will take time and probably reaffirm the original results; the client needs medical attention. 4 These are correct interventions if available, but the priority is medical attention and the practitioner should be notified immediately.
When assessing a client with Graves' disease, the nurse expects to identify: 1. Constipation, dry skin, and weight gain 2. Lethargy, weight gain, and forgetfulness 3. Weight loss, exophthalmos, and restlessness 4. Weight loss, protruding eyeballs, and lethargy (Nugent 29) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 Weight loss and restlessness occur because of an increased basal metabolic rate; exophthalmos occurs because of peribulbar edema. 1 These are associated with hypothyroidism because of the decreased metabolic rate. 2 Lethargy and weight gain are associated with hypothyroidism as a result of a decreased metabolic rate; forgetfulness is not related. 4 Although weight loss and exophthalmos occur with hyperthyroidism, the client will be hyperactive, not hypoactive. (Nugent 111) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
When a client is experiencing hypovolemic shock with decreased tissue perfusion, the nurse expects that the body initially attempts to compensate by: 1. Producing less ADH 2. Producing more red blood cells 3. Maintaining peripheral vasoconstriction 4. Decreasing mineralocorticoid production (Nugent 20) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
3 With shock, arteriolar vasoconstriction occurs, raising the total peripheral vascular resistance and shifting blood to the major organs. 1 With shock, more antidiuretic hormone (ADH) is produced to promote fluid retention, which will elevate the blood pressure. 2 Although this is a response to hypoxia, peripheral vasoconstriction is a more effective compensatory mechanism. 4 With shock the mineralocorticoids increase to promote fluid retention, which elevates the blood pressure. (Nugent 101) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
What age-related changes are associated with the female genitalia? Select all that apply. 1 Firm breasts 2 Erected nipples 3 Graying of pubic hair 4 Dry vagina 5 Decreased size of the labia majora
3,4,5 An elderly female client may have dry, smooth, and thin vaginal walls due to atrophy of the vaginal tissue and secretory glands on the vaginal walls. Graying and thinning pubic hair and decreased size of the labia majora and clitoris are also normal signs of aging. The client may have increased flabbiness and fibrosis of the breasts, which hang lower on the chest wall, along with decreased erection of the nipples.
A client with a renal disorder is scheduled for an intravenous pyelogram (IVP). Which interventions should the nurse undertake prior to the procedure? Select all that apply. 1 Instruct the client to lie still during the procedure 2 Have the client remove all metal objects 3 Ensure that the consent form is signed 4 Administer an enema or cathartic to the client 5 Assess the client for iodine sensitivity
3,4,5 The presence, position, shape, and size of kidneys, ureters, and bladder can be evaluated using an intravenous pyelogram (IVP). The contrast medium used in the procedure may cause hypersensitivity reactions. Therefore, the nurse should assess the client for sensitivity to iodine prior to the procedure. The nurse should use a cathartic or enema to empty the colon of feces and gas. An IVP does need a consent form since the procedure is invasive. The nurse has the client remove all metal objects before performing a magnetic resonance imaging (MRI) procedure. The nurse instructs the client to lie still during a computed tomographic (CT) scan procedure; during an IVP the client may be asked to turn certain ways.
501. After a bilateral herniorrhaphy the nurse should assess a male client for the development of: 1. Hydrocele 2. Paralytic ileus 3. Urinary retention 4. Thrombophlebitis
3. Because of pain and the proximity of the operative site to the lower urinary tract, urinary retention is common after this surgery.
463. The practitioner orders contact precautions for a client with hepatitis A. What specific interventions are required for contact precautions? 1. Private room and the door must be kept closed 2. Persons entering the room must wear a gown, a mask, and gloves 3. Gown and gloves must be worn when handling articles contaminated by urine or feces 4. Gowns and gloves must be worn only when handling the client's soiled linen, dishes, or utensils
3. Hepatitis A is transmitted via the fecal-oral route; contact precautions must be used when there are articles that have potential fecal and! or urine contamination.
Which retrograde procedure involves the examination of the ureters and the renal pelvises? 1 Urethrogram 2 Cystogram 3 Pyelogram 4 Voiding cystourethrogram
3... A pyelogram is a retrograde examination of the ureters and the pelvis of both kidneys. A cystogram is a retrograde examination of the bladder. An urethrogram is a retrograde examination of the urethra. A voiding cystourethrogram is used to determine whether urine is flowing backward into the urethra.
A nurse evaluates that a client with chronic kidney disease understands an adequate source of high biologic-value (HBV) protein when the client selects which food from the menu? 1 Apple juice 2 Raw carrots 3 Cottage cheese 4 whole wheat bread
3... Cottage cheese contains more protein than the other choices. Apple juice is a source of vitamins A and C, not protein. Raw carrots are a carbohydrate source and contain beta-carotene. Whole wheat bread is a source of carbohydrates and fiber. Test-Taking Tip: Come to your test prep with a positive attitude about yourself, your nursing knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study (implementation), and (d) answering questions (evaluation).
834. A nurse is admitting a client with multiple trauma to the nursing unit. The client has a leg fracture and had a plaster cast applied. In positioning the casted leg, the nurse should: 1. Keep the leg in a level position. 2. Elevate the leg for 3 hours and put it flat for 1 hour. 3. Keep the leg level for 3 hours and elevate it for 1 hour. 4. Elevate the leg on pillows continuously for 24 to 48 hours.
4 Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. Options 1, 2, and 3 are incorrect.
827. A nurse is conducting health screening for osteoporosis. Which of the following clients is at greatest risk of developing this disorder? 1. A 25-year-old woman who jogs 2. A 36-year-old man who has asthma 3. A 70-year-old man who consumes excess alcohol 4. A sedentary 65-year-old woman who smokes cigarettes
4 Rationale: Risk factors for osteoporosis include female gender, postmenopausal, advanced age, low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide (Lasix) also increase the risk.
829. A nurse is one of several persons who witness a vehicle hit a pedestrian at fairly low speed on a small street. The victim is dazed and tries to get up. The leg appears fractured. The nurse would plan to: 1. Try to reduce the fracture manually. 2. Assist the victim to get up and walk to the sidewalk. 3. Leave the victim for a few moments to call an ambulance. 4. Stay with the victim and encourage the person to remain still.
4 Rationale: With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse should remain with the victim and have someone else call for emergency help. A fracture is not reduced at the scene. Before the victim is moved, the site of fracture is immobilized to prevent further injury.
The nurse is caring for a client in the postanesthesia care unit. The client had a suprapubic prostatectomy for cancer of the prostate and has a continuous bladder irrigation (CBI) in place. Which primary goal is the nurse trying to achieve with the CBI? 1 Provide continuous pressure on the prostatic fossa. 2 Stimulate continuous formation of urine. 3 Facilitate the measurement of urinary output. 4 Prevent the development of clots in the bladder.
4 A continuous flushing of the bladder dilutes the bloody urine and empties the bladder, preventing clots. Fluid instilled into the bladder does not affect kidney function. Urinary output can be measured regardless of the amount of fluid instilled. The urinary retention catheter is not designed to exert pressure on the prostatic fossa.
A client is taught how to change the dressing and how to care for a recently inserted nephrostomy tube. On the day of discharge the client states, "I hope I can handle all this at home; it's a lot to remember." Which is the best response by the nurse? 1 "Oh, a family member can do it for you." 2 "Perhaps you can stay in the hospital another day." 3 "I'm sure you can do it." 4 "You seem to be nervous about going home."
4 4 The response "You seem to be nervous about going home" is the best reply. Reflection conveys acceptance and encourages further communication. The response "I'm sure you can do it" is false reassurance that does not help to reduce anxiety. The response "Oh, a family member can do it for you" provides false reassurance and removes the focus from the client's needs. The response "Perhaps you can stay in the hospital another day" is unrealistic, and it is too late to suggest this
Which test helps to identify fibroids, tumors, and fistulas while performing a reproductive tract examination? 1 Mammography 2 Computed tomography 3 Ultrasonography 4 Hysterosalpingography
4 A hysterosalpingogram is an X-ray used to evaluate tubal anatomy and patency and used to identify uterine problems such as fibroids, tumors, and fistulas. A mammography is an X-ray of the soft tissue of the breast. An ultrasonography (US) is a technique used to assess fibroids, cysts, and masses. Computer tomography is used to detect and evaluate masses and identify lymphatic enlargement from metastasis. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.
The nurse observes a client with kidney failure has increased rate and depth of breathing. Which laboratory parameter does the nurse suspect is associated with this client's condition? 1 Potassium 8 mEq/L 2 Phosphorous 7 mg/dL 3 Hemoglobin 10 g/dL 4 Bicarbonate 15 mEq/L
4 An increased rate and depth of breathing is called Kussmaul respiration and occurs due to metabolic acidosis in clients with kidney disease. Serum bicarbonate level decreases in metabolic acidosis. The normal range of serum bicarbonate is 23-30 mEq/L. Therefore the bicarbonate value of 15 mEq/L is associated with Kussmaul respirations in the client. The normal serum potassium is 3.5-5 mEq/L. Therefore a potassium level of 8 mEq/L indicates hyperkalemia and is associated with changes in cardiac rate and rhythm. The normal range of hemoglobin is 12-16 g/dL in females and 14-18 g/dL in males. Therefore a Hgb of 10 g/dL indicates anemia; this is associated with fatigue, pallor, and shortness of breath. The normal range of serum phosphorous is 3-4.5 mg/dL. Therefore a phosphorous value of 7 mg/dL indicates hyperphosphatemia, which is associated with hypocalcemia and demineralization of bone.
A client is admitted to the hospital with a diagnosis of cancer of the liver with ascites and is scheduled for a paracentesis. Which nursing intervention is appropriate to include in the client's plan of care? 1 Marking the anesthetic insertion site 2 Cleansing the intestinal tract 3 Discussing the operating room set-up 4 Having the client void before the procedure
4 Because the trocar is inserted below the umbilicus, having the client void decreases the danger of puncturing the bladder. Cleansing the intestinal tract is not necessary because the gastrointestinal tract is not involved in a paracentesis. The primary healthcare provider, not the nurse, uses a local anesthetic to block pain during the insertion of the aspirating needle; marking the site usually is not done. A paracentesis usually is performed in a treatment room or at the client's bedside, not in the operating room.
A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? 1 Inability of the renal tubules to reabsorb water to dilute the acid contents of blood 2 Impaired glomerular filtration, causing retention of sodium and metabolic waste products 3 Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention 4 Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate
4 Bicarbonate buffering is limited, hydrogen ions accumulate, and acidosis results. The rate of respirations increases in metabolic acidosis to compensate for a low pH. The fluid balance does not significantly alter the pH. The retention of sodium ions is related to fluid retention and edema rather than to acidosis.
The nurse is aware that the Cowper gland is also often referred to by which other term? 1 Skene gland 2 Prostate gland 3 Bartholin gland 4 Bulbourethral gland
4 Cowper glands are accessory glands of the male reproductive system; they are also referred to as the bulbourethral glands. Skene glands are a part of the female reproductive system. The prostate gland is also a gland of the male reproductive system. Bartholin glands are part of the female reproductive system.
A client with acute kidney injury is to receive peritoneal dialysis and asks why the procedure is necessary. Which is the nurse's best response? 1 "It speeds recovery because the kidneys are not responding to regulating hormones." 2 "It removes toxic chemicals from the body so you will not get worse." 3 "It prevents the development of serious heart problems." 4 "It helps perform some of the work usually done by the kidneys."
4 Dialysis removes chemicals, wastes, and fluids usually removed from the body by the kidneys. The mention of heart problems is a threatening response and may cause increased fear or anxiety. Stating that peritoneal dialysis "removes toxic chemicals from the body so you will not get worse" is threatening and can cause an increase in anxiety. Dialysis helps maintain fluid and electrolytes; the nephrons are damaged in acute kidney injury, so it may or may not speed recovery.
A client scheduled for a transurethral prostatectomy expresses concern about the effect the surgery will have on sexual ability. Which information should the nurse share with the client? 1 Will have prolonged erections 2 Will be impotent 3 May have a diminished sex drive 4 May experience retrograde ejaculations
4 Ejection of semen into the bladder instead of the urethra is common after a transurethral prostatectomy. The surgery should not interfere with the libido and will not cause prolonged erections. Impotence is not typical with this approach; it may occur with the retroperitoneal approach.
The nurse is providing education to a client with calculi in the calyces of the right kidney. The client is scheduled to have the calculi removed. Which information should the nurse include in the teaching? 1 The surgery will be performed transurethrally. 2 After surgery, a suprapubic catheter will be in place. 3 During the surgery, the right ureter will be removed. 4 After surgery, there will be a small incision in the right flank area.
4 If the calculi are in the renal pelvis, a percutaneous pyelolithotomy is performed; the calculi are removed via a small flank incision. Removal of the right ureter is not necessary. Performing surgery transurethrally is used for calculi in the ureters and renal pelvis. Placement of a suprapubic catheter usually is unnecessary.
What is the concentration of estradiol in the blood during the follicular phase of the menstrual cycle? 1 159 pg/mL 2 165 pg/mL 3 171 pg/mL 4 130 pg/mL
4 In the follicular phase of the menstrual cycle, 20-150 pg/mL of estradiol is released. Therefore 130 pg/mL of estradiol would be its concentration during the follicular phase of the menstrual cycle. Concentrations of 159, 165, and 171 pg/mL are greater than the reference range.
A nurse is evaluating a client's understanding of peritoneal dialysis. Which information in the client's response indicates an understanding of the purpose of the procedure? 1 Providing fluid for intracellular spaces 2 Cleaning the peritoneal membrane 3 Reestablishing kidney function 4 Removing toxins in addition to other metabolic wastes
4 Peritoneal dialysis uses the peritoneum as a selectively permeable membrane for diffusion of toxins and wastes from the blood into the dialyzing solution. Peritoneal dialysis acts as a substitute for kidney function; it does not reestablish kidney function. The dialysate does not clean the peritoneal membrane; the semipermeable membrane allows toxins and wastes to pass into the dialysate within the abdominal cavity. Fluid in the abdominal cavity does not enter the intracellular compartment
Which type of hypersensitivity reaction is present in a client with a body temperature of 102 °F, severe joint pain, rashes on the extremities, and enlarged lymph nodes from serum sickness? 1 Delayed reaction 2 Cytotoxic reaction 3 Immediate reaction 4 Immune complex-mediated reaction
4 Serum sickness is a type III immune complex-mediated reaction. A delayed reaction is a type IV hypersensitivity reaction that may include poison ivy skin rashes, graft rejection, and sarcoidosis. A cytotoxic reaction is a type II hypersensitivity reaction that includes autoimmune hemolytic anemia, Goodpasture syndrome, and myasthenia gravis. An immediate reaction is a type I hypersensitive reaction that includes allergic asthma, hay fever, and anaphylaxis. Test-Taking Tip: Serum sickness is manifested by elevated body temperature, severe joint pain, rashes on limbs, and enlarged lymph nodes. Recall the type of hypersensitivity reaction to which serum sickness belongs.
Which condition should be reported immediately to the primary healthcare provider? 1 Rectal bleeding for 2 days after prostate biopsy 2 Pelvic pain immediately after colposcopy 3 Light vaginal bleeding for 1 to 2 days following a hysterosalpingogram 4 Body temperature of 102° F with vaginal discharge 48 hours after cervical biopsy
4 The client with cervical biopsy should immediately report to the primary healthcare provider if experiencing a body temperature of 102° F with vaginal discharge. This is because fever and vaginal discharge that develops 48 hours after cervical biopsy may be the signs of infection related to the procedure. The client should take pain relievers for pelvic pain after colposcopy. Light vaginal bleeding for 1 to 2 days following hysterosalpingogram is common. If the amount of bleeding increases or extends beyond 2 days, the healthcare provider should be notified. Light rectal bleeding for a few days is common after prostate biopsy.
The urinalysis report of a client reveals cloudy urine. What does a nurse infer from the client's report? 1 The client has a biliary obstruction. 2 The client has diabetic ketoacidosis. 3 The client has been on a starvation diet. 4 The client has a urinary infection.
4 The urine becomes cloudy when an infection is present due to the presence of leukocytes. Therefore the nurse concludes that the client has a urinary infection. In cases of biliary obstruction, the urine contains bilirubin. The presence of ketones in the urine indicates diabetic ketoacidosis or prolonged starvation
A client with ascites is scheduled for a paracentesis. To prepare the client for the abdominal paracentesis the nurse should: 1. Shave the client's abdomen 2. Medicate the client for pain 3. Encourage the client to drink fluids 4. Instruct the client to empty the bladder
4 Emptying the bladder of urine keeps the bladder in the pelvic area and prevents puncture when the abdominal cavity is entered. 1 This is not necessary. 2 This is not necessary. 3 Encouraging fluids is unsafe; the bladder will rise into the abdominal cavity and may be punctured.
To prevent future attacks of glomerulonephritis, the nurse planning discharge teaching includes instructions for the client to: 1. Take showers instead of bubble baths 2. Avoid situations that involve physical activity 3. Continue the same restrictions on fluid intake 4. Seek early treatment for respiratory infections
4 A common cause of glomerulonephritis is a streptococcal infection. This infection initiates an antibody formation that damages the glomeruli. 1 The alkalinity of bubble baths is linked to urethritis, not glomerulonephritis. 2 Moderate activity is helpful in preventing urinary stasis, which can precipitate urinary infection. 3 Any fluid restriction is moderated as the client improves; fluid is allowed to prevent urinary stasis.
A 72-year-old male complaining of dysuria, nocturia, and difficulty starting the urinary stream is scheduled for a cystoscopy and biopsy of the prostate gland. After the procedure the client complains that he is unable to void. The nurse should: 1. Limit oral fluids until he voids 2. Assure him that this is expected 3. Insert a urinary retention catheter 4. Palpate above the pubic symphysis
4 A full bladder is palpable with urinary retention and distention, which are common problems after a cystoscopy because of urethral edema. 1 Fluids dilute the urine and reduce the chance of infection after cystoscopy and should not be limited. 2 Although urinary retention can occur, it is not expected; the nurse must assess the extent of bladder distention and discomfort. 3 More conservative nursing methods such as running water or placing a warm cloth over the perineum should be attempted to precipitate voiding; catheterization carries a risk of infection.
When teaching a client about the diet after a pancreaticoduodenectomy (Whipple procedure) performed for cancer of the pancreas, the statement the nurse should include is: 1. "There are no dietary restrictions; you may eat what you desire." 2. "Your diet should be low in calories to prevent taxing your pancreas." 3. "Meals should be restricted in protein because of your compromised liver function." 4. "Low-fat meals should be eaten because of interference with your fat digestion mechanism."
4 A pancreaticoduodenectomy leads to malabsorption because of impaired delivery of bile to the intestine; fat metabolism is interfered with, causing dyspepsia. 1 These clients are anorexic, require small frequent meals, and should eat a high-calorie, high-protein, low-fat diet. 2 High-calorie meals are needed for energy and to promote use of protein for tissue repair. 3 High protein is required for tissue building; there is no problem with the liver in clients with cancer of the pancreas unless direct extension occurs.
A nurse assesses a newly admitted client with renal colic to determine the signs and symptoms that may be present. The nurse should assess the client for which primary subjective symptom? 1. Uremia 2. Nausea 3. Voiding at night 4. Flank discomfort
4 A subjective symptom must be experienced and described by the client; flank pain, pain on the side of the body between the ribs and the ileum, accompanies renal colic. 1 This is an objective sign that can be verified by observation or measurement. 2 Although nausea is a subjective symptom and it can occur with the severe pain associated with renal colic, it is not as significant as flank pain. 3 This is an objective sign that can be verified by observation or measurement.
A client diagnosed with multiple myeloma asks the practitioner about what treatment will be administered. The nurse expects the practitioner to reply: 1. "Alpha-interferon therapy." 2. "Radiation therapy on an outpatient basis." 3. "Surgery to remove the lesion and lymph nodes." 4. "Chemotherapy utilizing a combination of drugs." (Nugent 19) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 A variety of drugs affect rapidly dividing cells at different stages of cell division. 1 Although this is an acceptable therapy, it is not the first treatment used. 2 This is not a primary approach; it may be used to alleviate pain and treat acute vertebral lesions. 3 Multiple myeloma is a disorder of the bone; there are no lesions that can be removed. (Nugent 99) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
The response after a gastroscopy that indicates a major complication is: 1. Difficulty swallowing 2. Increased GI motility 3. Nausea with vomiting 4. Abdominal distention with pain
4 Abdominal distention, which may be associated with pain, can indicate perforation, a complication that can lead to peritonitis. 1 A local inflammatory response to insertion of the fiberoptic tube may result in a sore throat and dysphagia once the anesthesia wears off; this is expected. 2 This, together with cramping, is an expected response. 3 This is not indicative of any particular problem in this situation.
To motivate an obese client to eventually include aerobic exercises in a weight-reduction program, the nurse discusses exercise and its relationship to weight loss. The nurse evaluates that this teaching is effective when the client states, "I know that exercise will: 1. decrease my appetite." 2. lower my metabolic rate." 3. raise my resting heart rate." 4. increase my lean body mass."
4 Exercise builds skeletal muscle mass and reduces excess fatty tissue. 1 Appetite may increase with exercise. 2 The metabolic rate will increase with exercise. 3 During aerobic exercise the heart rate will increase, but between periods of exercise the heart rate will decrease because of the development of collateral circulation.
A client with type 2 diabetes travels frequently and asks how to plan meals during trips. The nurse's most appropriate response is: 1. "You can order diabetic foods on most airlines and in restaurants." 2. "You should plan your food ahead and carry it with you from home." 3. "You can monitor your blood glucose level frequently and can eat accordingly." 4. "You should make regular food choices and follow your food plan wherever you are." (Nugent 32) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 According to an individual's needs, consistency and regularity in the food plan should be maintained; this is a basic principle of dietary management of diabetes. 1 This is not necessary; the client can make selections from regular food choices. 2 This cannot always be done; it is unnecessary because choices can be made within the food plan 3 The client should follow the food plan. (Nugent 114) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A 62-year-old client is admitted for hypertension, and serum electrolyte studies have yielded abnormal results. The scheduled workup includes a scan for an aldosteronoma. The nurse concludes that this scan is ordered to rule out disease of the: 1. Kidney cortex 2. Thyroid gland 3. Pituitary gland 4. Adrenal cortex (Nugent 28-29) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 An aldosteronoma is an aldosterone-secreting adenoma of the adrenal cortex. 1 An aldosteronoma is not a tumor of the kidney cortex. 2 An aldosteronoma is not a tumor of the thyroid gland. 3 An aldosteronoma is not a tumor of the pituitary gland. (Nugent 110) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. The priority nursing intervention is to: 1. Weigh the client daily 2. Restrict the client's oral fluid intake 3. Measure the client's urine specific gravity 4. Observe the client for increasing confusion
4 An increased serum ammonia level impairs the CNS, causing an altered level of consciousness. 1 Increasing ammonia levels are not related to weight. 2 An alteration in fluid intake will not affect the serum ammonia level. 3 This is not the priority; the priority is to monitor the client's neurological status.
What should the nurse do when a client is scheduled for a barium swallow? 1. Give clear fluids on the day of the test 2. Ask the client about allergies to iodine 3. Administer cleansing enemas before the test 4. Ensure a laxative is ordered after the procedure
4 Barium will harden and may create an impaction; a laxative and increased fluids promote elimination of barium. 1 The client must be kept NPO. 2 Iodine is not used with barium. 3 This is not part of the preparation; feces in the lower GI tract will not interfere with visualization of the upper GI tract.
A client is suspected of having late-stage (tertiary) syphilis. When obtaining a health history, the nurse determines that the statement by the client that most supports this diagnosis is: 1. "I noticed a wart on my penis." 2. "I have sores all over my mouth." 3. "I've been losing a lot of hair lately." 4. "I'm having trouble keeping my balance."
4 Neurotoxicity, as manifested by ataxia, is evidence of tertiary syphilis, which may involve the CNS; other CNS signs include confusion, paralysis, delusions, impaired judgment, and slurred speech. 1 A sore on the penis occurs in the secondary stage. 2 Sores in the mouth occur in the secondary stage. 3 Alopecia is not a sign of late-stage syphilis.
A client with multiple myeloma is scheduled to have a chest x-ray examination and a bone scan. For this client, the primary responsibility of the nursing and radiology staff is to: 1. Explain the procedure and its purpose 2. Observe the client for the presence of pallor 3. Provide for rest periods during the procedure 4. Handle the client with supportive movements (Nugent 19) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Because of bone erosion, pathological fractures are a common complication of multiple myeloma. 1 Although this is done, the priority is to prevent injury. 2 Although this is an adaptation to the associated anemia, it is not life threatening. 3 Although this is important, preventing pathological fractures is the priority. (Nugent 99) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
When taking the blood pressure of a client who has AIDS, the nurse must: 1. Don clean gloves 2. Use barrier techniques 3. Put on a mask and gown 4. Wash the hands thoroughly (Nugent 18) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Because this procedure does not involve contact with blood or secretions, additional protection is not indicated. 1 These are necessary only when there is risk of contact with blood or body fluid. 2 These are necessary only when there is risk of contact with blood or body fluid. 3 A mask and gown are indicated only if there is a danger of secretions or blood splattering on the nurse (for example, during suctioning). (Nugent 98) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A nurse asks a client to make a list of the foods that cause dyspepsia. If the client has cholecystitis, the foods that are most likely to be included on this list are: 1. Nuts and popcorn 2. Meatloaf and baked potato 3. Chocolate and boiled shrimp 4. Fried chicken and buttered corn
4 Cholecystitis is often accompanied by intolerance to fatty foods, including fried foods and butter. 1 Because these foods have a high fiber content, they cause flatulence and pain for clients with lower intestinal problems such as diverticulosis. 2 These foods contain less fat than do fried foods or butter. 3 Neither chocolate nor boiled seafood contains as much fat as fried chicken or butter.
The nurse instructs a client diagnosed with hepatitis A about untoward signs and symptoms related to hepatitis that may develop. The one that should be reported to the practitioner is: 1. Fatigue 2. Anorexia 3. Yellow urine 4. Clay-colored stools
4 Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines. 1 It is unnecessary to call the practitioner because this symptom is characteristic of hepatitis from the onset of clinical manifestations. 2 It is unnecessary to call the practitioner because this symptom is characteristic of hepatitis from the onset of clinical manifestations. 3 This is the expected color of urine.
474. A client with cirrhosis of the liver and malnutrition begins to develop slurred speech, confusion, drowsiness, and tremors. With these signs and symptoms, the diet should be limited to: 1. 20 grams of protein, 2000 calories 2. 80 grams of protein, 1000 calories 3. 100 grams of protein, 2500 calories 4. 150 grams of protein, 1200 calories
474. 1 The signs and symptoms indicate hepatic coma; protein is reduced according to tolerance, and calories are increased to prevent tissue catabolism.
A nurse teaches a client with type 2 diabetes how to provide self-care to prevent infections of the feet. The nurse evaluates that the teaching was effective when the client says, "I should: 1. massage my feet and legs with oil or lotion." 2. apply heat intermittently to my feet and legs." 3. eat foods high in protein and carbohydrate kilocalories." 4. control my blood glucose with diet, exercise, and medication." (Nugent 31) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Controlling the diabetes decreases the risk of infection; this is the best prevention. 1 If not completely absorbed, these may provide a warm, moist environment for bacterial growth. 2 Coexisting neuropathy may result in injury from heat application. 3 Protein, carbohydrates, and fats must be in an appropriate balance; high carbohydrate intake can provide too many calories. (Nugent 113) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client is diagnosed as having a peptic ulcer. When teaching about peptic ulcers, the nurse instructs the client to report any stools that appear: 1. Frothy 2. Ribbon shaped 3. Pale or clay colored 4. Dark brown or black
4 Dark brown or black stools (melena) indicate gastrointestinal bleeding. 1 Frothy stools are indicative of inadequate fat absorption and are associated with sprue. 2 Ribbon-shaped stools indicate a bowel mass or obstruction. 3 Clay-colored stools usually are related to problems that cause a decrease in bile.
A client who had a gastric resection for cancer of the stomach is admitted to the postanesthesia care unit with a nasogastric tube. The nurse expects to observe: 1. Periodic vomiting 2. Intermittent bouts of diarrhea 3. Gastric distention after 6 hours 4. Bloody drainage for the first 12 hours
4 Drainage is bright red initially and gradually becomes darker red during the first 24 hours. 1 If the nasogastric tube is functioning correctly, secretions will be removed and vomiting will not occur. 2 Because the bowel was emptied before surgery and the client is now NPO, intestinal activity is not expected. 3 If the nasogastric tube is functioning correctly, gastric distention will not occur.
A client develops a gallstone that becomes lodged in the common bile duct. The practitioner schedules an endoscopic sphincterotomy. Preoperative teaching includes information that for the procedure the client will: 1. Have a spinal anesthetic 2. Receive an epidural block 3. Have a general anesthetic 4. Receive an intravenous sedative
4 During the procedure a sedative is administered intravenously as needed to help the client stay calm. 1 This is not used during this procedure. 2 This is not used during this procedure. 3 This is not used during this procedure.
A client who has type 1 diabetes is admitted to the hospital for major surgery. Before surgery the client's insulin requirements are elevated but well controlled. Postoperatively, the nurse anticipates that the client's insulin requirements will: 1. Decrease 2. Fluctuate 3. Increase sharply 4. Remain elevated (Nugent 32) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Emotional and physical stress may cause insulin requirements to remain elevated in the postoperative period. 1 Insulin requirements will remain elevated rather than decrease. 2 Fluctuating insulin requirements are usually associated with noncompliance, not surgery. 3 A sharp increase in the client's insulin requirements may indicate sepsis, but this is not expected. (Nugent 114) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client with type 2 diabetes is taking one oral hypoglycemic tablet daily. The client asks whether an extra pill should be taken before exercise. The best response by the nurse is: 1. "You will need to decrease your exercise." 2. "An extra pill will help your body use glucose correctly." 3. "When taking medicine your diet will not be affected by exercise." 4. "No, but you should observe for signs of hypoglycemia while exercising." (Nugent 31) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Exercise improves glucose metabolism; with exercise there is a risk of developing hypoglycemia, not hyperglycemia. 1 Exercise should not be decreased because it improves glucose metabolism. 2 An extra tablet will probably result in hypoglycemia because exercise alone improves glucose metabolism. 3 Control of glucose metabolism is achieved through a balance of diet, exercise, and pharmacologic therapy. (Nugent 113-114) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A male client with chronic liver disease reports that his gums bleed spontaneously. In addition, the nurse identifies small hemorrhagic lesions on his face. The nurse concludes that the client needs additional: 1. Bile salts 2. Folic acid 3. Vitamin A 4. Vitamin K (Nugent 17) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Fat-soluble vitamin K is essential for synthesis of prothrombin by the liver; a lack results in hypoprothrombinemia, inadequate coagulation, and hemorrhage. 1 Although cirrhosis may interfere with production of bile, which contains the bilirubin needed for optimum absorption of vitamin K, the best and quickest manner to counteract the bleeding is to provide vitamin K intramuscularly. 2 Folic acid is a coenzyme with vitamins B12 and C in the formation of nucleic acids and heme; thus a deficiency may lead to anemia, not bleeding. 3 Vitamin A deficiency contributes to development of polyneuritis and beriberi, not hemorrhage. (Nugent 97) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
After surgery for cancer of the pancreas, the client's nutrition and fluid regimen will be influenced by the remaining amount of functioning pancreatic tissue. Considering both the exocrine and the endocrine functions of the pancreas, the client's postoperative regimen will primarily include managing the intake of: 1. Alcohol and caffeine 2. Fluids and electrolytes 3. Vitamins and minerals 4. Fats and carbohydrates
4 Formation of lipase necessary for digestion of fats is an exocrine function; the endocrine function is to secrete insulin, which is a hormone essential in carbohydrate metabolism. 1 Although it is necessary to avoid alcohol, this is not related to pancreatic exocrine functions; caffeine is unrelated to pancreatic function. 2 Fluid and electrolyte problems are not related specifically to exocrine or endocrine pancreatic functioning. 3 Deficiencies of vitamins and minerals may occur because of inadequate intake, but these deficiencies are not specifically related to exocrine or endocrine pancreatic functioning.
A mother whose son has hepatitis A states that there is only one bathroom in their home and she is worried that other members of the family may get hepatitis. The nurse's best reply is: 1. "I suggest that you buy a commode exclusively for your son's use." 2. "There is no problem with your son sharing the same bathroom with everyone." 3. "Your son may use the bathroom, but you need to use disposable toilet covers." 4. "It is important that family members, including your son, wash their hands after using the bathroom."
4 Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper handwashing. 1. This is unnecessary; cleansing the toilet and washing the hands should control the transmission of microorganisms. 2 If the son uses the same bathroom as others, provision must be made for the cleaning of equipment or disposal of contaminated wastes. 3 The use of disposable toilet covers is inadequate to prevent the spread of microorganisms if the bathroom used by the son also is used by others. Handwashing by all family members must be part of the plan to prevent the spread of hepatitis to other family members.
A client has end-stage kidney disease and is admitted for a kidney transplant. The nurse teaches the client that the donor must: 1. Have the same blood type 2. Be a member of the same family 3. Be approximately the same body size 4. Have matching leukocyte antigen complexes
4 Human leukocyte antigen compatibility provides the most specific predictions of the body's tendency to accept or reject foreign tissue. 1 Although ABO compatibility is necessary, the exact blood type is not. 2 This is unsafe unless the family member has matching leukocyte antigen complexes. This may increase the possibility of a match, but there is no guarantee that a family member will match. 3 Differences in body size do not cause rejection.
A client is brought to the emergency service after an automobile collision. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. Based on this information, the nurse assesses the client for which early response to decreased arterial pressure? 1. Warm and flushed skin 2. Confusion and lethargy 3. Increased pulse pressure 4. Reduced peripheral pulses (Nugent 20) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Hypovolemia results in a decreased cardiac output and a decreased arterial pressure, which are reflected by a feeble, weak peripheral pulse. 1 The skin will be cool and pale because of vasoconstriction. 2 These are late signs of shock. 3 The pulse pressure narrows with decreased cardiac pressure associated with hypovolemic shock. (Nugent 100-101) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A 75-year-old male with a history of cancer of the prostate is admitted for a prostatectomy. The client's prostate specific antigen (PSA) levels have been increasing. This finding should prompt the nurse to plan to: 1. Measure intake and output 2. Institute seizure precautions 3. Monitor his plasma pH for acidosis 4. Handle him gently when turning him
4 Increasingly elevated PSA levels may indicate a worsening of the client's condition with possible metastasis to the bone, increasing the risk of pathological fractures; therefore, handling must be gentle. 1 Although measuring intake and output is necessary for any client with prostatic cancer because of the risk of bladder obstruction, it is not the priority for this client. 2 Seizure precautions are not necessary; a PSA elevation indicates bone, not brain, involvement. 3 Elevated PSA levels do not significantly affect the plasma pH.
A client is diagnosed as having type 2 diabetes. A priority teaching goal is, "The client will be able to: 1. perform foot care daily." 2. administer insulin as ordered." 3. test urine for both sugar and acetone." 4. identify pending hypoglycemia or hyperglycemia." (Nugent 31) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Knowledge of the signs and treatment for hypoglycemia or hyperglycemia is critical to client health and well-being and essential for survival. 1 Although this is important, it is not the priority. 2 The client has type 2 diabetes, which usually is controlled by oral hypoglycemics. 3 Self-serum glucose monitoring is more accurate than sugar and acetone (S&A) urine measurements to identify serum glucose levels. (Nugent 113) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client is scheduled for an intravenous pyelogram (IVP). The nurse explains that on the day before the IVP the client must: 1. Avoid fats and proteins 2. Drink a large amount of fluids 3. Omit dinner and limit beverages 4. Take a laxative before going to bed
4 Laxatives remove feces and flatus, providing better visualization. 1 An IVP does not require restrictions of fat and proteins. 2 Large amounts of fluids may dilute the dye, impairing visualization. 3 A light dinner and beverage are permitted.
471. A client with a long history of alcohol abuse is admitted to the hospital with ascites, jaundice, and confusion. A diagnosis of hepatic cirrhosis is made. A nursing priority is to: 1. Institute safety measures 2. Monitor respiratory status 3. Measure abdominal girth daily, 4. Test stool specimens for blood
471. 1 The high ammonia levels contribute to deterioration of mental function and then to hepatic encephalopathy and hepatic coina; safety is the priority.
When assisting a client with type 1 diabetes, the nurse identifies a 5-cm nodule on the upper arm, where the client states she has been injecting her insulin at home. The nurse concludes that the nodule, which is neither warm nor painful, is a result of: 1. Keratosis 2. An allergy 3. An infection 4. Lipodystrophy (Nugent 33) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Lipodystrophy is a noninflammatory reaction causing localized atrophy or hypertrophy and a localized increase in collagen deposits. 1 Injections of insulin will not cause a horny growth such as a wart or callus. 2 An allergic response will precipitate a localized or systemic inflammatory response. 3 Hyperthermia and localized heat, erythema, and pain are associated with an infection. (Nugent 115) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
After the surgical creation of an ileostomy, a client is transferred to a rehabilitation unit. The client asks for help in selecting breakfast. What should the nurse encourage the client to eat or drink? 1. Hot coffee and oranges 2. Shredded wheat and milk 3. Toast and a western omelet 4. Cream of wheat and bananas
4 Low-residue foods will not increase motility. 1 Warmth and the fiber in the orange juice will increase motility and should be avoided. 2 Wheat cereal contains roughage and should be avoided. 3 Toast and the vegetables in a western omelet are high in residue; also the omelet is fried, which should be avoided.
During a home visit to a client, the nurse identifies tremors of the client's hands. When discussing this assessment, the client reports being nervous, having difficulty sleeping, and feeling as if the collars of shirts are getting tight. Which problem should be reported to the practitioner? 1. Increased appetite 2. Recent weight loss 3. Feelings of warmth 4. Fluttering in the chest (Nugent 29) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Many of these problems are associated with hyperthyroidism; palpitations may indicate cardiovascular changes requiring prompt intervention. The increased metabolism associated with hyperthyroidism can lead to heart failure. 1 Although an increased appetite becomes a compensatory mechanism for the increased metabolism associated with hyperthyroidism, it is not life threatening. 2 Although unexplained weight loss can result from catabolism associated with hyperthyroidism, it is not life threatening. 3 Although a feeling of warmth caused by the increased metabolism associated with hyperthyroidism is uncomfortable, it is not life threatening. (Nugent 111) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Before obtaining blood for protein-bound iodine, T3, and T4 tests the nurse should ask a client, suspected of having a hyperactive thyroid, if the client has had: 1. Allergies to seafood 2. More protein intake than usual 3. Anything to drink before the test 4. Recent x-rays using radiopaque dye (Nugent 29) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Many radiopaque dyes contain iodine, which will alter the protein-bound iodine test results. 1 The tests ordered do not require this information. 2 This is not specifically related to these studies. 3 This is not specifically related to these studies. (Nugent 111) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client is to be discharged after a laser laparoscopic cholecystectomy. The nurse evaluates that the discharge instructions are understood when the client states: 1. "I can change the bandages every day." 2. "I should stay on a full liquid diet for 3 days." 3. "I should not clean the surgical sites for a week." 4. "I may have mild shoulder pain for about a week."
4 Mild shoulder pain is common up to 1 week after surgery because of diaphragmatic irritation secondary to abdominal stretching or residual carbon dioxide that was used to inflate the abdominal cavity during surgery. 1 The bandages are removed the second day postoperatively. 2 Clients generally tolerate food after 24 to 48 hours. 3 The client may bathe and shower as usual.
A client who has a gastric ulcer asks what to do if epigastric pain occurs. The nurse evaluates that teaching is effective when the client states, "I will: 1. increase my food intake." 2. take an aspirin with milk." 3. eliminate fluids with meals." 4. take an antacid preparation."
4 Over-the-counter antacid preparations neutralize gastric acid and relieve pain. 1 Although eating food initially prevents gastric acid from irritating the gastric walls, it can precipitate acid production. 2 Aspirin is contraindicated because it irritates gastric mucosa and promotes bleeding by preventing platelet aggregation. 3 Reduction of fluids with meals does not affect pain; it helps prevent dumping syndrome.
A nurse is obtaining the health history of a client with a left ureteral calculus who is scheduled for a transurethral ureterolithotomy. Which description of pain should the nurse expect the client to report? 1. Boring pain in the left flank 2. Pain that intensifies on urination 3. Dull pain that is constant in the costovertebral angle 4. Spasmodic pain on the left side that radiates to the suprapubic area
4 Pain with ureteral stones is caused by spasm and is excruciating and intermittent; it follows the path of the ureter to the bladder. 1 Pain is spasmodic and excruciating, not boring. 2 Pain intensifies as the calculus lodges in the ureter and spasms occur in an attempt to dislodge it. 3 Spasmodic pain on the left side that radiates to the suprapubis is typical of pain caused by a stone in the renal pelvis.
A male client with liver dysfunction reports that his gums bleed spontaneously. In addition, the nurse identifies small hemorrhagic lesions on his face. The nurse concludes that the client needs additional vitamin: 1. D 2. E 3. A 4. K
4 Petechiae are evidence of capillary bleeding; the diseased liver is no longer able to metabolize vitamin K, which is necessary to activate blood clotting factors. 1 Vitamin D is not involved in the clotting process. 2 Vitamin E is not involved in the clotting process. 3 Vitamin A is not involved in the clotting process, even though the transformation of carotene to vitamin A takes place in the liver.
A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care. The nurse advises the client to: 1. Skip the oral hypoglycemic pill, drink plenty of fluids, and stay in bed 2. Avoid food, drink clear liquids, take a daily temperature, and stay in bed 3. Eat as much as possible, increase fluid intake, and call the office again the next day 4. Take the oral hypoglycemic pill, drink warm fluids, and perform a serum glucose test before meals and at hour of sleep (Nugent 31-32) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Physiological stress increases gluconeogenesis, requiring continued pharmacological therapy despite an inability to eat; fluids prevent dehydration; monitoring serum glucose levels permits early intervention if necessary. 1 Skipping the oral hypoglycemic can precipitate hyperglycemia; serum glucose levels must be monitored. 2 Food intake should be attempted to prevent acidosis; oral hypoglycemics should be taken, and serum glucose levels should be monitored. 3 These are incomplete instructions; oral hypoglycemics should be taken, and serum glucose levels should be monitored; eating as much as possible can precipitate hyperglycemia. (Nugent 114) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A long-term complication that a client must be made aware of after a pancreaticoduodenectomy for cancer of the pancreas is hypoinsulinism. The nurse evaluates that the teaching about hypoinsulinism is understood when the client states, "I should seek medical supervision if I experience: 1. oliguria." 2. anorexia." 3. weight gain." 4. increased thirst."
4 Polydipsia is characteristic of hypoinsulinism (diabetes mellitus) because excessive urine is excreted related to glycosuria. 1 Polyuria, not oliguria, is characteristic of diabetes mellitus because the kidneys excrete excess fluid with the glucose. 2 Increased appetite is characteristic of diabetes mellitus because of impaired metabolism. 3 Weight loss characterizes diabetes mellitus because of the use of body mass as a source of energy.
A client with cholelithiasis has a laser laparoscopic cholecystectomy. Postoperatively it is most appropriate for the nurse to: 1. Wait about 24 hours to begin clear liquids 2. Monitor the abdominal incision for bleeding 3. Offer clear carbonated beverages to the client 4. Instruct the client to resume moderate activity in 2 to 3 days
4 Recovery will be rapid because there is no large abdominal incision. 1 Clear liquids may be started as soon as the client is awake and a gag reflex has returned. 2 With a laparoscopic cholecystectomy there will be one or more puncture wounds, not an incision, on the abdomen. 3 Carbonated beverages will create gas, which will distend the intestines and increase pain.
Part of discharge teaching for a client with a sigmoid colostomy includes how to protect clothing from colostomy leakage. What is the nurse's most appropriate response when the client asks about the use of appliances and dressings? 1. "Appliances are used to avoid soiling your clothing." 2. "Special appliances are expensive but they provide for better bowel control." 3. "I will give you enough appliances to last until your next visit to the physician." 4. "Many people do not need appliances once they regulate their bowels with routine irrigations."
4 Regular irrigation and effective evacuation prevent unexpected bowel movements; generally a drainage pouch is needed only immediately after an irrigation. 1 Once the colostomy is regulated, an appliance is necessary only immediately after the irrigation (approximately 1 hour). 2 Appliances collect what is evacuated; they do not control the function of the colostomy; a "special" appliance is not needed. 3 This response does not address the client's concern.
A nurse assesses for the development of pernicious anemia when a client has a history of: 1. Hemorrhage 2. Diabetes mellitus 3. Unhealthy dietary habits 4. Having had a gastrectomy
4 Removal of the fundus of the stomach destroys the parietal cells that secrete intrinsic factor (needed to combine with vitamin B12 preliminary to its absorption in the ileum). 1 Hemorrhaging may cause anemia; however, pernicious anemia occurs when the intrinsic factor is not produced. 2 The beta cells of the pancreas are not involved in secretion of intrinsic factor. 3 Dietary intake does not affect the production of intrinsic factor.
Which is the best advice regarding foot care to give a client with the diagnosis of diabetes? 1. Remove corns on the feet 2. Wear shoes that are larger than the feet 3. Examine the feet weekly for potential sores 4. Wear synthetic fiber socks when exercising (Nugent 32) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Research demonstrates that socks with synthetic fibers wick away moisture better than other fabrics when participating in vigorous activities. 1 Self-removal of corns can result in injury to the feet. 2 Shoes that do not fit appropriately will create friction causing sores, blisters, and calluses. 3 The feet should be examined daily, not weekly. (Nugent 115) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A male client, age 56, is being assessed for possible cancer of the urinary bladder. Of the client's signs and symptoms, the one most significant for cancer of the urinary tract is: 1. Dysuria 2. Retention 3. Hesitancy 4. Hematuria
4 Research statistics indicate that hematuria is the most common early sign of cancer of the urinary system, probably because of the urinary system's rich vascular network. 1 Dysuria is not specific for bladder cancer; usually it is associated with an enlarged prostate in the male. 2 Retention is not specific for bladder cancer; usually it is associated with an enlarged prostate in the male. 3 Hesitancy is not specific for bladder cancer; usually it is associated with an enlarged prostate in the male.
When teaching a client how to prevent constipation, the nurse evaluates that the dietary teaching is understood when the client states that the preferred breakfast cereal is: 1. Froot Loops 2. Corn Flakes 3. Cap'n Crunch 4. Shredded Wheat
4 Shredded Wheat contains 5.5 grams of fiber per serving, which is more than the other choices. 1 Froot Loops contain 0.8 gram of fiber per serving. 2 Corn Flakes contain 0.7 gram of fiber per serving. 3 Cap'n Crunch contains 0.7 gram of fiber per serving.
After a cholecystectomy to remove a cancerous gallbladder, the client has a T-tube in place that has drained 300 mL of bile-colored fluid during the first 24 hours. The nurse should: 1. Clamp the tube intermittently to slow drainage 2. Increase the rate of intravenous fluids to compensate for this loss 3. Empty the portable drainage system and reestablish negative pressure 4. Consider this an expected response after surgery and record the results
4 The T-tube provides an outlet for bile produced by the liver and is expected to drain 300 to 500 mL in the first day. 1 Clamping the tube during the early postoperative period may cause a buildup of pressure and leakage of bile into the peritoneum. 2 The rate of fluid administration is prescribed by the practitioner. 3 Drainage from the T-tube is by gravity; negative pressure is not applied.
A client who had a kidney transplant develops leukopenia 3 weeks after surgery. The nurse concludes that the leukopenia probably is caused by: 1. Bacterial infection 2. High creatinine levels 3. Rejection of the kidney 4. Antirejection medications
4 The WBC count can drop precipitously. If leukocytes are less than 3000/mm3, the drug may have to be stopped to prevent irreversible bone marrow depression. 1 Leukocytosis, not leukopenia, occurs with an infection. 2 High creatinine levels are related to kidney failure, but do not cause leukopenia. 3 The WBC count is increased, not decreased, with kidney rejection.
When planning care for a client with a continuous bladder irrigation after a transurethral vaporization of the prostate, the nurse should: 1. Measure the output hourly 2. Monitor the specific gravity of the urine 3. Irrigate the catheter with saline three times daily 4. Exclude the amount of irrigant instilled from the output
4 The amount of irrigant instilled into the bladder must be deducted from the total output to determine the amount of urine produced. 1 Unless the irrigant is subtracted from the output, the total will be inaccurate. 2 Specific gravity measures the concentration of urine; this measurement will be inaccurate because the urine is diluted with GU irrigant. 3 This is unnecessary; the urinary bladder is constantly being irrigated with GU irrigant.
Halfway through the administration of a unit of blood, a client complains of lumbar pain. After stopping the transfusion and replacing the tubing, the nurse should: 1. Obtain vital signs 2. Notify the blood bank 3. Assess the pain further 4. Increase the flow of normal saline (Nugent 17) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 The blood must be stopped first, tubing must be replaced and then normal saline should be infused to keep the line patent and maintain blood volume. 1 While this assessment is being made, the client's circulating blood volume will decrease. 2 This can be done later. 3 While this assessment is being made, the client's circulating blood volume will decrease. (Nugent 97) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
The nurse should ask the client with secondary syphilis about sexual contacts during the past: 1. 21 days 2. 30 days 3. 3 months 4. 6 months
4 The client is in the secondary stage, which begins from 6 weeks to 6 months after primary contact; therefore, a 6-month history is needed to ensure that all possible contacts are located. 1 Any time less than 6 months may miss contacts that may have become infected. 2 Any time less than 6 months may miss contacts that may have become infected. 3 Any time less than 6 months may miss contacts that may have become infected.
The nurse identifies a small amount of bile-colored drainage on the dressing of a client who has had a liver biopsy. The nurse concludes that: 1. Fluid is leaking into the intestine 2. The pancreas has been lacerated 3. This is a typical, expected response 4. A biliary vessel has been penetrated
4 The flow of bile through the puncture site indicates that a biliary vessel was punctured; this is a common complication after a liver biopsy. 1 Fluid will leak through the puncture site or into the peritoneum, not the intestine. 2 The pancreas does not contain bile; it is in the upper left, not upper right, quadrant. 3 This is a complication, not an expected outcome.
A 50-year-old executive reports a loss of 20 pounds in 3 months. The stools are black and tarry, and a colonoscopy is scheduled. The nurse prepares the client for this test by: 1. Administering an oil-retention enema just before the test 2. Instructing that a bland diet be eaten the night before the test 3. Explaining that the pretest cathartic will cause diarrhea after the test 4. Telling the client not to eat or drink anything the morning of the test
4 The initiation of the gastrocolic reflex can cause intestinal contents to reach the lower GI tract and interfere with visualization of the colon. 1 An oil-retention enema will interfere with visualization during the colonoscopy and therefore should not be administered. 2 A liquid, not bland, diet should be consumed the night before the test. 3 Diarrhea should not occur after the test.
When preparing a client to go home with total parenteral nutrition (TPN), the nurse helps the client plan: 1. The days to be used for administration 2. For daily insertion of the circulatory access 3. For professional help to administer the TPN 4. A schedule of administration around regular activity
4 The less disruptive the procedure, the greater the acceptance by the client. 1 Most often, total parenteral nutrition is set up to run daily during sleeping hours. 2 Depending on the type of circulatory access used, it may not need to be changed for weeks. 3 The client or a significant other can be taught the principles of administration.
The nurse teaches a client with exophthalmos how to reduce discomfort and prevent corneal ulceration. The nurse evaluates that the teaching is understood when the client states, "I should: 1. eliminate excessive blinking." 2. not move my extraocular muscles." 3. elevate the head of my bed at night." 4. avoid using a sleeping mask at night." (Nugent 30) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 The mask may irritate or scratch the eyes if the mask moves during sleep. 1 Blinking of the eyes will bathe the eyes and prevent corneal ulceration. 2 This will not relieve edema or prevent ulceration of the eyes. 3 Although this will help reduce periorbital edema, it will not prevent ulceration of the cornea. (Nugent 111) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
After a subtotal gastrectomy a client experiences an episode reflective of dumping syndrome. About 1½ hours after the initial attack, the client experiences a second period of feeling "shaky." The nurse determines that this latter effect is caused by: 1. A second more extensive rise in glucose 2. An overwhelmed insulin-adjusting mechanism 3. A distention of the duodenum from an excessive amount of chyme 4. An overproduction of insulin that occurs in response to the rise in blood glucose
4 The rapid absorption of carbohydrates from the food mass causes an elevation of blood glucose, and the insulin response often causes transient hypoglycemic symptoms. The elevation in insulin usually occurs 90 minutes to 3 hours after eating and is known as late dumping syndrome. 1 The physiological adaptations related to late dumping syndrome are caused by an increase in insulin, not glucose. 2 The insulin-adjusting mechanism is not overwhelmed, but responds vigorously, causing rebound hypoglycemia. 3 Dumping syndrome is related to the high glucose content of food, not the amount of food, entering the duodenum.
hen assessing the laboratory values of a client with type 2 diabetes, the nurse expects the results to reveal: 1. Ketones in the blood but not the urine 2. Glucose in the urine but not in the blood 3. Urine and blood positive for glucose and ketones 4. Urine negative for ketones and glucose in the blood (Nugent 31) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 The reason for the lack of ketonuria in type 2 diabetes is unknown. One theory is that extremely high hyperglycemia and hyperosmolarity levels block the formation of ketones, stimulating lipogenesis rather than lipolysis. 1 This does not occur with type 2 diabetes. 2 This is impossible; if glycosuria is present, there must first be a level of glucose in the blood exceeding the renal threshold of 160 to 180 mg/dL. 3 This is expected in type 1 diabetes. (Nugent 113) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client is scheduled for emergency abdominal surgery. What is the priority preoperative nursing objective when caring for this client? A) Recording accurate vital signs B) Alleviating the client's anxiety C) Teaching about early ambulation D) Maintaining the client's nutritional status
B) Alleviating the client's anxiety
The nurse is caring for a client who is receiving azathioprine (Imuran), cyclosporine, and prednisone before kidney transplant. These medications are administered to: 1. Stimulate leukocytosis 2. Provide passive immunity 3. Prevent iatrogenic infection 4. Reduce antibody production (Nugent 19) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 These drugs suppress the immune system, decreasing the body's production of antibodies in response to the new organ, which acts as an antigen. These drugs decrease the risk of rejection. 1 Leukocytosis is inhibited by these drugs. 2 These drugs do not provide immunity; they interfere with natural immune responses. 3 Because these drugs suppress the immune system, they increase the risk of infection. (Nugent 100) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
The nurse teaches a group of clients that nutritional support of natural defense mechanisms indicates the need for a diet high in: 1. Essential fatty acids 2. Dietary cellulose and fiber 3. Tryptophan, an amino acid 4. Vitamins A, C, E, and selenium (Nugent 20) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 These nutrients stimulate the immune system. 1 The role of fatty acids in natural defense mechanisms is uncertain. 2 These have no known effect on natural defense mechanisms. 3 Tryptophan has no known effect on natural defense mechanisms. (Nugent 100) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
On the third postoperative day after a subtotal thyroidectomy for a tumor, a client complains of a "funny, jittery feeling." On the basis of this statement, the nurse's best action is to: 1. Explain that this reaction is expected and not a concern 2. Take the vital signs and place the client in a high-Fowler's position 3. Request stat serum calcium and phosphorus levels and chart the results 4. Test for Chvostek's and Trousseau's signs and notify the practitioner of the complaints (Nugent 30) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 These symptoms may indicate impending hypocalcemic tetany, a complication after removal of parathyroid tissue during a thyroidectomy. 1 These symptoms may be related to postoperative anxiety, but the priority is to assess for impending tetany. 2 This is not helpful for the complaint made by the client; further assessment for tetany is indicated. 3 Physical assessment and notification of the practitioner are the priorities. (Nugent 112) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
After 2 months of self-management for symptoms of gastritis is unsuccessful, a client goes to the practitioner, and extensive carcinoma of the stomach is diagnosed. The client asks the nurse how the disease got so advanced. The nurse's explanation is based on the knowledge that carcinoma of the stomach is: 1. Painful in the early stages of the disease process 2. Difficult to accurately diagnose until late in the disease process 3. Usually diagnosed after the discovery of enlarged lymph nodes in the epigastric area 4. Rarely diagnosed early because the symptoms usually are nonspecific until late in the disease
4 This cancer is usually asymptomatic in the early stages; the stomach accommodates the mass. 1 Gastric cancer is painless in its early stages. 2 It can be accurately diagnosed by gastric washings or biopsy. 3 This is typical of Hodgkin's disease, not gastric carcinoma.
For what common early clinical manifestation should the nurse monitor in clients with renal carcinoma? 1. Flank pain 2. Weight gain 3. Periorbital edema 4. Intermittent hematuria
4 This is a classic sign of renal carcinoma; it is due to capillary erosion by the cancerous growth. 1 Dull flank pain may occur but not as frequently as bleeding. 2 Weight loss, not weight gain, will occur. 3 This will not occur with renal carcinoma; it may occur with glomerulonephritis.
Femoral vein catheter
Client with a ________ should not sit up more than 45 degrees of lean forward, because the catheter may kink and occlude
The practitioner orders 2 units of packed red blood cells for a client who is bleeding. Before blood administration the nurse's priority is: 1. Obtaining the client's vital signs 2. Letting the blood reach room temperature 3. Monitoring the hemoglobin and hematocrit levels 4. Determining proper typing and crossmatching of blood (Nugent 17) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 This is absolutely necessary to prevent an acute immunological reaction if the donated blood is not compatible with the client's blood. 1 Although important, this is not the highest priority. 2 Blood must be kept cool until ready to use. If blood is at room temperature for 30 minutes prior to administration it should be returned to the blood bank; after it is started, blood must be administered within 4 hours. 3 This is not the highest priority; these laboratory results were part of the data used to determine the need for the blood. (Nugent 96) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
After years of unprotected sex, a 20-year-old man is diagnosed as having AIDS. The client states, "I'm not worried because they have a cure for AIDS." The best response by the nurse is: 1. "Repeated phlebotomies may be able to rid you of the virus." 2. "You may be cured of AIDS after prolonged pharmacologic therapy." 3. "Perhaps you should have worn condoms to prevent contracting the virus." 4. "There is no cure for AIDS but there are drugs that can slow down the virus." (Nugent 18) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 This is an honest response that corrects the client's misconception about the effectiveness of the current antiviral medications. 1 Phlebotomy is not the treatment used to remove the virus from the client's body. 2 Current pharmacological treatment does not eliminate the virus from the body; it can slow its progress and may even effect a remission (although the medications are never discontinued), but there is no known cure. 3 This is a nontherapeutic, judgmental response that can alienate the client and precipitate feelings of guilt. (Nugent 97) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A practitioner orders total parenteral nutrition 1 L every 12 hours. The primary nursing responsibility is to monitor the client's: 1. Electrolytes 2. Urinary output 3. Blood pressure 4. Serum glucose levels
4 This is essential because the solution is hyperosmolar, and a concentrated source of glucose can result in hyperglycemia. 1 Although important, it is not the priority. 2 Although important, it is not the priority. 3 Although important, it is not the priority.
472. A client with a history of gastrointestinal varices develops severe hematemesis, and the practitioner inserts a Sengstaken-Blakemore tube. The nurse understands that this tube is a: 1. Single-lumen tube for gastric lavage 2. Double-lumen tube for intestinal decompression 3. Triple-lumen tube used to compress the esophagus 4. Multi-lumen tube for gastric and intestinal decompression
472. 3 One lumen inflates the esophageal balloon, the second inflates the gastric balloon, and the third decompresses the stomach.
A male client comes to the emergency department because he has a discharge from his penis. The practitioner suspects gonorrhea and asks the nurse to obtain a specimen and to send it for a culture. The nurse should: 1. Instruct the client to provide a semen specimen 2. Swab the discharge when it appears on the prepuce 3. Teach the client how to obtain a clean catch specimen of urine 4. Swab the drainage directly from the urethra to obtain a specimen
4 This method obtains a specimen uncontaminated by environmental organisms. 1 This is not as accurate as obtaining the purulent discharge from the site of origin. 2 This will contaminate the specimen with organisms external to the body. 3 This will dilute and possibly contaminate the specimen.
A client with Parkinson's disease complains about a problem with elimination. The nurse should encourage the client to: 1. Eat a banana daily 2. Decrease fluid intake 3. Take cathartics regularly 4. Increase residue in the diet
4 This produces bulk, which stimulates defecation; the muscles used in defecation are weak in clients with Parkinson's disease. 1 Bananas are binding and will intensify the problem of constipation. 2 This will intensify the problem; fluids need to be increased. 3 Cathartics are irritating to the intestinal mucosa, and their regular administration promotes dependence.
The nurse teaches a client receiving peritoneal dialysis that the reason the dialysis solution is warmed to body temperature before it is instilled into the peritoneal cavity is to: 1. Force potassium back into the cells, thereby decreasing serum levels 2. Add extra warmth to the body because metabolic processes are disturbed 3. Help prevent cardiac dysrhythmias by speeding up removal of excess potassium 4. Encourage removal of serum urea by preventing constriction of peritoneal blood vessels
4 This promotes vasodilation so that urea, a large-molecular substance, is shifted from the body into the dialyzing solution. 1 Heat does not affect the shift of potassium into the cells. 2 The removal of metabolic wastes is affected in kidney failure, not the metabolic processes. 3 Excess serum potassium is removed by dialyzing with a potassium-free solution, not by heat.
When a Schilling test is ordered for a client suspected of having cobalamin deficiency because of pernicious anemia, the nurse plans to: 1. Give medications on time 2. Order foods low in vitamin B12 3. Keep an accurate intake and output 4. Collect a 24- to 48-hour urine specimen (Nugent 18) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 This test assesses parietal cell function. After radioactive cobalamin is administered, its excretion is measured; if cobalamin cannot be absorbed as in pernicious anemia, very little is excreted in the urine. 1 This test is not affected by medications. 2 The results of this test are not affected by food; with pernicious anemia there is a deficiency of intrinsic factor, which is necessary for vitamin B12 use. 3 Intake and output records are not necessary with a Schilling test. (Nugent 98) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
To facilitate micturition in a male client, the nurse should instruct him to: 1. Use a urinal for voiding 2. Drink cranberry juice daily 3. Wash his hands after voiding 4. Assume the standing position for voiding
4 This uses gravity to allow urine to exert pressure on the area of the trigone, initiating relaxation of the urinary sphincter and facilitating micturition. 1 Although this may be important when urine is collected to be strained, analyzed, or measured, it will not facilitate micturition. 2 An acid-ash diet may be used to prevent urinary infection and the formation of calcium stones; it will not facilitate micturition. 3 This is important after urination but will not help facilitate micturition.
An older adult develops severe bone marrow suppression from chemotherapy for cancer. The nurse should: 1. Monitor for signs of alopecia 2. Encourage an increase in fluids 3. Monitor intake and output of fluids 4. Advise use of a soft toothbrush for oral hygiene (Nugent 19) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Thrombocytopenia occurs with most chemotherapy treatment programs; using a soft toothbrush helps prevent bleeding gums. 1 Although alopecia does occur, it is not related to bone marrow suppression. 2 Increasing fluids will neither reverse bone marrow suppression nor stimulate hematopoiesis. 3 This is not related to bone marrow suppression. (Nugent 98) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
After treatment with propylthiouracil for hyperthyroidism, a client has the thyroid ablated with 131I. On a visit to the endocrine clinic, the client exhibits signs and symptoms of thyrotoxic crisis (thyroid storm). What is often associated with thyrotoxic crisis? 1. Deficiency of iodine 2. Decreased serum calcium 3. Increased sodium retention 4. Excessive hormone replacement (Nugent 30) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Thyrotoxic crisis (thyroid storm) is the body's response to excessive circulating thyroid hormones. 1 A deficiency of iodine results in a deficiency in thyroid hormone production. 2 A decreased serum calcium causes tetany. 3 Sodium retention is unrelated to thyrotoxic crisis; thyrotoxic crisis is caused by excessive circulating thyroid hormones. (Nugent 112) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
After a thyroidectomy a client should be monitored for thyrotoxic crisis, which is evidenced by: 1. An increased pulse deficit 2. A decreased blood pressure 3. A decreased heart rate and respirations 4. An increased temperature and pulse rate (Nugent 30) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
4 Thyrotoxic crisis is severe hyperthyroidism; excessive amounts of thyroxine increase the metabolic rate, thereby raising the pulse and temperature. 1 During crisis there usually is no increase in the difference between the apical and the peripheral pulse rates (pulse deficit). 2 The blood pressure will increase to meet the oxygen demand caused by the increased metabolic rate during crisis. 3 Because of the increased metabolic rate, the pulse and respiratory rates increase to meet the body's oxygen needs. (Nugent 112) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
473. A client with Laennec's cirrhosis has a Sengstaken-Blakemore tube in place. The client becomes increasingly confused and tries to climb out of bed. The client's breath becomes fetid. What is the nursing priority? 1. Apply a safety jacket 2. Give the pm sedative as ordered 3. Notify the practitioner immediately 4. Provide oxygen via a nasal catheter
473. 1 Measures must be taken immediately to ensure client safety.
Ipratropium (Atrovent HFA and Combivent)
Client with an allergy to peanuts should not take ________, because both products contain soy lecithin, which is in the same plant family as peanuts
A client who was diagnosed with cancer of the head of the pancreas 2 months ago is admitted to the hospital with weight loss, severe epigastric pain, and jaundice. When performing the admission history and physical assessment, the nurse expects the client's stool to be: 1. Green 2. Brown 3. Red-tinged 4. Clay-colored
4 Tumors of the head of the pancreas usually obstruct the common bile duct where it passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The feces will be clay-colored when bile is prevented from entering the duodenum. 1 Green stools may occur with prolonged diarrhea associated with gastrointestinal inflammation. 2 The feces are brown when there is unobstructed bile flow into the duodenum. 3 Inflammation or ulceration of the lower intestinal mucosa results in blood-tinged stools.
467. When discussing a scheduled liver biopsy with a client, the nurse explains that for several hours after the biopsy the client will have to remain in: 1. The left side-lying position with the head of the bed elevated 2. A high Fowler's position with both arms supported on several pillows 3. The right side-lying position with pillows placed under the costal margin 4. Any comfortable recumbent position as long as the client remains immobile
467. 3 In this position the liver capsule at the entry site is compressed against the chest wall and escape of blood and/or bile is impeded.
468. A client who has had right upper quadrant pain for several months now experiences clay-colored stools and visits the local clinic. Based on the reported history and elevated liver enzymes, a needle biopsy of the liver is scheduled. The nurse explains that: 1. The procedure is painless because general anesthesia is used 2. Disfiguring scars are minimal because a small incisionis made 3. Lying on the right side after the procedure is required because it will decrease the risk of hemorrhage 4. A light meal should be eaten 2 hours before the procedure because it stimulates gastrointestinal secretions
468. 3 Because of the vascularity of the liver, compression of the needle insertion site limits the risk of hemorrhage; also it decreases the risk of bile leakage.
469. The nurse identifies a small amount of bile-colored drainage on the dressing of a client who has had a liver biopsy. The nurse concludes that: 1. Fluid is lealdng into the intestine 2. The pancreas has been lacerated 3. This is a typical, expected response 4. A biliary vessel has been penetrated
469. 4 The flow of bile through the puncture site indicates that a biliary vessel was punctured; this is a common complication after a liver biopsy.
470. The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. The priority nursing intervention is to: 1. Weigh the client daily 2. Restrict the client's oral fluid intake 3. Measure the client's urine specific gravity 4. Observe the client for increasing confusion
470. 4 An increased serum ammonia level impairs the CNS, causing an altered level of consciousness.
Pathological fractures
Client with multiple myeloma is at risk for ______________
475. A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply. 1. Fever 2. Tachypnea 3. Hypertension 4. Abdominal rigidity 5. Increased bowel sounds
475. Answer: 1,2,4 1 The metabolic rate will be increased and the temperature-regulating center in the hypothalamus resets to a higher than usual body temperature because of the influence of pyrogenic substances related to the peritonitis. 2 Tachypnea results as the metabolic rate increases and the body attempts to meet cellular oxygen needs. 4 With increased intraabdominal pressure, the abdominal wall will become rigid and tender.
477. One month after abdominal surgery a client is readmitted to the hospital with recurrent abdominal pain and fever. The medical diagnosis is fistula formation with peritonitis. The nurse should maintain the client in the: 1. Supine position 2. Right Sims position 3. Semi-Fowler's position 4. Most comfortable position
477. 3 This position promotes localization of purulent material and inflammation and prevents an ascending infection.
478. A nurse is performing a physical assessment of a client with ulcerative colitis. The finding most often associated with a serious complication of this disorder is: 1. Decreased bowel sounds 2. Loose, blood-tinged stools 3. Distention of the abdomen 4. Intense abdominal discomfort
478. 1 Decreased intestinal motility is associated with serious problems, such as perforation or toxic megacolon.
479. A client with colitis inquires as to whether surgery will eventually be necessary. When teaching about the disease and its treatment, the nurse should emphasize that: 1. Medical treatment for colitis is curative; surgery is not required 2. Surgery for colitis is considered only as a last resort for most clients 3. Surgery for colitis is done early in the course of the disorder for most clients 4. Medical treatment is all that will be needed if the client can acquire some emotional stability
479. 2 Medical treatment is directed toward reducing motility of the inflamed bowel, restoring nutrition, and preventing and treating infection; surgery is used selectively for those who are acutely ill or have excessive exacerbations.
480. When caring for a client who had abdominal intestinal surgery, it is important for the nurse to consider that: 1. Rectal intubation will relieve vomiting 2. Air swallowing causes gastric distention 3. Preoperative enemas prevent a postoperative ileus 4. Clear liquids a day after surgery stimulate peristalsis
480. 2 When anxious, in pain, or performing deep breathing exercises, it is common for air to be swallowed, which can cause gastric distention.
481. When discussing nutrition with a client who has inflammatory bowel disease of the ascending colon, the most appropriate suggestion by the nurse concerning food to include in the diet is: 1. Scrambled eggs and applesauce 2. Barbecued chicken and French fries 3. Fresh fruit salad with cheddar cheese 4. Chunky peanut butter on whole wheat bread
481. 1 Low-residue foods produce less fecal waste, decreasing bowel contents and irritation; protein promotes healing and calories provide energy.
482. A client with colitis has a hemicolectomy performed. After surgery the nurse identifies that, in addition to having vomited 300 mL of dark green viscous fluid, the client has increasing abdominal distention and absent bowel sounds. Immediate care should be directed toward: 1. Replacing fluid losses 2. Decreasing the vomiting 3. Decompressing the bowel 4. Restoring electrolyte balance
482. 3 Decompression removes collected secretions behind the nonfunctioning bowel segment (paralytic ileus), thus reducing pressure on the suture line and allowing healing.
483. After surgery for creation of an ileostomy, a client is to be discharged. Before discharge, the primmy nursing intervention is to: 1. Coax the client into caring for the ileostomy alone 2. Evaluate the client's ability to care for the ileostomy 3. Ensure the client understands the dietary limitations that must be followed 4. Have the client change the dry sterile dressing on the incision without assistance
483. 2 The client's feelings, knowledge, and skills concerning the ileostomy must be assessed before discharge.
Elevated
Clients with a respiratory disorder should be positioned with the HOB ________
486. A client with the diagnosis of cancer of the transverse colon is transferred from the postanesthesia care unit to a room on a surgical unit after a colon resection with an anastomosis. The nurse on the unit receives the client from the transporting nurse and observes that an IV is in progress and the client has a nasogastric tube and an indwelling urinary catheter. Place the nursing actions in order of priority when receiving this client on the unit. 1. Assess the airway 2. Take the vital signs 3. Check the abdominal dressing 4. Receive the report from the nurse
486. Answer: 4, 1, 3, 2 The first step is for the nurse to receive report from the transporting nurse. The receiving nurse should be informed about the type of surgery performed, important events that occurred during surgery, and the client's response and current status. Once the report is completed, the next step is for the receiving nurse to ensure that the client has a patent airway. Vital signs are then taken to assess the client's current cardiopulmonary status and to assess for signs of hemorrhage or other postoperative complications. This assessment follows the ABCs (airway, breathing, circulation) of assessment. After the client's vital signs are determined to be stable, the nurse should assess and monitor the dressing, IV, and the indwelling urinary catheter.
487. A 50-rear-old executive reports a loss of 20 pounds in 3 months. The stools are black and tarry, and a colonoscopy is scheduled. The nurse prepares the client for this test by: 1. Administering an oil-retention enema just before the test 2. Instructing that a bland diet be eaten the night before the test 3. Explaining that the pretest cathartic will cause diarrhea after the test 4. Telling the client not to eat or drink anything the morning of the test
487. 4 The initiation of the gastrocolic reflex can cause intestinal contents to reach the lower GI tract and interfere with visualization of the colon.
489. A client who has cancer of the sigmoid colon is to have an abdominoperineal resection with a permanent colostomy. Before surgery a low-residue diet is ordered. The nurse explains that this is necessary to: 1. Limit production of flatus in the intestine 2. Prevent irritation of the intestinal mucosa 3. Reduce the amount of stool in the large bowel 4. Lower the bacterial count in the gastrointestinal tract
489. 3. 3. This diet is low in fiber; after digestion and absorption there is only a small amount of residue to be eliminated.
494. A client returns from surgery with a permanent colostomy. During the first 24 hours the colostomy does not drain. What does the nurse determine is the probable cause of this response? 1. Intestinal edema after surgery 2. Presurgical decrease in fluid intake 3. Absence of gastrointestinal motility 4. Effective functioning of nasogastric suction
494. 3. 3. This is caused by intestinal manipulation and the depressive effects of anesthesia and analgesics.
496. A client has a colostomy after surgery for cancer of the colon. What is the nurse's most therapeutic intervention during the postoperative period? 1. Empty the colostomy bag when it is three fourths full 2. Allow one half inch between the stoma and the appliance 3. Help the client to remove the appliance on the first postoperative day 4. Apply stoma adhesive around the stoma and then attach the appliance
496. 4. 4. Stoma adhesive protects the skin and helps to keep the appliance attached to the skin
500. An 80-year-old male client had surgery for a strangulated hernia. One hour after surgery his blood pressure drops from 134/80 to 114/76. Assessment reveals that he does not have postoperative bleeding. The nurse should: 1. Turn him onto his left side 2. Encourage him to move his legs 3. Call the practitioner immediately 4. Administer his prescribed pain medication
500. 2. 2. The lowered blood pressure may be caused by pooling of blood in peripheral vessels; moving the legs will aid venous return.
502. A client receiving a 1500-calorie diet eats these foods for breakfast: 1 cup of milk (12 grams of carbohydrate, 8 grams of protein, 10 grams of fat); 3/4 cup corn flakes (15 grams of carbohydrate, 2 grams of protein)j and half of an orange (5 grams of carbohydrate). How many calories has this client ingested? 1. 208 2. 258 3. 416 4.456
502. 2. 2. The client has ingested 258 calories. Carbohydrates and proteins each yield 4 calories per gram, and fat yields 9 calories per gram. The total carbohydrate calories are 32 x 4 = 128. The total protein calories are 10 x 4 = 40. The total fat calories are 10 x 9 = 90; 128 + 40 + 90 = 258 calories.
614. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the appropriate nursing intervention? 1. Notify the physician. 2. Administer the prescribed pain medication. 3. Call and ask the operating room team to perform the surgery as soon as possible. 4. Reposition the client and apply a heating pad on warm setting to the client's abdomen.
614. 1 Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.
615. The client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client's pain. What type of pain is consistent with this diagnosis? 1. Burning and aching, located in the left lower quadrant and radiating to the hip 2. Severe and unrelenting, located in the epigastric area and radiating to the back 3. Burning and aching, located in the epigastric area and radiating to the umbilicus 4. Severe and unrelenting, located in the left lower quadrant and radiating to the groin
615. 2 Rationale: The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. The other options are incorrect.
616. The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain? 1. Right lower quadrant, radiating to the back 2. Right lower quadrant, radiating to the umbilicus 3. Right upper quadrant, radiating to the left scapula and shoulder 4. Right upper quadrant, radiating to the right scapula and shoulder
616. 4 Rationale: During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. This is determined by the pattern of dermatomes in the body. The other options are incorrect.
621. The client has undergone esophagogastroduodenoscopy. The nurse places highest priority on which item as part of the client's care plan? 1. Monitoring the temperature 2. Monitoring complaints of heartburn 3. Giving warm gargles for a sore throat 4. Assessing for the return of the gag reflex
621. 4 Rationale: 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.
622. The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography procedure. The nurse determines that the client needs further information if the client makes which statement? 1. "I know I must sign the consent form." 2. "I hope the throat spray keeps me from gagging." 3. "I'm glad I don't have to lie still for this procedure." 4. "I'm glad some IV medication will be given to relax me."
622. 3 Rationale: The client does have to lie still for endoscopic retrograde cholangiopancreatography (ERCP), which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.
623. The physician has determined that the client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D
623. 1 Rationale: Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.
624. The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E
624. 2 Rationale: Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of the function of the parietal cells. The source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. The client is not at risk for vitamin A, C, or E deficiency.
625. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is appropriate? 1. Clamp the T-tube. 2. Irrigate the T-tube. 3. Notify the physician. 4. Document the findings.
625. 4 Rationale: Following cholecystectomy, drainage from the T-tube is initially bloody and then turns to a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.
627. The nurse is caring for a client following a Billroth II procedure. Which postoperative prescription should the nurse question and verify? 1. Leg exercises 2. Early ambulation 3. Irrigating the nasogastric tube 4. Coughing and deep-breathing exercises
627. 3 Rationale: In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically prescribed by the physician. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.
628. The nurse is providing discharge instructions to a client following gastrectomy and instructs the client to take which measure to assist in preventing dumping syndrome? 1. Ambulate following a meal. 2. Eat high carbohydrate foods. 3. Limit the fluids taken with meals. 4. Sit in a high Fowler's position during meals.
628. 3 Rationale: Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.
633. The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which symptom(s) of duodenal ulcer? 1. Weight loss 2. Nausea and vomiting 3. Pain relieved by food intake 4. Pain radiating down the right arm
633. 3 Rationale: A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the midepigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.
636. The client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1. This is a normal, expected event. 2. The client is experiencing early signs of ischemic bowel. 3. The client should not have the nasogastric tube removed. 4. This indicates inadequate preoperative bowel preparation.
636. 1 Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect.
637. The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? 1. Folate deficiency 2. Malabsorption of fat 3. Intestinal obstruction 4. Fluid and electrolyte imbalance
637. 4 Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.
640. A client with Crohn's disease is scheduled to receive an infusion of infliximab (Remicade). What intervention by the nurse will determine the effectiveness of treatment? 1. Monitoring the leukocyte count for 2 days after the infusion 2. Checking the frequency and consistency of bowel movements 3. Checking serum liver enzyme levels before and after the infusion 4. Carrying out a Hematest on gastric fluids after the infusion is completed
640. 2 Rationale: The principal manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab (Remicade) is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Options 1, 3, and 4 are unrelated to this medication.
641. The client has a PRN prescription for loperamide hydrochloride (Imodium). For which condition should the nurse plan to administer this medication? 1. Constipation 2. Abdominal pain 3. An episode of diarrhea 4. Hematest-positive nasogastric tube drainage
641. 3 Rationale: Loperamide is an antidiarrheal agent. It is used to manage acute and chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options 1, 2, and 4.
642. The client has a PRN prescription for ondansetron (Zofran). For which condition should the nurse administer this medication to the postoperative client? 1. Paralytic ileus 2. Incisional pain 3. Urinary retention 4. Nausea and vomiting
642. 4 Rationale: Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. The other options are incorrect.
646. The client who chronically uses nonsteroidal anti-inflammatory drugs (NSAIDs) has been taking misoprostol (Cytotec). The nurse determines that the medication is having the intended therapeutic effect if which of the following is noted? 1. Resolved diarrhea 2. Relief of epigastric pain 3. Decreased platelet count 4. Decreased white blood cell count
646. 2 Rationale: The client who chronically uses nonsteroidal anti-inflammatory drugs (NSAIDs) is prone to gastric mucosal injury. Misoprostol is a gastric protectant and is given specifically to prevent this occurrence. Diarrhea can be a side effect of the medication but is not an intended effect. Options 3 and 4 are incorrect.
647. The client has been taking omeprazole (Prilosec) for 4 weeks. The ambulatory care nurse evaluates that the client is receiving optimal intended effect of the medication if the client reports the absence of which symptom? 1. Diarrhea 2. Heartburn 3. Flatulence 4. Constipation
647. 2 Rationale: Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called heartburn by clients. Omeprazole is not used to treat the conditions identified in options 1, 3, and 4.
When encouraging a client to cough and deep breath after a bilateral mastectomy, the client says, "Leave me alone! Don't you know I'm in pain?" What is the nurse's best response? A) "I know it hurts to cough, but try to use the IS." B) "We'll start this tomorrow; I will give you something for your pain." C) "I understand that you are in pain; rest now, and I'll come back later." D) "Your pain is to be expected, but you must attempt to expand your lungs."
A) "I know it hurts to cough, but try to use the IS."
The practitioner orders a transfusion of 2 units of packed red blood cells for a client. When administering blood, the priority nursing intervention is to: 1. Warm the blood to 98° F to prevent chills 2. Use an infusion pump to increase accuracy of infusion 3. Infuse the blood at a slow rate during the first 10 minutes 4. Draw blood samples from the client after each unit is transfused (Nugent 17) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A slow rate provides time to recognize a reaction that is developing before too much blood is administered. 1 This is avoided to prevent clotting and hemolysis. 2 Infusion pumps will cause red blood cell damage; blood should flow by gravity through an appropriate filter. 4 This is not necessary. (Nugent 97) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client with cancer of the thyroid is scheduled for a thyroidectomy. Postoperatively the nurse plans to have a: 1. Quiet, dimly lit room for the client 2. Tracheostomy set at the client's bedside 3. Large soft pillow for use under the client's head 4. Suction machine set on intermittent suction at the client's bedside (Nugent 30) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A tracheostomy set should be available in the event there is excessive edema at the surgical site, which can cause tracheal compression. 1 This is not necessary after a thyroidectomy. 3 The head should be kept in anatomical alignment, the neck not flexed or hyperextended; a small soft pillow can be used to accomplish alignment. 4 Intermittent suction does not provide the constant suction needed to clear the airway. (Nugent 112) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A) "How will this affect your present sexual activity?" B) "How active is your current sex life?" C) "How has your sex life changed as you have become older?" D) "Tell me about your sexual needs as an older adult."
A) "How will this affect your present sexual activity?" - (A) offers an open-ended question most relevant to the client's statement. (B) does not offer the client the opportunity to express concerns. (C and D) are even less relevant to the client's statement.
A client receives spinal anesthesia during labor and birth. Twenty-four hours later, she tells a nurse that she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia? Select all that apply. A) "I have ringing in my ears." B) "It improves when I lie down." C) "Bright lights really bother my eyes." D) "It gets better as soon as I walk a while." E) "My head hurts more when I am sitting watching tv." F) My head hurts more when I am lying on my side breastfeeding."
A) "I have ringing in my ears." B) "It improves when I lie down." C) "Bright lights really bother my eyes." E) "My head hurts more when I am sitting watching tv."
The antigout medication allopurinol (Zyloprim) is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse? A) "I take aspirin for my pain." B) "I frequently eat fruit and drink fruit juices." C) "I drink a great deal of water, so I have to get up at night to urinate." D) "I observe my skin daily to see if I have an allergic rash to the medication."
A) "I take aspirin for my pain." - The client should be taught to avoid aspirin (A) because the ingestion of aspirin or diuretics can precipitate an attack of gout. (B, C, and D) are all appropriate for the treatment of gout. The client's urinary pH can be increased by the intake of alkaline ash foods, such as citrus fruits and juices, which will help reduce stone formation (B). Increasing fluids helps prevent urinary calculi (stone) formation and should be encouraged, even if the client must get up at night to urinate (C). Allopurinol has a rare but potentially fatal hypersensitivity syndrome, which is characterized by a rash and fever. The medication should be discontinued immediately if this occurs (D).
The nurse is teaching a nursing student about caring for a client who is undergoing blood studies for antidiuretic hormone stimulation. Which statements made by the nursing student indicate effective instruction? Select all that apply. A) "I will assess the pulse rate after rehydrating the client." B) "I will perform the test if the serum sodium level is high." C) "I will perform the test if the osmolarity is 200 mOsm (mmol)/kg." D) "I will hydrate the client with oral fluids before performing the test." E) "I will discontinue the test if the client's weight loss is greater than 4.4 lbs (2 kg)."
A) "I will assess the pulse rate after rehydrating the client." C) "I will perform the test if the osmolarity is 200 mOsm (mmol)/kg." E) "I will discontinue the test if the client's weight loss is greater than 4.4 lbs (2 kg)." - The client's pulse rate and blood pressure should be assessed after rehydration for orthostatic hypertension after the procedure to ensure adequate fluid volume. The test should be performed if the serum osmolarity is less than 300 mOsm (mmol)/kg to avoid severe dehydration in clients who have central or nephrogenic diabetes insipidus. The test should be discontinued if the client's weight loss is greater than 2 kg. The test should not be performed if the serum sodium levels are high because severe dehydration may develop in central or nephrogenic diabetes insipidus clients. The client should have nothing by mouth before the test. Oral fluids are given to the client to rehydrate if the client is experiencing dehydration during the test.
After assessing a client, the nurse anticipates that the client has hyperpituitarism. Which questions asked by the nurse helps confirm the diagnosis? Select all that apply. A) "Is there any change in your vision?" B) "Do you experience severe headaches?" C) "Are you suffering with frequent urination?" D) "Do you eat more than five times a day?" E) "Is there any change in your menstrual cycle?
A) "Is there any change in your vision?" B) "Do you experience severe headaches?" E) "Is there any change in your menstrual cycle? - Hyperpituitarism manifests with vision disturbances and severe headaches. Due to hypersecretion of prolactin in females, a change in menstrual cycle may also be observed. Frequent urination is observed in a client with diabetes insipidus. Clients with diabetes mellitus experience intense hunger.
Three days after birth, a breastfeeding newborn becomes jaundice. The parents bring the infant to the clinic and blood is drawn for an indirect serum bilirubin level. The test result is 12 mg/DL. The nurse explains that it is physiologic jaundice, a benign condition which is caused by: A) Immature liver function B) An inability to synthesize bile C) An increased maternal hemoglobin level D) High hemoglobin with low hematocrit levels
A) Immature liver function
Which instructions should the nurse provide to an adolescent female client who is initiating treatment with isotretinoin (Accutane) for acne vulgaris? (Select all that apply.) A) "Notify the health care provider immediately if you think you are pregnant." B) "If your acne gets worse, stop the medication and call the health care provider." C) "Take a daily multiple vitamin to prevent deficiencies and promote dermal healing." D) "Dermabrasion for deep acne scars should be postponed for 1 month after therapy is stopped." E) "If you begin crying more than usual and feel sad, stop the drug and call the health care provider." F) "Before, during, and after therapy, two effective forms of birth control must be used at the same time."
A) "Notify the health care provider immediately if you think you are pregnant." E) "If you begin crying more than usual and feel sad, stop the drug and call the health care provider." F) "Before, during, and after therapy, two effective forms of birth control must be used at the same time." - (A, E, and F) are correct. Isotretinoin (Accutane) has been found to cause pregnancy category D drug-related birth defects, premature births, and fetal death (A), which necessitates the use of effective birth control methods before, during, and after therapy (F). Accutane is associated with sadness (E), depression, suicidal ideations, and other serious mental health problems. An initial exacerbation of acne (B) is common when starting drug therapy. Accutane is a retinoid related to vitamin A, and taking additional multivitamin supplements (C) can predispose the client to vitamin A toxicity. The client should stop taking Accutane at least 6 months before cosmetic procedures, such as dermabrasion (D), because the drug can increase the chances of scarring.
A client with diabetes asks the nurse whether the new forearm stick glucose monitor gives the same results as a fingerstick. What is the nurse's best response to this question? A) "There is no difference between readings." B) These types of monitors are meant for children." C) "Readings are on a different scale for each monitor." D) "Faster readings can be obtained from a fingerstick."
A) "There is no difference between readings."
Before discharge, a client who had a colostomy for colorectal cancer questions the nurse about resuming activity. What should the nurse teach the client about activity? A) "With guidance, a near-normal lifestyle, include complete sexual function, is possible." B) "Activities of daily living should be resumed as soon as possible so you avoid being depressed." C) Most sports activities, except for swimming, can be resumed based on your overall physical condition." D) "After surgery, changes in activities must be made to accommodate for physiologic changes caused by the operation."
A) "With guidance, a near-normal lifestyle, include complete sexual function, is possible."
A client who is scheduled to have an abdominal panhysterectomy asks the nurse how the surgery will affect her periods. How should the nurse respond? A) "You will not have any more periods." B) "Your periods will become more regular." C) "Your periods will become lighter until they disappear." D) "You will notice that the time between periods will be longer."
A) "You will not have any more periods."
A physically ill client is being verbally aggressive to the nursing staff. What is the most appropriate initial nursing response? A) Accept the client's behavior B) Explore the situation with the client C) Withdraw from contact with the client D) Tell the client the reason for the staff's actions
A) Accept the client's behavior - At this time, the client is using this behavior as a coping mechanism, and accepting the client's behavior is the best action by the nurse.
The nurse is administering the early morning dose of insulin aspart (NovoLog), 5 units subcutaneously, to a client with diabetes mellitus type 1. The client's fingerstick serum glucose level is 140 mg/dL. Considering the onset of insulin aspart (NovoLog), when should the nurse ensure that the client's breakfast be given? A) 5 minutes after subcutaneous administration B) 30 minutes after subcutaneous administration C) 1 to 2 hours after administration D) Any time because of a flat peak of action
A) 5 minutes after subcutaneous administration - Insulin aspart is a very rapidly acting insulin, with an onset of 5 to 15 minutes. Insulin aspart (NovoLog) should be administered when the client's tray is available (A). Insulin aspart (NovoLog) peaks in 45 minutes to 1½ hours (B and C) and has a duration of 3 to 4 hours. The client should have eaten to ensure absorption of the meal so that serum glucose levels will coincide with the peak. Insulin glargine (Lantus) has a flat peak of action (D) and is usually given at bedtime.
As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider? A) A 6-month-old with failure to thrive that has a closed anterior fontanel. B) A 24-month-old with gastroenteritis that has a closed posterior fontanel. C) A 2-month-old with chickenpox that has an open posterior fontanel. D) A 28-month-old with hydrocephalus that has an open anterior fontanel.
A) A 6-month-old with failure to thrive that has a closed anterior fontanel. - At six months of age the anterior fontanel should be open, and it should not be closed until approximately 18 months of age. (B and C) are normal findings. A child with hydrocephalus may have a delayed closing of the fontanel (D).
A nurse is caring for a client after a left pneumonectomy for cancer. The nurse palpates the client's trachea routinely. What is the rationale for this nursing intervention? A) A mediastinal shift may have occurred B) Nodular lesions may demonstrate metastasis C) Tracheal edema may lead to an obstructed airway D) The cuff on the endotracheal tube may be overinflated
A) A mediastinal shift may have occurred
Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable? A) A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B) Pneumonia, with a sputum culture of gram-negative bacteria C) Urinary tract infection, with positive blood cultures D) Culture of a diabetic foot ulcer shows gram-positive cocci
A) A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) - The client with colonized MRSA (A) is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy (B), which makes recovery very difficult. Positive blood cultures (C) indicate a systemic infection. Poor circulation places the diabetic with an infected ulcer (D) at high risk for poor healing and bone infection.
Which clinical indicators identified by the nurse support the probably presence of fecal impaction in a client? Select all that apply. A) Abdominal cramps B) Fecal liquid seepage C) Hyperactive bowel sounds D) Bright red blood in the stool E) Decreased number of bowel movements
A) Abdominal cramps B) Fecal liquid seepage C) Hyperactive bowel sounds
A nurse is caring for a client with diabetes who is scheduled for a radiographic study requiring contrast. What should the nurse expect the HCP to prescribe? A) Acetylcysteine before the test B) Renal-friendly contrast medium for the test C) Forced diuresis with mannitol after the test D) Hydration with dextrose and water throughout the test
A) Acetylcysteine before the test - Acetylcysteine is an antioxidant that scavenges oxygen free radicals, which are released when contrast medium causes cell death to renal tubular tissue; it also induces slight vasodilation.
An adult client has prescriptions for morphine sulfate 2.5 mg IV q6h and ketorolac (Toradol) 30 mg IV q6h. Which action should the nurse implement? A) Administer both medications according to the prescription. B) Hold the ketorolac to prevent an antagonistic effect. C) Hold the morphine to prevent an additive drug interaction. D) Contact the healthcare provider to clarify the prescription.
A) Administer both medications according to the prescription. - Morphine and ketorolac (Toradol) can be administered concurrently (A), and may produce an additive analgesic effect, resulting in the ability to reduce the dose of morphine, as seen in this prescription. Toradol is an antiinflammatory analgesic, and does not have an antagonistic effect with morphine (B), like an agonist-antagonist medication would have. An additive analgesic effect is desirable (C), because it allows a reduced dose of morphine. This prescription does not require any clarification, and can be administered safely as written (D).
The nurse places a heating pad on the lower leg of a client with peripheral vascular disease (PVD). When the heating pad is removed, the client's skin is blistered and a full-thickness burn is evident. What consequence can occur based on the nurse's action? A) All elements are present to find the nurse liable for damages. B) The injury was not foreseeable therefore the nurse is not liable. C) Client harm occurred which is enough evidence to prove liability. D) The standard of care was not breached so the nurse is not liable.
A) All elements are present to find the nurse liable for damages. - The nurse has a duty to deliver safe care. If that duty is breached, the injury foreseeable, and the client suffers harm, then the elements for establishing liability are present (A). In caring for a client with PVD, the nurse should anticipate that heat injury (B) is possible and provide the standard of care to prevent harm (D). Client harm (C) represents only one element and should not be the lone criteria for determining liability.
A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas? A) Ammonia level B) Culture and sensitivity C) WBC count D) AST level
A) Ammonia level
A 26-year-old primigravida client is experiencing increasing discomfort and anxiety during the active phase of labor. She requests something for pain. Which analgesic should the nurse anticipate administering? A) Butorphanol (Stadol) B) Hydromorphone (Dilaudid) C) Morphine sulfate D) Codeine sulfate
A) Butorphanol (Stadol) - Butorphanol (Stadol) (A) is a mixed agonist-antagonist analgesic resulting in good analgesia but with less respiratory depression, nausea, and vomiting compared with opioid agonist analgesics (B, C, and D).
The nurse anticipates administering Rho(D) immune globulin (RhoGAM) to which individual(s)? (Select all that apply.) A) An Rh-negative woman who has had a miscarriage at 24 weeks B) The father of a baby of an Rh-positive fetus C) An Rh-negative mother after delivery with an Rh-positive infant with a negative direct Coomb's test D) An Rh-positive infant within 72 hours of birth E) An Rh-negative mother with a negative antibody titer at 28 weeks
A) An Rh-negative woman who has had a miscarriage at 24 weeks C) An Rh-negative mother after delivery with an Rh-positive infant with a negative direct Coomb's test E) An Rh-negative mother with a negative antibody titer at 28 weeks - (A, C, and E) are all candidates for RhoGAM. RhoGAM should never be given to an infant or father (B and D)
Which nursing intervention has the highest priority during IV administration of mechlorethamine HCl (nitrogen mustard) and actinomycin (Actinomycin D)? A) Assess for extravasation at the IV site during infusion. B) Premedicate with antiemetics 30 to 60 minutes before infusion. C) Monitor cardiac rate and rhythm during the IV infusion. D) Check the granulocyte count daily for the presence of neutropenia.
A) Assess for extravasation at the IV site during infusion. - Mechlorethamine HCl (nitrogen mustard) and actinomycin (Actinomycin D) are vesicants; therefore, assessment for blister formation and/or tissue sloughing that can occur with leakage of these agents into surrounding subcutaneous tissues is essential to ensure client safety during the IV infusion (A). (B, C, and D) do not have the priority of (A) during the administration of vesicants.
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement? A) Assist the client to walk to the bathroom and do not leave the client alone. B) Request that the UAP assist the client onto a bedpan. C) Ask if the client needs to have a bowel movement or void. D) Assess the client's bladder to determine if the client needs to urinate.
A) Assist the client to walk to the bathroom and do not leave the client alone. - Barbiturates cause central nervous system (CNS) depression and individuals taking these medications are at greater risk for falls. The nurse should assist the client to the bathroom (A). A bedpan (B) is not necessary as long as safety is ensured. Whether the client needs to void or have a bowel movement, (C) is irrelevant in terms of meeting this client's safety needs. There is no indication that this client cannot voice her or his needs, so assessment of the bladder is not needed (D).
A spouse spends most of the day with a client who is receiving chemotherapy for an inoperable cancer. The spouse says to the nurse, "What can I do to help?" How can the nurse support the client's spouse? A) Assist the couple to maintain open communication B) Offer the couple a description of the disease progression C) Instruct the spouse about the action of the mediations D) Meet privately with the spouse to explore feelings
A) Assist the couple to maintain open communication
The nurse is correct in withholding an older adult client's dose of nifedipine (Procardia) if which assessment finding is obtained? A) Blood pressure of 90/56 mm Hg B) Apical pulse rate of 68 beats/min C) Potassium level of 3.3 mEq/L D) Urine output of 200 mL in 4 hours
A) Blood pressure of 90/56 mm Hg - Nifedipine (Procardia) is a calcium channel blocker that causes a decrease in blood pressure. It should be withheld if the blood pressure is lowered, and 90/56 mm Hg is a low blood pressure for an adult male (A). A pulse rate less than 60 beats/min is an indication to withhold the drug (B). A potassium level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding does not affect the administration of Procardia (C). Urine output of more than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200- mL output in 4 hours is slightly less than normal and warrants follow-up, it is not an indication to withhold a nifedipine (Procardia) dose (D).
A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority? A) Call the healthcare provider immediately if his nail beds appear blue. B) Check his fingers hourly for the first 48 hours to see that he is able to move them without pain. C) Be sure his arm remains above his heart for the first 24 hours. D) Take his temperature q4h for the next two days and call if an elevation is noted.
A) Call the healthcare provider immediately if his nail beds appear blue. - Cyanosis (A) indicates impaired circulation to fingers and should be reported immediately. Although the actions described in (B, C, and D) may be indicated, they are implemented rather excessively--and might tend to frighten the parents. It is not necessary to check the child's ability to move his fingers hourly for 2 days (B). Elevating the arm above the heart will help to decrease swelling but (C) is stated in a frightening way. It is not necessary to take the child's temperature q4h unless indicated by other symptoms.
A nurse is caring for a client with a history of COPD. WHat complications are most commonly associated with COPD? A) Cardiac problems B) Joint inflammation C) Kidney dysfunction D) Peripheral neuropathy
A) Cardiac problems
Which action should the nurse implement when providing nasogastric (NG) feeding to an unresponsive client? A) Check residual volume every four hours. B) Stimulate the gag reflex every eight hours. C) Administer small amounts of the formula. D) Give the feeding while the client is supine.
A) Check residual volume every four hours. - The gastric residual volume should be assessed every four hours (A) to evaluate absorption of the feeding and to determine delayed gastric emptying. (C) is not indicated unless the client cannot tolerate the prescribed volume of feeding. (B and D) are contraindicated. Stimulating the gag reflex (B) and administering NG feedings while the client is supine (D) increases the risk of aspiration.
What should the nurse do when collecting a 24-hour urine specimen? A) Check to verify if a preservative is needed B) Weigh the client before starting the collection C) Discard the last voided specimen of the 24-hour period D) Assess the client's intake and output for the previous 24-hour period
A) Check to verify if a preservative is needed
A client with type 1 diabetes has an above-the-knee amputation because of severe lower extremity arterial disease. What is the nurse's primary responsibility two days after surgery when preparing the client to eat dinner? A) Checking the client's serum glucose level B) Assisting the client out of bed into a chair C) Placing the client in the high-Fowler position D) Ensuring the client's residual limb is elevated
A) Checking the client's serum glucose level - Because the client has type 1 diabetes, it is essential that the blood glucose level be determined before meals to evaluate the level of control of diabetes and the possible need for insulin coverage. To prevent flexion contractures of the hip, the client should not sit for a prolonged time; this is not the priority. Raising the head of the bed flexes the hips, which may result in hip flexion contractures; this is not the priority. Ensuring the client's residual limb is elevated may result in a hip flexion contracture and should be avoided.
Which measurements should be used to accurately calculate a pediatric medication dosage? (Select all that apply.) A) Child's height and weight. B) Adult dosage of medication. C) Body surface area of child. D) Average adult's body surface area. E) Average pediatric dosage of medication. F) Nomogram determined mathematical constant.
A) Child's height and weight. C) Body surface area of child. F) Nomogram determined mathematical constant. - Correct selections are (A, C, and F). The most accurate calculations of pediatric dosages use the child's height and weight (A). The child's BSA is calculated using the square root of weight in kg times height in cm divided by 3600 or the square root of weight in lb times height in inches divided by 3131 (C), then the child's BSA is multiplied by the recommended published dose per BSA. The nomogram (F) is used to plot the child's height and weight, and the point at which they intersect is the BSA mathematical constant used to calculate the child's dose. (B, D, and E) are not used to calculate pediatric dosages.
A hospitalized client hurriedly approaches the nurse, saying that it sounds like there is a roaring fire in the bathroom. In reality, the client's roommate has just turned on the shower in full force. What term best describes this experience? A) Illusion B) Delusion C) Dissociation D) Hallucination
A) Illusion - An illusion is a misperception of an actual stimulus
A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information? A) Children need to retain a sense of initiative without impinging on the rights and privileges of others. B) Negative feelings of doubt and shame are characteristic of 4-year-old children. C) Role conflict is a common problem of children this age. She is just wondering where she fits into society. D) At this age children compete and like to produce and carry through with tasks. She is just competing with her mother.
A) Children need to retain a sense of initiative without impinging on the rights and privileges of others. - Children aged 3 to 6 are in Erickson's "Initiative vs. Guilt" stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative without impinging on the rights of others (A). (B) describes the "Autonomy vs. Shame and Doubt," stage (1 to 3 years of age). (C) describes an adolescent (12 to 18 years of age), the "Identity vs. Role Confusion" stage. (D) describes a child 6 to 12 years of age, the "Industry vs. Inferiority" stage.
The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with the diagnosis of left-sided heart failure? (Select all that apply.) A) Confusion B) Peripheral edema C) Crackles in the lungs D) Dyspnea E) Distended neck veins
A) Confusion C) Crackles in the lungs D) Dyspnea - Left-sided heart failure results in pulmonary congestion caused by the left ventricle's inability to pump blood to the periphery. Confusion, crackles in the lungs, and dyspnea are all signs of pulmonary congestion (A, C, and D). (B and E) are associated with right-sided heart failure.
A nurse is assessing a client with hypothyroidism. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply. A) Cool skin B) Photophobia C) Constipation D) Periorbital edema E) Decreased appetite
A) Cool skin C) Constipation D) Periorbital edema E) Decreased appetite - Cool skin is related to the decreased metabolic rate associated with insufficient thyroid hormone. Constipation results from a decrease in peristalsis related to the reduction in the metabolic rate associated with hypothyroidism. Periorbital and facial edemas are caused by changes that cause myxedema and third-space fluid effusion seen in hypothyroidism. Decreased appetite is related to metabolic and gastrointestinal manifestations of the hypothyroidism. Photophobia is associated with exophthalmos that occurs with hyperthyroidism.
What is a nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. A) Count the client's respirations B) Document the intensity of the client's pain C) Withhold the medication if the client reports pruritus D) Verify the number of doses in the locked cabinet before administering the prescribed dose E) Discard the medication in the client's toilet before leaving the room if the medication is refused
A) Count the client's respirations B) Document the intensity of the client's pain D) Verify the number of doses in the locked cabinet before administering the prescribed dose - Pruritus is a common side effect that can be managed with antihistamines. The nurse should NOT discard the opioid in the patient's room. Any waste of an opioid must be witnessed by another nurse.
While preparing a client for her first Pap smear, a nurse determines that she appears anxious. What should the nurse include as part of the teaching plan? A) Current statistics on the incidence of cervical cancer B) Description of the early symptoms of cervical cancer C) Explanation of why there is a small risk for cervical cancer D) Written instructions about the purpose of a pap smear
A) Current statistics on the incidence of cervical cancer
A client had a suprapubic prostatectomy. Which type of tube can the nurse expect the client to have when he returns to his room from the PACU? A) Cystostomy B) NG C) Nephrostomy D) Ureterostomy
A) Cystostomy
The parents of a 3-week-old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain? A) Description of vomiting episodes in past 24 hours. B) Number of wet diapers in last 24 hours. Incorrect C) Feeding and sleep schedule. D) Amount of formula consumed during the past 24 hours.
A) Description of vomiting episodes in past 24 hours. - A description of the vomiting episodes (A) will assist the nurse in determining the reason for the symptoms, which may be helpful in developing a plan of care for this infant. (B and C) provide related information but are not as helpful as (A). (D) may be related to the vomiting, but the nurse should first obtain a better description of the vomiting episodes.
Which intervention is most important for a nurse to implement prior to administering atropine PO? A) Determine the presence of 5 to 35 bowel sounds/min. B) Assess the blood pressure, both lying and standing. C) Verify that the client's tendon reflexes are 2+. D) Have the client rate his or her pain on a 0 to 10 scale.
A) Determine the presence of 5 to 35 bowel sounds/min. - Anticholinergic drugs, such as atropine, have antispasmodic and antisecretory properties, which relax the gastrointestinal tract, and are therefore contraindicated in a client with intestinal atony (A). Anticholinergic drugs do not have an effect on (B) (used to determine dehydration) or (C). Atropine itself has no analgesic effect; it is used with opioids to potentiate their effect (D).
Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? Select all that apply. A) Diarrhea B) Listlessness C) Weight loss D) Bradycardia E) Decreased appetite
A) Diarrhea C) Weight loss
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A) Document that the client responds to painful stimulus. B) Observe the client's response to verbal stimulation. C) Place the client on seizure precautions for 24 hours. D) Report decorticate posturing to the health care provider.
A) Document that the client responds to painful stimulus. - The client has demonstrated a purposeful response to pain, which should be documented as such (A). Response to painful stimulus is assessed after response to verbal stimulus, not before (B). There is no indication for placing the client on seizure precautions (C). Reporting (D) is nonpurposeful movement.
A nurse is assessing a client with a diagnosis of hypothyroidism. Which clinical manifestation should the nurse expect when assessing this client? Select all that apply. A) Dry skin B) Brittle hair C) Weight loss D) Resting tremors E) Heat intolerance
A) Dry skin B) Brittle hair
A nurse is caring for a client with cholelithasis and obstructive jaundice. When assessing this client, the nurse should be alert for which common clinical indication associated with this condition? Select all that apply. A) Ecchymosis B) Yellow sclera C) Dark brown stool D) Straw-colored urine E) Pain in the right upper quadrant
A) Ecchymosis B) Yellow sclera E) Pain in the right upper quadrant
Fludrocortisone is prescribed for a client with adrenal insufficiency. Which responses to the medication should the nurse instruct the client to report? Select all that apply. A) Edema B) Rapid weight gain C) Fatigue in the afternoon D) Unpredictable changes in mood E) Increased frequency of urination
A) Edema B) Rapid weight gain
A chemotherapeutic regimen with doxorubicin HCl (Adriamycin) is being planned for a client recently diagnosed with cancer. What diagnostic test results should the nurse review prior to initiating this treatment? A) Electrocardiogram (ECG) B) Arterial blood gases (ABGs) C) Serum cholesterol level D) Pelvic ultrasound
A) Electrocardiogram (ECG) - Baseline cardiac function studies (A) are required to monitor the irreversible cardiotoxic effects of doxorubicin HCl (Adriamycin). (B) assesses disturbances of acid-base balance. (C) is not affected by this chemotherapeutic agent. (D) is used to detect pelvic abnormalities such as tumors but is not specific for the administration of Adriamycin.
A very busy hospital unit has had several discharges and the census is unusually low. What is the best way for the charge nurse to use the time of the nursing staff? A) Encourage staff to participate in online in-service education. B) Assign staff to make sure that all equipment is thoroughly cleaned. C) Ask which staff members would like to go home for the remainder of the day. D) Notify the supervisor that the staff needs additional assignments.
A) Encourage staff to participate in online in-service education. - Online educational programs are available around the clock, so staff can engage in continuing education programs when the opportunity arises, such as during periods of low census (A). (B) is not the responsibility of the nursing staff. (C) is not the best use of staff and does not use the extra time provided by the low census. The charge nurse should use the time to improve the unit, and requesting additional assignments is not necessary (D).
While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement? A) Encourage the client to see the clinic's grief counselor. B) Determine if the client has a family history of suicide attempts. C) Inquire about whether the life partner was suffering from AIDS. D) Consult with the health care provider about the client's need for antidepressant medications.
A) Encourage the client to see the clinic's grief counselor. - The client is exhibiting normal grieving behaviors, so referral to a grief counselor (A) is the most important intervention for the nurse to implement. (B) is indicated, but is not a high-priority intervention. (C) is irrelevant at this time but might be important when determining the client's risk for contracting the illness. An antidepressant may be indicated (D), depending on further assessment, but grief counseling is a better action at this time because grief is an expected reaction to the loss of a loved one.
A nurse is working with a client who has the diagnosis of borderline personality disorder with antisocial behavior. What personality traits should the nurse expect the client to exhibit. Select all that apply. A) Engaging B) Indecisive C) Withdrawn D) Manipulative E) Perfectionist
A) Engaging D) Manipulative
What nursing actions best promote communication when obtaining a nursing history? Select all that apply. A) Establishing eye contact B) Paraphrasing the client's message C) Asking "why" and "how" questions D) Using broad, open-ended statements E) Reassuring the client that there is no cause for alarm F) Asking questions that can be answered with a "yes" or "no"
A) Establishing eye contact B) Paraphrasing the client's message D) Using broad, open-ended statements
A client with a brain tumor develops a urine output of 300 mL/hr, dry skin, and dry mucous membranes. Which nursing intervention is the most appropriate to perform for this client? A) Evaluate urine specific gravity. B) Implement fluid restrictions. C) Provide emollients to the skin to prevent breakdown. D) Slow down the intravenous (IV) fluids and notify the primary healthcare provider
A) Evaluate urine specific gravity. - Urine output of 300 mL/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce antidiuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There is no indication to reduce fluids. Providing emollients to prevent skin breakdown is important but does not assist with determining the underlying cause of the increased urine output. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.
A client who has just had a kidney transplant is transferred from the PACU to the ICU. How often should the nurse in the ICU monitor the client's urinary output? A) Every hour B) Every 2 hours C) Every half hour D) Every 15 minutes
A) Every hour
A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test? A) Failure to collect all urine specimens during the period of the study will invalidate the test. B) Blood is collected to measure the amount of creatinine and determine the glomerular filtration rate (GFR). C) Dialysis is started when the GFR is lower than 5 mL/min. D) Discard the first voiding, and record the time and amount of urine of each voiding for 24 hours.
A) Failure to collect all urine specimens during the period of the study will invalidate the test. - Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test, so all urine should be collected during the period of the study or the results are inaccurate (A). As renal function decreases, the creatinine level will decrease in the urine (B). Dialysis is usually started when the GFR is 12 mL/min (C). There is no need to record the frequency and amount of each voiding (D) during the time span of urine collection.
A client is diagnosed with hyperthyroidism and is treated with 131I. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms should be included in the teaching? Select all that apply. A) Fatigue B) Dry skin C) Insomnia D) Intolerance to heat E) Progressive weight gain
A) Fatigue B) Dry skin E) Progressive weight gain - Fatigue is caused by a decreased metabolic rate associated with hypothyroidism. Dry skin most likely is caused by decreased glandular function associated with hypothyroidism. Progressive weight gain is associated with hypothyroidism in response to a decrease in the metabolic rate because of insufficient thyroid hormone. Insomnia is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone. Intolerance to heat is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone.
A client who is hypertensive receives a prescription for hydrochlorothiazide (HCTZ). When teaching about the side effects of this drug, which symptoms are most important for the nurse to instruct the client to report? A) Fatigue and muscle weakness B) Anxiety and heart palpitations C) Abdominal cramping and diarrhea D) Confusion and personality changesA
A) Fatigue and muscle weakness - Thiazide diuretics, such as HCTZ, cause potassium wasting in the urine, so the client should be instructed to report fatigue and muscle weakness (A), which are characteristic of hypokalemia. Although (B, C, and D) should be reported, they are not indicative of hypokalemia, which is a side effect of HCTZ that can cause cardiac dysrhythmias.
To avoid a false positive result for fecal occult blood in a stool specimen, the nurse should instruct the client to avoid ingestion of which substances prior to collecting a sample? (Select all that apply.) A) Fish. B) Beef. C) Vitamin C tablets. D) Turkey. E) Ibuprofen (Advil). F) Coffee.
A) Fish. B) Beef. C) Vitamin C tablets. E) Ibuprofen (Advil). - Correct selections are (A, B, C, and E). The fecal occult blood test, or guaiac test, measures microscopic amounts of blood in the feces. False positive results can occur from food products such as fish (A), beef and other red meats (B), green vegetables, vitamin C supplements (C), aspirin, and nonsteroidal antiinflammatory medications, including ibuprofen (E). (D and F) do not affect the results of fecal occult blood testing.
Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her HCP. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action? A) Give the infant to the client and instruct her regarding the infant's care B) Explain to the client that she can leave, but her infant must remain in the hospital C) Emphasize to the client that the infant is a minor and legally must remain until orders are received D) Tell the client that hospital policy prevents the staff from releasing the infant until ready to discharge
A) Give the infant to the client and instruct her regarding the infant's care - When a client signs herself and her infant out of the hospital, she is legally responsible for her infant.
When a developmental appraisal is performed on a 6-month-old infant, which observation is most important to the nurse in light of a diagnosis of hydrocephalus? A) Head lag B) Positive Babinski reflex C) Inability to sit unsupported D) Absence of the grasp reflex
A) Head lag
The cervix of a client in labor is dilated 8 cm. She tells the nurse that she has the desire to push and is becoming increasingly uncomfortable. She requests pain medication. How should the nurse respond? A) Help her to take panting breaths B) Prepare the birthing bed for the birth C) Assist her out of bed to the bathroom D) Administer the prescribed butorphanol (Stadol)
A) Help her to take panting breaths
A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly? A) Help the client dangle his legs. B) Apply compression stockings. C) Assist with passive leg exercises. D) Ambulate three times a day.
A) Help the client dangle his legs. - The client who has arterial PVD may benefit from dependent positioning, and this can be achieved with bedside dangling (A), which will promote gravitation of blood to the feet, improve blood flow, and relieve pain. (B) is indicated for venous insufficiency (C) and indicated for bed rest. Ambulation (D) is indicated to facilitate collateral circulation and may improve long-term complaints of pain.
A nurse is caring for a client who had an adrenalectomy. For what clinical response should the nurse monitor while steroid therapy is being regulated? A) Hypotension B) Hyperglycemia C) Sodium retention D) Potassium excretion
A) Hypotension - After an adrenalectomy, adrenal insufficiency causes hypotension because of fluid and electrolyte imbalances.
What should the nurse consider when obtaining informed consent from a 17-year-old adolescent? A) If the client is allowed to give consent B) The client cannot make informed decisions about health care C) If the client is permitted to give voluntary consent when parents are not available D) The client probably will be unable to choose between alternatives when asked to consent
A) If the client is allowed to give consent - A person is legally unable to sign a consent until the age of 18 years unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent.
A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. WHat should the nurse conclude is the reason why metabolic acidosis develops with kidney failure? A) Inability of the renal tubules to secrete hydrogen ions to conserve bicarbonate B) Depressed RR by metabolic wastes, causing CO2 retention C) Inability of the renal tubules to reabsorb water to dilute the acid contents of blood D) Impaired glomerular filtration, causing retention of sodium and metabolic waste products
A) Inability of the renal tubules to secrete hydrogen ions to conserve bicarbonate
Which instruction(s) should the nurse give to a female client who just received a prescription for oral metronidazole (Flagyl) for treatment of trichomonas vaginalis? (Select all that apply.) A) Increase fluid intake, especially cranberry juice. B) Do not abruptly discontinue the medication; taper use. C) Check blood pressure daily to detect hypertension. D) Avoid drinking alcohol while taking this medication. E) Use condoms until treatment is completed. F) Ensure that all sexual partners are treated at the same time.
A) Increase fluid intake, especially cranberry juice. D) Avoid drinking alcohol while taking this medication. E) Use condoms until treatment is completed. F) Ensure that all sexual partners are treated at the same time. - Correct selections are (A, D, E, and F). Increased fluid intake and cranberry juice (A) are recommended for prevention and treatment of urinary tract infections, which frequently accompany vaginal infections. It is not necessary to taper use of this drug (B) or to check the blood pressure daily (C), as this condition is not related to hypertension. Flagyl can cause a disulfiram-like reaction if taken in conjunction with ingestion of alcohol, so the client should be instructed to avoid alcohol (D). All sexual partners should be treated at the same time (E) and condoms should be used until after treatment is completed to avoid reinfection (F).
A client is diagnosed with Crohn's disease, and parenteral vitamins are prescribed. The client asks why the vitamin has to be given IV rather than by mouth. What rationals for this route should the nurse include in a response to the question? Select all that apply. A) More rapid action results B) They are ineffective orally C) They decrease colon irritability D) Intestinal absorption may be inadequate E) Allergic responses are less likely to occur
A) More rapid action results B) They are ineffective orally D) Intestinal absorption may be inadequate
A primipara presents to the perinatal unit describing rupture of the membranes (ROM), which occurred 12 hours prior to coming to the hospital. An oxytocin (Pitocin) infusion is begun, and 8 hours later the client's contractions are irregular and mild. What vital sign should the nurse monitor with greater frequency than the typical unit protocol? A) Maternal temperature B) Fetal blood pressure C) Maternal respiratory rate D) Fetal heart rate E) Maternal temperature
A) Maternal temperature - (A) should be monitored frequently as a primary indicator of infection. This client's rupture of membranes (ROM) occurred at least 20 hours ago (12 hours before coming to the hospital, in addition to 8 hours since hospital admission). Delivery is not imminent, and there is an increased risk of the development of infection 24 hours after ROM. (B) cannot be established with standard bedside monitoring. (C) is not specifically related to ROM. (D) is always monitored during labor; this situation would not prompt the nurse to increase FHR monitoring.
A client with arthritis increases the dose of ibuprofen to abate joint discomfort. After several weeks the client becomes increasingly weak. The HCP determines that the client is severely anemia and admits the client to the hospital. What clinical indicators does the nurse expect to identify when performing an assessment? Select all that apply. A) Melena B) Tachycardia C) Constipation D) Clay-colored stools E) Painful BM
A) Melena B) Tachycardia
A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which classic signs of hepatic coma should the nurse assess this client? Select all that apply. A) Mental confusion B) Increased cholesterol C) Brown-colored stools D) Flapping hand tremors E) Hyperactive DTRS
A) Mental confusion D) Flapping hand tremors
Which is an independent nursing action that should be included in the plan of care for a client after an episode of ketoacidosis? A) Monitoring for signs of hypoglycemia as a result of treatment B) Withholding glucose in any form until the situation is corrected C) Giving fruit juices, broth, and milk as soon as the client is able to take fluids orally D) Regulating insulin dosage according to the amount of ketones found in the client's urine
A) Monitoring for signs of hypoglycemia as a result of treatment - During treatment for acidosis, hypoglycemia may develop; careful observation for this complication should be made by the nurse. Whole milk and fruit juices are high in carbohydrates which are contraindicated in DKA (Option C).
What is the priority nursing intervention on admission of a primigravida in labor? A) Monitoring the fetal heart rate B) Asking the client when she last ate C) Obtaining the client's health history D) Determining if membranes have ruptured
A) Monitoring the fetal heart rate - Monitoring the fetus for signs of distress typically takes priority.
A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer. The healthcare provider's prescriptions include morphine with a patient-controlled analgesia (PCA), nasogastric tube (NGT) to low intermittent nasogastric suction, and IV fluids and antibiotics. The client complains of increasing abdominal pain 12 hours after returning to the surgical unit. The nurse determines the client has no bowel sounds, and 200 ml of bright red nasogastric drainage is in the suction canister in the past hour. What is the priority action the nurse should implement? A) Notify the healthcare provider. B) Irrigate the nasogastric tube per prescription. C) Assess the client's use of the PCA device. D) Splint the abdomen to relieve pressure on the incision.
A) Notify the healthcare provider. - Although nasogastric aspirate can be bright red initially, the color should gradually darken over the first 24 hours. A sudden increase in the volume of bright red gastric drainage indicates bleeding, and the healthcare provider should be notified immediately (A). (B, C, and D) should be implemented, but the client's complaints of pain and signs of bleeding require immediate action to prevent hemorrhagic shock.
A nurse is assessing a client who is experiencing postmenopausal bleeding. The tentative diagnosis is endometrial cancer. Which findings in the client's history are risk factors associated with endometrial cancer? Select all that apply. A) Obesity B) Mullparity C) Cigarette smoking D) Early onset of menopause E) Family history of endometrial cancer F) Previous hormonal replacement therapy
A) Obesity E) Family history of endometrial cancer F) Previous hormonal replacement therapy
Contraceptives that have estrogen-like and/or progesterone like compounds are prepared in a variety of forms. Which contraceptives should the nurse identify as having a hormonal component? Select all that apply. A) Oral contraceptives B) Diaphragms C) Cervical caps D) Female condoms E) Foam spermicides F) Transdermal agents
A) Oral contraceptives E) Foam spermicides F) Transdermal agents
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client? A) Oral hygiene should be performed before the medication. B) Antifungal medications are available in tablet, suppository, and liquid forms. C) Candida albicans is the organism that causes the white lesions in the mouth. D) The dietary intake of dairy and spicy foods should be limited.
A) Oral hygiene should be performed before the medication. - HIV infection causes depression of cell-mediated immunity that allows an overgrowth of Candida albicans (oral moniliasis), which appears as white, cheesy plaque or lesions that resemble milk curds. To ensure effective contact of the medication with the oral lesions, oral liquids should be consumed and oral hygiene performed before swishing the liquid Mycostatin (A). (B and C) provide the client with additional information about the pathogenesis and treatment of opportunistic infections, but (A) allows the client to participate in self-care of the oral infection. Dietary restriction of spicy foods reduces discomfort associated with stomatitis, but restriction of dairy products is not indicated (D).
A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? A) Orient the client to the unit environment B) Have a copy of hospital regulations available C) Explain that there is no reason to be concerned D) Reassure the client that the staff is available to answer questions
A) Orient the client to the unit environment
A nurse is caring for a client who had insertion of radium for cancer of the cervix. For what radium reaction should the nurse assess the client? A) Pain B) Nausea C) Excoriation D) Restlessness
A) Pain
A nurse is caring for a client who is admitted with urethral colic and hematuria. The client also has stage 1 HTN and is overweight. The decrease in which clinical indicator associated with this client's status should the nurse be most concerned about at this time? A) Pain B) Weight C) Hematuria D) HTN
A) Pain
A nurse is assessing a client who is being admitted for a surgical repair of a rectocele. What signs or symptoms does the nurse expect the client to report? Select all that apply. A) Painful intercourse B) Crampy abdominal pain C) Bearing-down sensation D) Urinary stress incontinence E) Recurrent UTI's
A) Painful intercourse C) Bearing-down sensation
Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A) Place the client in a side-lying position. B) Pull the auricle upward and outward. C) Hold the dropper 6 cm above the ear canal. D) Place a cotton ball into the inner canal. E) Pull the auricle down and back.
A) Place the client in a side-lying position. B) Pull the auricle upward and outward. - The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).
The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family? A) Polyuria and polydipsia. B) Lethargy and fatigue. C) Increased facial hair. D) Facial bone structure changes.
A) Polyuria and polydipsia. - Signs and symptoms of diabetes or hyperglycemia (A) need to be reported. Those receiving growth hormone should be monitored to detect elevated blood sugars and glucose intolerance. (B) is associated with any number of heath alterations, but is not associated with the growth hormone therapy. (C and D) are normal changes that occur with 12-year-old males.
A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A) Pulse characteristics B) Open airway C) Entrance and exit wounds D) Cervical spine injury
A) Pulse characteristics - Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity (A) is a priority. Because the client is talking, he has an open airway (B), so that assessment is not necessary. Assessing for (C and D) should occur after assessing for adequate circulation.
Which information from the client's history does the nurse identify as a risk factor for developing osteoporosis? A) Receives long-term steroid therapy B) Has a history of hypoparathyroidism C) Engages in strenuous physical activity D) Consumes high doses of the hormone estrogen
A) Receives long-term steroid therapy - Increased levels of steroids increase bone demineralization.
A nurse is providing dietary teaching for a client who is receiving a high-protein diet while recovering from an acute episode of colitis. What should the nurse include in the rationale for this diet? A) Repairs tissues B) Slows peristalsis C) Corrects the anemia D) Improves muscle tone
A) Repairs tissues
Minocycline (Minocin), 50 mg PO every 8 hours, is prescribed for an adolescent girl diagnosed with acne. The nurse discusses self-care with the client while she is taking the medication. Which teaching points should be included in the discussion? (Select all that apply.) A) Report vaginal itching or discharge. B) Take the medication at 0800, 1500, and 2200 hours. C) Protect skin from natural and artificial ultraviolet light. D) Avoid driving until response to medication is known. E) Take with an antacid tablet to prevent nausea. F) Use a nonhormonal method of contraception if sexually active.
A) Report vaginal itching or discharge. C) Protect skin from natural and artificial ultraviolet light. D) Avoid driving until response to medication is known. F) Use a nonhormonal method of contraception if sexually active. - Correct selections are (A, C, D, and F). Adverse effects of tetracyclines include superinfections, photosensitivity, and decreased efficacy of oral contraceptives. Therefore, the client should report vaginal itching or discharge (A), protect the skin from ultraviolet light (C), and use a nonhormonal method of contraception (F) while on the medication. Minocycline (Minocin) is known to cause dizziness and ataxia, so until the client's response to the medication is known, driving (D) should be avoided. Tetracyclines should be taken around the clock (B) but exhibit decreased absorption when taken with antacids, so (E) is contraindicated.
The nurse witnesses a male client's signature for surgical consent for a Billroth II procedure after the surgeon discusses the procedure and its implication with the client. After signing the consent, the client questions the importance of a change in his diet postoperatively. What action should the nurse implement? A) Review information about dumping syndrome. B) Have the client sign another consent. C) Notify the surgeon about the client's comment. D) Explain the surgical procedure.
A) Review information about dumping syndrome. - Further review of information about potential dumping syndrome (A), which is managed postoperatively with dietary modification after a Billroth II procedure (partial gastrectomy), should be explained to address the client's expressed concern. (B) is not necessary since informed consent verifies the client's understanding of surgical risks and the surgical procedure. (C) is not indicated because the client does not question his consent for the surgery. (D) may be indicated if the client asks for further interpretation of the surgeons's explanation.
The nurse is assessing a client admitted to the hospital with a tentative diagnosis of an adrenal cortex tumor. When assessing the client, which of these are signs of Cushing disease? Select all that apply. A) Round face B) Dependent edema in the feet and ankles C) Increased fatty deposition in the extremities D) Thin, translucent skin with bruising E) Increased fatty deposition in the neck and back
A) Round face B) Dependent edema in the feet and ankles D) Thin, translucent skin with bruising E) Increased fatty deposition in the neck and back - Changes in fat distribution may result in a round face and fat pads on the neck, back, and shoulders. There are increased levels of steroids and aldosterone, causing sodium and water retention in clients with Cushing syndrome. This increased fluid retention results in dependent peripheral edema. Skin changes result from increased blood vessel fragility and include bruises and thin or translucent skin. The extremities appear thinner from muscle wasting and weakness, not thicker from fatty deposition. Hypertension, not hypotension, is expected because of sodium and water retention.
A client admitted to the ED has ketones in the blood and urine. Which situation associated with this physiologic finding should be the nurse's focus when collecting additional data about this client? A) Starvation B) Alcoholism C) Bone healing D) Positive nitrogen balance
A) Starvation - In starvation there are inadequate carbohydrates available for immediate energy, and stored fats are used in excessive amounts, producing ketones.
A nurse is monitoring for clinical manifestations of infection in a client with a diagnosis of Addison disease. Which body mechanism related to infections process does the nurse conclude is impaired as a result of this disease? A) Stress response B) Electrolyte balance C) Metabolic process D) Respiratory function
A) Stress response - Because of diminished glucocorticoid production, there is a decreased response to stress, reducing the ability to fight infection.
A homeless person is brought into the ED after prolonged exposure to cold weather. WHat clinical manifestations of hypothermia does the nurse anticipate? Select all that apply. A) Stupor B) Erythema C) Increased anxiety D) Rapid respirations E) Paresthesia in the affected body parts
A) Stupor E) Paresthesia in the affected body parts
During the initial nursing assessment history, a client tells the nurse that he is taking tetracycline hydrochloride (Sumycin) for urethritis. Which medication taken concurrently with Sumycin could interfere with its absorption? A) Sucralfate (Carafate) B) Hydrochlorothiazide (Diuril) C) Acetaminophen (Tylenol) D) Phenytoin (Dilantin)
A) Sucralfate (Carafate) - Sucralfate (Carafate) (A) is used to treat duodenal ulcers and will bind with tetracycline hydrochloride (Sumycin), inhibiting this antibiotic's absorption. (B, C, and D) have no drug interaction properties that prohibit concurrent use with tetracycline hydrochloride (Sumycin).
A client is being treated for osteoporosis with alendronate (Fosamax), and the nurse has completed discharge teaching regarding medication administration. Which morning schedule would indicate to the nurse that the client teaching has been effective? A) Take medication, go for a 30 minute morning walk, then eat breakfast. B) Take medication, rest in bed for 30 minutes, eat breakfast, go for morning walk. C) Take medication with breakfast, then take a 30 minute morning walk. D) Go for a 30 minute morning walk, eat breakfast, then take medication.
A) Take medication, go for a 30 minute morning walk, then eat breakfast. - Alendronate (Fosamax) is best absorbed when taken thirty minutes before eating in the morning. The client should also be advised to remain in an upright position for at least thirty minutes after taking the medication to reduce the risk of esophageal reflux and irritation. (A) is the best schedule to meet these needs. (B, C, and D) do not meet these criteria.
The health care provider prescribes oral contraceptives for a client who wants to prevent pregnancy. Which information is the most important for the nurse to provide to this client? A) Take one pill at the same time every day until all the pills are gone. B) Use condoms and foam instead of the pill while on any antibiotics. C) Limit sexual intercourse for at least one cycle after starting the pill. D) Use another contraceptive if two or more pills are missed in one cycle
A) Take one pill at the same time every day until all the pills are gone. - To maintain adequate hormonal levels for contraception and enhance compliance, oral contraceptives should be taken at the same time each day (A). There is no strong pharmacokinetic evidence that shows a relationship between the category of broad-spectrum antibiotic use and altered hormone levels in oral contraceptive users, so (B) is not indicated at this time. Abstinence (C) is the best method to prevent pregnancy during the first cycle. If a client misses two pills during the first week (D), the client should take two pills a day for 2 days and finish the package while using a backup method of birth control until her next menstrual cycle.
A 17-year-old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assesses his vital signs: temperature 100° F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take? A) Tell the student to proceed directly to his regularly scheduled class. B) Call the parent and suggest re-taking the student's temperature at home. C) Give the student a glass of cool fluids, then retake his temperature. D) Send the student to class, but re-verify his temperature after lunch.
A) Tell the student to proceed directly to his regularly scheduled class. - This student has just completed football practice, and increased muscle activity increases body heat production. A temperature of 100° F is normal for this student at this time. The student should attend class (A) since no further nursing action is required. (B) would alarm the parents unnecessarily. (C) would provide a false reading of body temperature. (D) is unnecessary since these findings are within normal limits.
Which situation requires intervention by the nurse who is caring for a terminally ill client in a hospital? A) The case manager notifies the family that the critical pathway requires transfer to a hospice facility. B) The case manager notifies the social worker of the client's financial needs related to hospice care. C) The social worker describes the client's feelings of grief to the spiritual counselor. D) The social worker provides information about long-term care facilities to the client.
A) The case manager notifies the family that the critical pathway requires transfer to a hospice facility. - Critical pathways provide care guidelines, rather than required methods of care. The nurse should intervene in the situation described in (A) to ensure that the client and family are aware of options available. (B, C, and D) reflect appropriate actions by members of the interdisciplinary team, and require no intervention by the nurse.
Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the nurse? A) The color of the dialysate outflow is opaque yellow. B) The dialysate outflow is greater than the inflow. C) The inflow dialysate feels warm to the touch. D) The inflow dialysate contains potassium chloride.
A) The color of the dialysate outflow is opaque yellow. - Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse should obtain a specimen for culture, assess the client, and notify the health care provider (A). (B and C) are desired. (D) is commonly done to prevent hypokalemia.
The clinic nurse is taking the history for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain? A) Type of reaction to loud noises. B) Any surgeries on the ears since birth. C) Drainage from the infant's ears. D) Number of ear infections since birth.
A) Type of reaction to loud noises. - Ototoxicity diminishes hearing acuity and causes symptoms of tinnitus and vertigo in older children who can express subjective symptoms, so assessing an infant's reaction to loud noises (A) helps to determine an infant's risk for a hearing deficit related to a history of the mother taking an ototoxic drug, such as aspirin, while pregnant. (B, C, and D) are not associated with exposure to aspirin in utero.
A client is admitted to the surgical unit from the PACU with a Salem sump NG tube that is to be attached to wall suction. Which nursing action should the nurse implement when caring for this client? A) Use NS to irrigate the tube B) Employ sterile technique when irrigating the tube C) Withdraw the tube quickly when decompression is terminated D) Allow the client to have small sips of ice water unless nauseated
A) Use NS to irrigate the tube
To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement? A) Use a happy-face/sad-face pain scale. B) Ask the mother if she thinks the analgesic is working. C) Assess for changes in the child's vital signs. D) Teach the child to point to a numeric pain scale.
A) Use a happy-face/sad-face pain scale. - A 4-year-old can readily identify with simple pictures (A) to show the nurse how he/she is feeling. (B) could be used to validate what the child is telling the nurse via the "faces" pain scale, but it is best to elicit the child's assessment of his/her pain level. (C) may not accurately reflect the effectiveness of pain medication as they can also be affected by other variables, such as fear. (D) requires abstract number skills beyond the level of a 4-year-old.
A category X drug is prescribed for a young adult female client. Which instruction is most important for the nurse to teach this client? A) Use a reliable form of birth control. B) Avoid exposure to ultra violet light. C) Refuse this medication if planning pregnancy. D) Abstain from intercourse while on this drug.
A) Use a reliable form of birth control. - Drugs classified in the category X place a client who is in the first trimester of pregnancy at risk for teratogenesis, so women in the childbearing years should be counseled to use a reliable form of birth control (A) during drug therapy. (B) is not a specific precaution with Category X drugs. The client should be encouraged to discuss plans for pregnancy with the healthcare provider, so a safer alternative prescription (C) can be provided if pregnancy occurs
A female client with rheumatoid arthritis take ibuprofen (Motrin) 600 mg PO 4 times a day. To prevent gastrointestinal bleeding, misoprostol (Cytotec) 100 mcg PO is prescribed. Which information is most important for the nurse to include in client teaching? A) Use contraception during intercourse. B) Ensure the Cytotec is taken on an empty stomach. C) Encourage oral fluid intake to prevent constipation. D) Take Cytotec 30 minutes prior to Motrin.
A) Use contraception during intercourse. - Cytotec, a synthetic form of a prostaglandin, is classified as pregnancy Category X and can act as an abortifacient, so the client should be instructed to use contraception during intercourse (A) to prevent loss of an early pregnancy. (B) is not necessary. A common side effect of Cytotec is diarrhea, so constipation prevention strategies are usually not needed (C). Cytotec and Motrin should be taken together (D) to provide protective properties against gastrointestinal bleeding.
The nurse is preparing the 0900 dose of losartan (Cozaar), an angiotensin II receptor blocker (ARB), for a client with hypertension and heart failure. The nurse reviews the client's laboratory results and notes that the client's serum potassium level is 5.9 mEq/L. What action should the nurse take first? A) Withhold the scheduled dose. B) Check the client's apical pulse. C) Notify the healthcare provider. D) Repeat the serum potassium level.
A) Withhold the scheduled dose. - The nurse should first withhold the scheduled dose of Cozaar (A) because the client is hyperkalemic (normal range 3.5 to 5 mEq/L). Although hypokalemia is usually associated with diuretic therapy in heart failure, hyperkalemia is associated with several heart failure medications, including ARBs. Because hyperkalemia may lead to cardiac dysrhythmias, the nurse should check the apical pulse for rate and rhythm (B), and the blood pressure. Before repeating the serum study (D), the nurse should notify the healthcare provider (C) of the findings.
A nurse is assessing a male newborn. Which characteristics should alert the nurse to conclude that the newborn is a preterm infant? Select all that apply. A) Wrinkled, thin skin B) Multiple sole creases C) Small breast bud size D) Presence of scrotal rugae E) Pinna remaining flat when folded
A) Wrinkled, thin skin C) Small breast bud size E) Pinna remaining flat when folded
155. As Mr. Mesta's condition improves, he mentions his dislike for the low-sodium, low-protein diet ordered by his doctor. He states, "That food is not fit for a man to eat!" The best response that the nurse could make at this time is: A. "It must be difficult for you to accept these changes In your diet, Mr. Mesta." B. "Well, you've got to make the best of it, Mr. Mesta. You've really no choice but to follow the doctor's orders." C. "It could be worse, Mr. Mesta. That poor person In the next bed isn't allowed to eat anything at all" D. "Maybe we could talk to your doctor, Mr. Mesta. We could ask him. to put you on a regular diet since you will be going home soon."
A. ''It must be difficult for you to accept these changes in your diet, Mr. Mesta." This response is the most supportive of the four choices given. It shows concern and understanding for Mr. Mesta's situation in a nonjudgmental way. B is a less desirable response since it focuses on telling the client what to do and suggest he is powerless in the situation. C is also an undesirable response if the nurse hopes to achieve long-term compliance with the prescribed diet. The fact that another client cannot eat may be true, but it is unlikely to motivate Mr. Mesta to change his dietary habits. D is incorrect and suggests that the nurse does not understand the need for long-term changes in dietary habits.
37. The nurse needs to know that lactulose and neomycin are given to clients with hepatic encephaiopathy to: A. Decrease fecal pH and ammonia absorption. B. Induce peristalsis and promote bowel movement. C. Reduce antibacterial activity in the intestines. D. Remove potassium and magnesium in the intestines.
A. Decrease fecal pH and ammonia absorption. Lactulose, a synthetic disaccharide that contains galactose and fructose, reduces the ammonia level by expeliing the ammonia Into the bowel through its laxative action. Neomycin reduces the ammonia-forming bacteria in the intestinal tract. Thus, lactulose and neomycin are effective drugs used in clients with hepatic encephalopathy because they reduce the ammonia level in the body. The pharmacologic actions of lactulose and neomycin are not Included in B, C, and D they are incorrect responses.
115. The nurse is observing for the possible complication of postoperative peritonitis. Which sign or symptom is feast indicative of peritonitis? A. Hyperactive bowel sounds. B. Pain, local or general. C. Abdominal rigidity. D. Shallow respirations.
A. Hyperactive bowel sounds. Absence of bowel sounds is indicative of peritonitis, as in B, C, and D.
128. As she Is preparing for discharge, Ms. Norfolk reports to the nurse that she has pain In the calf of her left leg. The nurse assesses the situation and finds a positive Romans' sign. The nurse's decision Is to: A Put Ms. Norfolk on bedrest. B. Measure her left calf and reassess in 4 hours. C. Assist Ms. Norfolk In ambulation. D. Massage the cramp In her calf.
A. Put Ms. Norfolk on bedrest. Thrombophlebitis is a very serious complication and the client must be immobilized to prevent further life threatening problems. B Is incorrect because problems should be reported immediately. C and D are incorrect because they could assist a clot in traveling from the calf to a vital organ. The nurse should not ambulate and should never massage the client when thrombophlebitis is suspected.
390. Because of chronic crampy pain, diarrhea, and cachexia, a young adult is to receive total parenteral nutrition (TPN) via a central line. Before preparing a client for the insertion of the catheter, the nurse is aware that a: 1. Parenteral solution may be administered intermittently 2. Fluoroscopy must be done before the catheter is inserted 3. Jugular vein is the most commonly used catheter insertion site 4. Client will experience a moderate amount of pain during the procedure
Ans: 1 1 Although the central venous catheter remains in situ, total parenteral nutrition does not have to infuse continuously. Continuous versus intermittent administration depends on the practitioner's order.
859. As an acute episode of rheumatoid arthritis subsides, active and passive range-of-motion exercises are taught to the client's spouse. The nurse should teach that direct pressure should not be applied to the client's joints because this may precipitate: 1. Pain 2. Swelling 3. Nodule formation 4. Tophaceous deposits
Ans: 1 1 Palpation will elicit tenderness because pressure stimulates nerve endings and causes pain.
865. After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. The nurse's greatest concern at this time is: 1. Addressing the pain 2. Reversing feelings of hopelessness 3. Promoting mobility in the residual limb 4. Acknowledging the grieving for the lost limb
Ans: 1 1 Phantom limb sensation is a real experience with no known cause or cure. The pain must acknowledged and interventions to relieve the discomfort explored.
456. A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. A priority nursing action during the first 48 hours after the client's admission is to: 1. Monitor the client's vital signs 2. Increase the client's fluid intake 3. Improve the client's nutritional status 4. Determine the client's reasons for drinking
Ans: 1 1. A client's vital signs, especially the pulse and temperature, will increase before the client demonstrates any of the more severe symptoms of withdrawal from alcohol.
401. During a health symposium a nurse teaches the group how to prevent food poisoning. The nurse evaluates that the teaching is understood when one of the participants states: 1. "Meats and cream-based foods need to be refrigerated." 2. "Once most food is cooked it does not need to be refrigerated." 3. "Poultry should be stuffed and then refrigerated before cooking." 4. "Cooked food should be cooled before being put into the refrigerator."
Ans: 1 1. A cold environment limits growth of microorganisms.
430. Three hours after a subtotal gastrectomy, a client who has a nasogastric tube to continuous low suction and IV fluids complains of nausea and abdominal pain. The client's abdomen appears distended and there are no bowel sounds. The nurse should first: 1. Instill air into the tube 2. Give the prn pain medication 3. Check bowel movements for blood 4. Notify the surgeon of absent bowel sounds
Ans: 1 1. Abdominal distention, nausea, and abdominal pain can be signs of nasogatric tube blockage. Instilling 30 ml of air may reestablish patency.
423. Immediately after a subtotal gastrectomy a client is brought to the postanesthesia care unit. The nurse identifies small blood clots in the gastric drainage. The nurse should: 1. Clamp the tube 2. Consider this an expected event 3. Instill the tube with iced normal saline 4. Notify the client's surgeon of this finding
Ans: 2 2. As a result of the trauma of surgery, some bleeding can be expected for 4 to 5 hours.
459. A client is diagnosed as having hepatitis A. The information from the admitting data that most likely is linked to hepatitis A is the client's history of working: 1. For a local plumber 2. In a hemodialysis unit of a hospital 3. As a dishwasher at a local restaurant 4. With occupational arsenic compounds
Ans: 1 1. Hepatitis A is primarily spread via a fecal-oral route; sewage-polluted water may harbor the virus.
864. A nurse is providing health teaching to a client with rheumatoid arthritis. The statement by the nurse that best describes a technique to reduce joint stress is: 1. "Respond to pain in your joints." 2. "Use your smaller muscles most frequently." 3. "Do your heavy tasks at one time to reduce muscle strain." 4. "Increase exercise to reduce swelling when your joints are swollen."
Ans: 1 1. Not neglecting joint pain protects the joints, especially if the pain lasts more than 1 or 2 hours after a particular activity.
832. An older female client is experiencing frequency and uses the bathroom often during the night. One night while attempting to go to the bathroom without assistance, she develops severe back pain and is found to have a vertebral compression fracture. The nurse understands that this is a: 1. Collapse of vertebral bodies 2. Demineralization of the spinal cord 3. Wear and tear of the spinous processes 4. Bulging of the spinal cord from the vertebra
Ans: 1 1. Osteoporotic vertebrae collapse under the weight of the upper body or by improper or rapid turning, reaching, or lifting.
435. A client with a tentative diagnosis of cholecystitis is discharged from the emergency department with instructions to make an appointment for a definitive diagnostic workup. The recommendation that will produce the most valuable diagnostic information is: 1. "Keep a journal related to your pain." 2. "Save all stool and urine for inspection." 3. "Follow the physician's orders exactly without question." 4. "Keep a record of the amount and type of fluid you are drinking daily."
Ans: 1 1. Pain is a cardinal symptom; it is helpful to have as much specific information about it as possible, particularly its description and its relationship to foods ingested.
445. A client with cholelithiasis is scheduled for a lithotripsy. Preoperative teaching should include the information that: 1. Opioids will be available for postoperative pain 2. Fever is a common response to this intervention 3. Heart palpitations often occur after the procedure 4. Anesthetics are not necessary during the procedure
Ans: 1 1. Painful biliary colic may occur in the postoperative period as a result of the passage of pulverized fragments of the calculi; this may occur 3 or more days after the lithotripsy.
823. A nurse is providing teaching about self-care to a client who had a cast applied for a fracture of the right ulna and radius. For which occurrence should the nurse instruct the client to immediately notify the practitioner? 1. Slight stiffness of the fingers 2. Increasing pain at the injury site 3. Small amount of bloody drainage on the cast 4. Bounding radial pulse in the affected extremity
Ans: 2 2 This may indicate cast pressure on a nerve and should be investigated further.
839. A male client has a diskectomy and fusion for a herniated nucleus pulposis. When two nurses are assisting the client to get out of bed for the first time he complains of feeling faint and lightheaded. The nurses should have the client: 1. Sit on the edge of the bed so they can hold him upright 2. Slide to the floor so he will not hurt himself when falling 3. Bend fonvard so that blood flow to his brain is increased 4. Lie down immediately so they can take his blood pressure
Ans: 1 1. Sitting maintains alignment of the back and allows the nurses to support the client until orthostatic hypotension subsides.
380. The most effective method for the nurse to evaluate a client's response to ongoing serum albumin therapy for biliary cirrhosis is to monitor the client's: 1. Weight daily 2. Vital signs frequently 3. Urine output every half hour 4. Urine albumin level evety shift
Ans: 1 1. The increased osmotic effect of therapy increases the intravascular volume and urinary output; weight loss reflects fluid loss.
398. A client has a body mass index (BMI) of 35 and verbalize the need to lose weight. The nurse encourages the client to lose weight safely by: 1. Decreasing portion size and fat intake 2. Increasing protein and vegetable intake 3. Decreasing carbohydrate and fat intake 4. Increasing fruits and limiting fluid intake
Ans: 1 1. The most effective and safest method for achieving weight loss is to decrease caloric intake. This is best accomplished by maintaining a balance of nutrients while decreasing portion size and fat intake. A gram of fat is 9 calories, whereas a gram of protein and a gram of carbohydrate are each 4 calories.
393. After surgical implantation of radon seeds for oral cancer, the nurse observes the client for the side effects of the radiation including: 1. Nausea and/or vomiting 2. Hematuria and/or occult blood 3. Hypotension and/or bradycardia 4. Abdominal cramping and/or diarrhea
Ans: 1 1. The mucosa of the mouth and the vomiting center in the brainstem may be affected, producing nausea and vomiting.
421. A client with extensive gastric carcinoma is admitted to the hospital for an esophagojejunostomy. What information should the nurse include in the teaching plan when preparing this client for surgery? 1. Chest tube will be in place immediately after surgery 2. Liquids by mouth may be permitted the evening after surgery 3. Complete bed rest may be necessary for two days after surgery 4. Trendelenburg's position will be used on the first day after surgery
Ans: 1 1. The thoracic cavity usually is entered for a complete resection, necessitating a chest tube.
434. The characteristics that alert the nurse that a client is at increased risk of developing gallbladder disease is a female: 1. Older than the age of 40, obese 2. Younger than the age of 40, history of high fat intake 3. Older than the age of 40, low serum cholesterol level 4. Younger than the age of 40, family history of gallstones
Ans: 1 1. These characteristics are well-established risk factors for gallbladder disease (3 Fs - female, fat, and forty).
816. A client is scheduled for arthroscopic knee surgery and asks the nurse about the procedure. The statement by the nurse that best describes the procedure is: 1. "It is surgical repair of a joint under direct visualization using an arthroscope." 2. "It is a radiological procedure that will help diagnose the extent of the knee injury." 3. "The procedure will determine the type of treatments the surgeon will prescribe." 4. "You will be anesthetized so that you do not remember anything about the procedure."
Ans: 1 1. This describes the procedure in which the surgeon uses a scope to visualize and operate on the knee.
382. A client is cautioned to avoid vitamin D toxicity while increasing protein intake. The nurse evaluates that dietary teaching is understood when the client states, "I must increase my intake of: 1. tofu products." 2. eggnog with fruit." 3. powdered whole milk." 4. cottage cheese custard."
Ans: 1 1. Tofu products increase protein without increasing vitamin D because, unlike milk products, tofu does not contain vitamin D.
491. An abdominoperineal resection with the creation of a colostomy is scheduled for a client with cancer of the rectum. The nurse anticipates that the client must sign a consent for a: 1. Permanent sigmoid colostomy 2. Permanent ascending colostomy 3. Temporary double-barrel colostomy 4. Temporary transverse loop colostomy
Ans: 1 1. When intestinal continuity cannot be resorted after removal of the anus, rectum, and adjacent colon, a permanent colostomy is formed.
429. After abdominal surgery a client returns to the unit with a nasogastric tube to decompression. The practitioner orders an antiemetic every 6 hours pm for nausea. When the client complains of nausea, the first action by the nurse is to: 1. Check for placement of the tube 2. Administer the ordered antiemetic 3. Irrigate the tube with normal saline 4. Notify the practitioner of the problem
Ans: 1 1. With a nasogatric tube for decompression in place, nausea may indicate tube displacement or obstruction. Checking placement can determine whether it is in the stomach; once placement is verified, then fluid can be instilled to ensure patency.
449. A 50-year-old man is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature of 101°F. He reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, the primary nursing concern for this client is: 1. Acute pain 2. Inadequate nutrition 3. Electrolyte imbalance 4. Disturbed self-concept
Ans: 1. 1. Pain with pancreatitis usually is severe and is the major symptom; it occurs because of the auto-digestive process in the pancrease and peritoneal irritation.
869. A nurse is teaching a client who is to have an above-the-knee amputation about postoperative activities. Which activity is designed to aid in the use of crutches? 1. Lifting weights 2. Changing bed positions 3. Caring for the residual limb 4. Performing phantom limb exercises
Ans: 1. 1. Preparation for crutch walking includes exercises to strengthen arm and shoulder muscles.
444. Because of prolonged bile drainage from aT-tube after a cholecystectomy, the nurse must monitor the client for responses related to a lack of fat -soluble vitamins such as: 1. Easy bruising 2. Muscle twitching 3. Excessive jaundice 4. Tingling of the fingers
Ans: 1. 1. Vitamin K, a precursor for prothrombin, cannot be absorbed without bile.
845. A client sustains a fracture of the femur after jumping from the second story of a building during a fire. The client is placed in Buck's traction until an open reduction and internal fixation is performed. The client keeps slipping down in bed. To alleviate this problem the nurse should: 1. Elevate the foot of the bed 2. Shorten the rope on the weights 3. Release the traction so the client can be repositioned 4. Move the client toward the head of the bed every couple of hours
Ans: 1. 1. This provides slight contertraction, which will prevent sliding down the bed.
856. A client sustains a complex comminuted fracture of the tibia with soft tissue injuries after being hit by a car while riding a bicycle. Surgical placement of an external fixator is performed to maintain the bone in alignment. Postoperatively it is most essential for the nurse to: 1. Cleanse the pin sites with alcohol several times a day 2. Perform a neurovascular assessment of both lower extremities 3. Ambulate the client with partial weight bearing on the affected leg 4. Maintain placement of an abduction pillow between the client's legs
Ans: 2 2 A neurovascular assessment identifies early signs and symptoms of compartment syndrome. Compartment syndrome is increased pressure within a closed fascial space caused by a fracture and/or soft tissue damage that compresses circulatory vessels, nerves, and tissues compromising viability of the limb. The nurse should monitor for the 6 P's: unrelenting pain, pallor, paresthesia, pressure, pulselessness, and paralysis. In addition, the circumference of the extremity will increase and the leg, will feel hard and In-m on palpation. Both legs are assessed for symmetry.
858. When assessing a client experiencing an acute episode of rheumatoid arthritis, the nurse observes that the client's finger joints are swollen. The nurse concludes that this swelling most likely is related to: 1. Urate crystals in the synovial tissue 2. Inflammation in the joint's synovial lining 3. Formation of bony spurs on the joint surfaces 4. Escaped fluid from the capillaries that increases interstitial fluids
Ans: 2 2 The pathological process involved with rheumatoid arthritis is accompanied by vascular congestion, fibrin exudate) and cellular infiltrate) causing inflammation of the synovium.
860. A practitioner orders bed rest for a client with acute arthritis who has bilateral, painful, swollen knee and wrist joints. To prevent flexion deformities during the acute phase, the client's positioning schedule should include placement in the: 1. Sims position 2. Prone position 3. Contour position 4. Trendelenburg position
Ans: 2 2 The prone position provides for extension of the hip and knee joints.
373. When assessing a client's abdomen, the nurse palpates the area directly above the umbilicus. This area is known as the: 1. Iliac area 2. Epigastric area 3. Hypogastric area 4. Suprasternal area
Ans: 2 2 The stomach is located within the sternal angle, known as the epigastric area.
818. A client with impaired balance is using a walker to provide support when ambulating. While observing the client transferring from a sitting to a standing position and using the walker, the nurse evaluates that further teaching is required when the client: 1. Slides toward the edge of the seat before standing 2. Holds both handles of the walker while rising to the standing position 3. Moves forward into the walker after transferring from sitting to standing 4. Stands in place holding on to the walker for at least 30 seconds before walking
Ans: 2 2. Because of the angle of force applied to a walker when a person uses it to move from a sitting to a standing position, the walker can become unstable and tip over. The arms of the chair should be used for support when rising from a sitting position.
404. Immediately after esophageal surgery the priority nursing assessment concerns the client's: 1. Incision 2. Respirations 3. Level of pain 4. Nasogastric tube
Ans: 2 2. Because of the trauma of surgery and the proximity of the esophagus to the trachea, respiratory assessments become the priority.
849. A client has an open reduction and internal fixation of a fractured hip. To prevent the most common complication after this type of surgery, the nurse expects the surgeon's order to state: 1. "Turn from side to side periodically." 2. "Apply sequential compression stockings." 3. "Encourage isometric exercises to the extremities." 4. "Perform passive range of motion to the affected extremity:
Ans: 2 2. Compressed air inflates the padded plastic stockings systematically from ankle to calf to thigh and then deflates; this prmotes venous return and prevents venous stasis and thromboembolism.
461. A client with jaundice associated with hepatitis expresses concern over the change in skin color. The nurse explains that this color change is a result of: 1. Stimulation of the liver to produce an excess quantity of bile pigments 2. Inability of the liver to remove normal amounts of bilirubin fi'om the blood 3. Increased destruction of red blood cells during the acute phase of the disease 4. Decreased prothrombin levels, leading to multiple sites of intradermal bleeding
Ans: 2 2. Damage to liver cells affects the ability to facilitate removal of bilirubin from the blood, with resulting deposition in the skin and sclera.
821. An x-ray film of a client's arm reveals a comminuted fracture of the radial bone. The nurse expects that with a comminuted fracture: 1. Bone protrudes through a break in the skin 2. The bone has broken into several fragments and the skin is intact 3. The bone is broken into two parts and the skin mayor may not be broken 4. Splintering has occurred on one side of the bone and bending on the other
Ans: 2 2. In a comminuted fracture, the bone is splintered or crushed.
417. Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of bloody drainage from the client's nasogastric tube. The nurse should: 1. Clamp the tube and call the surgeon immediately 2. Report the characteristics of drainage to the surgeon 3. Instill 30 mL of iced normal saline into the nasogastric tube 4. Continue to monitor the drainage and record the observations
Ans: 2 2. Large amounts of blood or excessive bloody drainage 12 hours postoperatively must be reported immediately because the client is hemorrhaging.
866. A client has an above-the-knee amputation because of a gangrenous leg ulcer. To prevent deformities after the second postoperative day the nurse should: 1. Place an abduction pillow between the legs 2. Encourage lying in the supine or prone position 3. Keep the client's residual limb elevated on a pillow 4. Teach the client to press the residual limb against a hard surface several times a day
Ans: 2 2. Lying in the horizontal position stretches the flexor muscles and prevents a flexion contraction of the hip.
840. When preparing a client for discharge after a laminectomy, the nurse evaluates that further health teaching is necessary when the client says, "I should: 1. sleep on a firm mattress to support my back." 3. spend most of day sitting in a straight-back chair." 3. put a pillow under my legs when sleeping on my back." 4. avoid lifting heavy objects until the physician tells me I can."
Ans: 2 2. Maintaining the sitting position for a prolonged period places excessive stress on the surgical area.
822. Clients who have casts applied to an extremity must be monitored for complications. The most significant complication for which the nurse should assess the client's extremity is: 1. Warmth 2. Numbness 3. Skin desquamation 4. Generalized discomfort
Ans: 2 2. Numbness is a neurological sign because it indicates pressure on the nerves and blood vessels and should be reported immediately. 1. Warmth is a sign of adequate circulation. 3. Skin desquamation results from inadequate skin care and can be managed with lotion or oil. 4. Some degree of discomfort is expected after cast application.
440. A 40-year-old client is admitted with biliary cancer. The associated jaundice gets progressively worse. The nurse is most concerned about the potential complication of: 1. Pruritus 2. Bleeding 3. Flatulence 4. Hypokalemia
Ans: 2 2. Obstruction of bile flow impairs absorption of vitamin K, a fat-soluble vitamin; prothrombin is not produces and the clotting process is prolonged.
411. A client is suspected of having a gastric peptic ulcer. When obtaining a history from this client, the nurse expects the reported pain to: 1. Intensify when the client vomits 2. Occur one to three hours after meals 3. Increase when the client eats fatty foods 4. Begin in the epigastrium, radiating across the abdomen
Ans: 2 2. Pain occurs after the stomach empties with a gastric peptic ulcer; ingesting food stimulates gastric secretions, which later act on the gastric mucosa of the empty stomach, causing the gnawing pain.
454. After revision of the pancreas because of cancer, total parenteral nutrition is instituted via a central venous infusion route. During the fourth hour of the infusion the client complains of nausea, fatigue, and a headache. The hourly urine output is twice the amount of the previous hour. The nurse should call the practitioner and: 1. Stop the infusion while covering the insertion site 2. Slow the infusion and check the serum glucose level 3. Prepare the client for immediate surgery for possible bowel obstruction 4. Increase fluids via a peripheral intravenous route and give analgesics for the headache
Ans: 2 2. Rapid administration can cause glucose overload, leading to osmotic diuresis and dehydration; slowing the infusion decreases the possibility of glucose overload.
831. When teaching about the dietary control of gout, the nurse evaluates that the dietary teaching is understood when the client states; "I will avoid eating: 1. eggs." 2. shellfish." 3. fried poultry." 4. cottage cheese."
Ans: 2 2. Shellfish contains more than 100 mg of purine per 100 grams.
842. After a cervical neck injury, a male client is placed in a halo fixation device with a body cast. A statement that indicates that the client's concern about body image has been successfully resolved is: 1. "I hate having everyone else do things for me." 2. ''I've gotten used to the brace. 1 may even miss it when it's gone." 3. ''I've been keeping my daily calories low in an attempt to lose weight." 4. "I can't get to sleep. However, I make up for it in the morning by sleeping later."
Ans: 2 2. The client is demonstrating acceptance and is looking toward the future.
827. While a woman with a fractured femur is being prepared for surgery, she exhibits cyanosis, tachycardia, dyspnea, and restlessness. What should the nurse do first? 1. Call the practitioner 2. Administer oxygen by mask 3. Place her in the high Fowler's position 4. Lower her to the Trendelenburg position
Ans: 2 2. The client probably has a fat embolus; oxygen reduces surface tension of the fat globules and reduces hypoxia.
814. A nurse is performing range-of-motion exercises with a client who had a brain attack. The nurse places the client's hand in the position exhibited in the picture (open hand with fingers fully extended). This position is known as: 1. Flexion 2. Extension 3. Adduction 4. Circumduction
Ans: 2 2. The fingers are flared out in the extended, abducted position.
399. A client has symptoms associated with salmonellosis. Relevant data to gather from this client include a history of: 1. Any rectal cancer in the family 2. All foods eaten in the past 24 hours 3. Any recent extreme emotional stress 4. An upper respiratory infection in the past 10 days
Ans: 2 2. The salmonella organism thrives in warm, most environments; washing, cooking, and refrigeration of food limits the growth of or eliminates the organism
378. The diet ordered for a client permits 190 grams of carbohydrates, 90 grams of fat, and 100 grams of protein. The nurse calculates that this diet contains approximately how many calories? 1. 920 calories 2. 1970 calories 3. 2470 calories 4. 2970 calories
Ans: 2 2. This diet contains approximately 1970 calories. There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein.
825. Three days after a cast is applied to a client's fractured tibia, the client reports that there is a burning pain over the ankle. The cast over the ankle feels warm to the touch, and the pain is not relieved when the client changes position. The nurse's priority action is to: 1. Obtain an order for an antibiotic 2. Report the client's concern to the practitioner 3. Administer the prescribed medication for pain 4. Explain that this is typical after a cast is applied
Ans: 2 2. This indicates tissue hypoxia or breakdown and should be reported to the practitioner.
379. A client's serum albumin value is 2.8 g/dL. The nurse evaluates that teaching is successful when the client says, "For lunch I am going to have: 1. fruit salad." 2. sliced turkey." 3. spinach salad." 4. clear beef broth."
Ans: 2 2. This serum albumin value indicates severe depletion of visceral protein stores; the expected range for serum albumin is 3.5 to 5.5 g/dL; white meat turkey (two slices 4 x 2 x 1/4 inch) contains approximately 28 grams of protein.
813. A nurse explains to a client that stimulation of calcium deposition in the bone after a distal femoral fracture is best achieved by: 1. Resting the extremity 2. Weight-bearing activity 3. Normal aging processes 4. Ingesting foods high in ca
Ans: 2 2. Weight bearing and the use of antigravity muscles stimulate bone formatiqn or osteoblastic function.
870. A client has a below-the-knee amputation. The nurse concludes that a major advantage of a postoperative prosthesis applied immediately is that it: 1. Decreases phantom limb sensations 2. Encourages a normal walking pattern 3. Reduces the incidence of wound infection 4. Allows for the fitting of the prosthesis before discharge
Ans: 2 2. Without the prosthesis, a walker or crutches will be necessary and require the readjustment of weight bearing on one leg.
414. After an acute episode of upper GI bleeding, a client vomits undigested antacids and complains of severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the practitioner, the nurse should: 1. Start oxygen via nasal cannula 2. Keep the client NPO in preparation for surgery 3. Inquire whether any red or black stools have been noted 4. Place the client in the supine position with the legs elevated
Ans: 2 These are classic indicators of a perforated ulcer, for which immediate surgery is indicated; this should be anticipated.
863. A client who has passed the acute phase of rheumatoid arthritis is now allowed out of bed as tolerated. After assisting the client out of bed, the nurse should place the client in a: 1. Low, soft lounge chair 2. Straight-back armchair 3. Wheelchair with footrests 4. Recliner chair with both legs elevated
Ans: 2. 2. This chair allows the hips and shoulders to be against the back of the chair while fully supporting the thighs.
844. A 67-year-old woman fen while washing windows in her apartment. X-ray films indicate an intertrochanteric fracture of the left femur. She is to be placed in Buck's traction until surgery is performed the next morning. Nursing care is based on the fact that the primary purpose of Buck's traction is to: 1. Reduce the fracture 2. Immobilize the fracture 3. Maintain abduction of the leg 4. Eliminate rotation of the femur
Ans: 2. A continuous pull on the lower extremity keeps bone fragments from moving and causing further trauma, pain and edema.
424. On the third postoperative day after a subtotal gastrectomy, a client complains of severe abdominal pain. The nurse palpates the client's abdomen and identifies rigidity. The nurse should first: 1. Assist the client to ambulate 2. Obtain the client's vital signs 3. Administer the prescribed analgesic 4. Encourage the use of the spirometer
Ans: 2. Rigidity and pain are hallmarks of bleeding from the suture line and/or peritonitis; vital signs provide supportive data.
374. A nurse is reviewing preoperative instructions with a client who is scheduled for orthopedic surgery at 8 o'clock the next morning. The nurse advises the client to: 1. Have dinner and then nothing by mouth after 6 PM 2. Drink full liquids tonight and clear liquids in the morning 3. Consume a light evening meal and no food or fluid after midnight 4. Eat lunch the day before surgery and then not drink or eat anything until after surgery
Ans: 3 3 Eating a light meal and eliminating food and fluids after midnight limit complications during and after surgery, which include aspiration, nausea, dehydration, and possible ileus.
855. When planning discharge teaching for a client who had a total hip replacement, the nurse should include encouraging the client to avoid: 1. Climbing stairs 2. Stretching exercises 3. Sitting in a low chair 4. Lying prone for half an hour
Ans: 3 3 Excessive flexion of the hip can cause dislocation of the femoral head.
817. The practitioner orders non-weight bearing with crutches for a client with a leg injury. Before arnbulation is begun, the most important activity the nurse should teach the client to facilitate walking with crutches is: 1. Sitting up in a chair to help strengthen back muscles 2. Keeping the unaffected leg in extension and abduction 3. Exercising the triceps, finger flexors, and elbow extensors 4. Using a trapeze frequently to strengthen the bicep muscles
Ans: 3 3 These sets of muscles are used in crutch walking and therefore need strengthening.
847. A client has an open reduction and internal fixation for a fractured hip. Postoperatively the nurse should position the client's affected extremity in: 1. External rotation 2. Slight hip flexion 3. Moderate abduction 4. Anatomical body alignment
Ans: 3 3. Abduction reduces stress on anatomical structures and maintains the head of the femur in the acetabulum.
854. A client with a distal femoral shaft fracture is at risk for developing a fat embolus. The nurse considers that a distinguishing sign that is unique to a fat embolus is: 1. Oliguria 2. Dyspnea 3. Petechiae 4. Confusion
Ans: 3 3. At the time of a fracture or orthopedic surgery, fat globules may move from the bone marrow into the bloodstream. Also elevated catecholamines cause mobilization of fatty acids and the development of fat globules. In addition to obstructing vessels in the lung, brain, and kidneys with systemic embolization of small vessels from fat globules, petechiae are noted in the buccal membranes, conjunctival sacs, hard palate, chest, and anterior axillary folds; these adaptations only occur with a fat embolism.
372. A 79-year-old client is admitted to the hospital with painful abdominal spasms and severe diarrhea of 2 days' duration. The order of physical skills the nurse should follow when performing an admitting examination of this client should be "inspection" followed by: 1. Percussion, palpation, auscultation 2. Percussion, palpation, auscultation 3. Auscultation, palpation, percussion 4. Auscultation, percussion, palpation
Ans: 3 3. Auscultation must be performed bedore palpation and percussion because they may influence intestinal peristalsis resulting in inaccurate results. Palpation is performed before percussion because percussion will have a greater impact on peristalsis.
403. The laboratory values of a client with cancer of the esophagus show a hemoglobin of 7 g/dL, hematocrit of 25%, and RBC count of 2.5 million/mm3. The outcome that takes priority at this time is, "The client will: 1. be free of in injury." 2. remain pain free." 3. demonstrate improved nutrition." 4. maintain an effective airway clearance."
Ans: 3 3. Based on the presented data, improving nutritional status is the priority at this time. The decreased hemoglobin and hematocrit levels and RBC count may be a result of malnutrition; also cancer of the esophagus can cause dysphagia and anorexia.
409. A male client is diagnosed with acute gastritis, secondary to alcoholism and cirrhosis. When obtaining this client's history, the nurse gives priority to the client's statement that: 1. His pain increases after meals 2. He experiences nausea frequently 3. His stools have a black appearance 4. He recently joined Alcoholics Anonymous
Ans: 3 3. Black (tarry) stools indicate upper GI bleeding; digestive enzymes act on the blood resulting in tarry stools. Hemorrhage can occur if erosion extends to blood vessels.
396. A client has decided to become a vegan and wishes to plan a diet to ensure adequate protein quality. To provide guidance, the nurse instructs this client to: 1. Add mille to grains to provide complete proteins 2. Use eggs and plant foods to provide essential amino acids 3. Plan a careful mixture of plant proteins to provide a balance of amino acids 4. Add cheese to grains and beans to increase the quality of the protein consumed
Ans: 3 3. Complementary mixtures of essential amino acids in plan proteins provide complete dietary protein equivalents.
828. A nurse is assisting a client with a full leg cast to use crutches. Which clinical manifestations alert the nurse that the client can no longer tolerate the crutch walking? 1. Pulse of 100 and deep respirations 2. Flushed skin and slowed respirations 3. Profuse diaphoresis and rapid respirations 4. Blood pressure of 150/88 mm Hg and shallow respirations
Ans: 3 3. Diaphoresis and tachypnea indicate that the client has exceeded tolerance for the activity.
872. A 48-year-old farmer is admitted for the repair and revision of a residual limb immediately after the traumatic amputation of the left hand in a corn picker accident. A week after surgery the client complains of constant throbbing in the affected limb. Which is the most appropriate nursing intervention? 1. Applying cool compresses to the limb 2. Securing an order for pain medication 3. Elevating the extremity on two pillows 4. Loosening the bandage around the limb
Ans: 3 3. Elevation of the extremity promotes venous return, which limits edema and the related pressure on nerve endings that cause pain
400. A client is admitted to the hospital with the diagnosis of acute salmonellosis. The nurse expects that the client will receive: 1. Opioids 2. Antacids 3. Electrolytes 4. Antidiarrheals
Ans: 3 3. Fluids of dextrose and normal saline and electrolytes are administered to prevent profound dehydration caused by an excessive loss of water and electrolytes through diarrheal output.
843. A 30-year-old runner sustains multiple fractures of the left femur when hit by an automobile. At the scene ofthe accident, an immediate life-threatening systemic complication of injury to the long bones can be minimized by: 1. Elevating the affected limb 2. Encouraging deep breathing and coughing 3. Handling and transporting the client gently 4. Maintaining anatomic alignment of the client's limb
Ans: 3 3. Gentle intervention reduces pain and shock and inhibits the release of bone marrow into the system, which can cause a fat embolism.
394. A client with cancer of the tongue has radon seeds implanted. The plan of care states that the client is to receive meticulous oral hygiene. This plan can best be implemented by: 1. Offering a firm-bristled toothbrush 2. Providing an antiseptic mouthwash 3. Using a gentle spray of normal saline 4. Swabbing the mouth with a moistened gauze square
Ans: 3 3. Gentle sprays are effective in cleaning the mouth and teeth without disturbing the sensitive tissues or radon seeds.
386. A client is instructed to avoid straining on defecation postoperatively. The nurse evaluates that the related teaching is understood when the client states, "I must increase my intake of: 1. ripe bananas." 2. milk products." 3. green vegetables." 4. creamed potatoes."
Ans: 3 3. Green vegetables contain fiber, which promotes defecation.
442. During a laparoscopic cholecystectomy on an obese client, the surgeon encounters difficulty because of the presence of adhesions as a result of the client's having had a previous surgery. An abdominal cholecystectomy is performed. After surgery the nurse plans to alleviate tension on the surgical wound by: 1. Limiting deep breathing 2. Maintaining T-tube patency 3. Maintaining nasogastric tube patency 4. Encouraging the right side-lying position
Ans: 3 3. Maintaining nasogastric tube patency ensure gastric decompression, thus preventing abdominal distension, which places tension on the incision.
834. A client who is diagnosed as having a herniated nucleus pulposus complains of pain. The nurse concludes that the pain is caused by the: 1. Inflammation of the lamina of the involved vertebra 2. Shifting of two adjacent vertebral bodies out of alignment 3. Compression of the spinal cord by the extruded nucleus pulposus 4. Increased pressure of cerebrospinal fluid within the vertebral column
Ans: 3 3. Pain results because herniation of the nucleus pulposus into the spinal column irritates the spinal cord or the roots of spinal nerves.
439. A client undergoes an abdominal cholecystectomy with common duct exploration. In the immediate postoperative period the nursing action that is the priority for this client is: 1. Irrigating the T-tube frequently 2. Changing the dressing at least twice a day 3. Encouraging coughing and deep breathing 4. Promoting an adequate fluid and food intake
Ans: 3 3. Self-splinting results in shallow breathing, which does not aerate the lungs adequately, particularly the lower right lobe.
413. A traveling salesman develops gastric bleeding and is hospitalized. An important etiologic clue for the nurse to explore while taking this client's history is: 1. Any recent foreign travel 2. The client's usual dietary pattern 3. The medications that the client is taking 4. Any change in the status of family relationships
Ans: 3 3. Some medications, such as aspirin, NSAIDs, and prednisone, irritate the stomach lining and may cause bleeding with prolonged use.
385. Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop a stress ulcer (Curling's). Stress ulcers usually are evidenced by: 1. Unexplained shock 2. Melena for several days 3. Sudden massive hemorrhage 4. Gradual drop in the hematocrit value
Ans: 3 3. Stress ulcers are asymptomatic until they produce massive hematemesis and rectal bleeding.
381. A practitioner orders a high-calorie, high-protein diet for a client who is a heavy smoker. In light of the history of smoking, the nurse encourages the client to eat foods high in: 1. Niacin 2. Thiamine 3. Vitamin C 4. Vitamin B-12
Ans: 3 3. The RDA requirement of vitam in C for an adult male is 90 mg; smoking accelerates oxidation of tissue vitamin C, so smokers need an additional 35mg/day.
833. A dock worker is admitted to the hospital with lower back pain and a tentative diagnosis of a herniated nucleus pulposus. When assessing the client's back pain, the nurse should ask: 1."Is there any tenderness in the calf of your leg?" 2. "Have you had any burning sensation on urination?" 3. "Do you have any increase in pain during bowel movements?" 4. "Does the pain progress from your flank around to your groin?"
Ans: 3 3. The Valsalva maneuver raises cerebrospinal fluid pressure, thereby causing pain.
871. A 70-year-old client is scheduled for a below-the-knee amputation because of a 10-year history of impaired arterial circulation to the lower extremities. The skill that the nurse teaches the client preoperatively that can be most helpful during the first several postoperative days is to: 1. Log-roll when turning in bed 2. Toughen the distal residual limb 3. Transfer from the bed to a wheelchair 4. Stand on one leg for five minutes several times a day
Ans: 3 3. The ability to transfer ensures mobility and a degree of independence postoperatively.
465. A 64-year-old client is suspected of having carcinoma of the liver, and a liver biopsy is scheduled. A liver biopsy may be contraindicated in certain situations. Therefore, for what should the nurse assess the client? 1. Confusion and disorientation 2. Presence of any infectious disease 3. Prothrombin time of less than 40% of normal 4. Inclusion of foods high in vitamins E and K in the client's diet
Ans: 3 3. This indicates that the client has a deficiency in clotting, which should be corrected before the biopsy to prevent hemorrhage.
408. A client who has a hiatal hernia is 5 feet 3 inches tall and weighs 140 pounds, asks the nurse how to prevent esophageal reflux. The nurse's best response is: 1. "Increase your intake of fat with each meal" 2. "Lie down after eating to help your digestion." 3. "Reduce your caloric intake to foster weight reduction." 4. "Drink several glasses of fluid during each of your meals."
Ans: 3 3. Weight reduction decreases intra-abdominal pressure, thereby decreasing the tendency to reflux: into the esophagus.
441. After a cholecystectomy to remove a cancerous gallbladder, the client has aT-tube in place that has drained 300 mL of bile-colored fluid during the first 24 hours. The nurse should: 1. Clamp the tube intermittently to slow drainage 2. Increase the rate of intravenous fluids to compensate for this loss 3. Empty the portable drainage system and reestablish negative pressure 4. Consider this an expected response after surgery and record the results
Ans: 4 4. The T-tube provides an outlet for bile produced by the liver and is expected to drain 300-500 mL in the first day.
829. A client with chronic osteomyelitis in a leg is to have a debridement of the infected bone. When planning for postoperative care the nurse expects that: 1. Frequent range-of-motion exercises are needed 2. Septicemia is a common postoperative complication 3. The client will be allowed out of bed after the first day 4. The client's leg may be immobilized in a cast or splint
Ans: 4 4. The infected bone is placed at rest and may be in a cast or splint to reduce pain and limit motion that promotes spread of the infection.
433. After a subtotal gastrectomy a client experiences an episode reflective of dumping syndrome. About 1.5 hours after the initial attack, the client experiences a second period of feeling "shaky." The nurse determines that this latter effect is caused by: 1. A second more extensive rise in glucose 2. An overwhelmed insulin-adjusting mechanism 3. A distention of the duodenum from an excessive amount of chyme 4. An overproduction of insulin that occurs in response to the rise in blood glucose
Ans: 4 4. The rapid absorption of carbohydrates from the food mass causes an elevation of blood glucose, and the insulin response often causes transient hypoglycemic symptoms. The elevation in insulin usually occurs 90 minutes to 3 hours after eating and is known as late dumping syndrome.
447. After a cholecystectomy a client asks whether there are any dietary restrictions that must be followed. The nurse evaluates that the dietary teaching is understood when the client tells a family member: 1. "I should avoid fatty foods for the rest of my life." 2. "I should not eat those foods that upset me before I had surgery." 3. "I need to eat a high-protein diet for several months after surgery." 4. "I probably will be able to tolerate a regular diet after this type of surgery."
Ans: 4 4. The response is individual, but ultimately most people can eat anything they want.
820. A nurse performs full range of motion on a client's extremities. When putting an ankle through range of motion, the nurse must perform: 1. Flexion, extension, and rotation 2. Abduction, flexion, adduction, and extension 3. Pronation, supination, rotation, and extension 4. Dorsiflexion, plantar flexion, eversion, and inversion
Ans: 4 4. These movements include all possible range of motion for the ankle joint.
867. A client who has an above-the-knee amputation is fitted with a prosthesis. The nurse evaluates the client's response to the prosthesis. Which indicates that the prosthesis fits the residual limb correctly? 1. Absence of phantom limb sensation 2. Uneven wearing down of the heels of the shoes 3. Shrinkage of the end portion of the residual limb 4. Darkened skin areas surrounding the end of the residual limb
Ans: 4. 4. The even distribution of hemosiderin (iron-rich pigment) in the tissue in response to pressure of the prosthesis indicates a correct fit.
464. A nurse is performing the physical assessment of a client admitted to the hospital with a diagnosis of cirrhosis. What skin conditions should the nurse expect to observe? Select all that apply. 1. Vitiligo 2. Hirsutism 3. Melanosis 4. Ecchymoses 5. Telangiectasis
Ans: 4, 5 4 Ecchymoses are small areas of bleeding into the skin or mucous membrane forming a blue or purple patch. With cirrhosis there is decreased synthesis of prothombin in the liver. 5. Telangiectasis is a vascular lesion formed by dilation of a group of small blood vessels. When cirrhosis causes an increase in pressure in the portal circulation that results in a dilation of cutaneous blood vessels around the umbilicus, it is specifically called caput medusae.
848. After surgery for a fractured hip, a client complains of pain. The nurse should: 1. Notify the surgeon 2. Use distraction techniques 3. Medicate the client as ordered 4. Perform a complete pain assessment
Ans: 4. 4. A complete assessment must be performed to determine the location, characteristics, intensity, and duration of the pain. The pain may be incisional, result from a pulmonary embolus, or be cause by neurovascular trauma to the affected leg, and the intervention for each is different.
452. When teaching a client about the diet after a pancreaticoduodenectomy (Whipple procedure) performed for cancer of the pancreas, the statement the nurse should include is: 1. "There are no dietary restrictions; you may eat what you desire." 2. "Your diet should be low in calories to prevent taxing your pancreas." 3. "Meals should be restricted in protein because of your compromised liver function." 4. "Low-fat meals should be eaten because of interference with your fat digestion mechanism."
Ans: 4. 4. A pancreaticoduodenectomy leads to malabsorption because of impaired delivery of bile to the intestine; fat metabolism is interfered with, causing dyspepsia.
846. A 72-year-old male client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is: 1. Pneumonia 2. Hemorrhage 3. Wound infection 4. Pulmonary embolism
Ans: 4. 4. A pulmonary embolism is the most common complication of hip surgery because of high vascularity and the release of fat cells from the bone marrow.
462. A mother whose son has hepatitis A states that there is only one bathroom in their home and she is worried that other members of the family may get hepatitis. The nurse's best reply is: 1. "I suggest that you buy a commode exclusively for your son's use." 2. "There is no problem with your son sharing the same bathroom with everyone." 3. "Your son may use the bathroom, but you need to use disposable toilet covers." 4. "It is important that family members, including your son, wash their hands after using the bathroom."
Ans: 4. 4. Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper handwashing.
426. A client who has a gastric ulcer asks what to do if epigastric pain occurs. The nurse evaluates that teaching is effective when the client states, "I will: 1. increase my food intake." 2. take an aspirin with milk." 3. eliminate fluids with meals." 4. take an antacid preparation."
Ans: 4. 4. Over-the-counter antacid preparations neutralize gastric acid and relieve pain.
443. A client with cholelithiasis has a laser laparoscopic cholecystectomy. Postoperatively it is most appropriate for the nurse to: 1. Wait about 24 hours to begin clear liquids 2. Monitor the abdominal incision for bleeding 3. Offer clear carbonated beverages to the client 4. Instruct the client to resume moderate activity in 2 to 3 days
Ans: 4. 4. Recovery will be rapid because there is no large abdominal incision.
A 76-year-old obese client arrives at the clinic complaining of epigastric distress and esophageal burning. During the health history the client admits to binge drinking and frequent episodes of bronchitis. After diagnostic studies, a diagnosis of hiatal hernia is made. Which health problems most likely contributed to the development of the hiatal hernia? Select all that apply. 1. _____ Aging 2. _____ Obesity 3. _____ Bronchitis 4. _____ Alcoholism 5. _____ Esophagitis
Answer: 1, 2 1 Muscle weakness consistent with the aging process is associated with the development of a hiatal hernia. 2 Obesity causes stress on the diaphragmatic musculature, which weakens and allows the stomach to protrude into the thoracic cavity. 3 Inflammation of the bronchi will not weaken the diaphragm. 4 Alcoholism may cause an enlarged liver or pancreatitis but not a hiatal hernia. 5 Esophagitis does not cause a hiatal hernia.
A client who has been receiving hemodialysis for several years is to receive a kidney transplant. The nurse plans to review the essential information that the client should know before surgery. Select all that apply. 1. _____ Precautions needed to prevent infection 2. _____ Kidney may not function immediately 3. _____Urinary catheter will be present postoper-atively 4. _____ Immunosuppressive medications to be given preoperatively 5. _____ AV fistula will be used for drawing blood specimens preoperatively
Answer: 1, 2, 3 1 Because infection is a major complication of a kidney transplant, prevention begins with the recognition of the earliest signs and symptoms. 2 The transplanted kidney does not always function immediately; the client should know that dialysis may have to be continued for several weeks. 3 Just prior to surgery a urinary catheter is inserted and an antibiotic is instilled into the bladder to decrease the risk of infection. 4 Immunosuppressive therapy is started after, not before, surgery. 5 The vascular access is never used for drawing blood, or instilling IV medications.
406. A 76-year-old obese client arrives at the clinic complaining of epigastric distress and esophageal burning. During the health history the client admits to binge drinking and frequent episodes of bronchitis. After diagnostic studies, a diagnosis of hiatal hernia is made. Which health problems most likely contributed to the development of the hiatal hernia? Select all that apply. 1. Aging 2. Obesity 3. Bronchitis 4. Alcoholism 5. Esophagitis
Answer: 1,2 1. Muscle weakness consistent with the aging process is associated with the development of a hiatal hernia. 2. Obesity causes stress on the diaphragmatic musculature, which weakens and allows the stomach to protrude into the thoracic cavity.
While assessing a client during a routine examination, a nurse in the clinic identifies signs and symptoms of hyperthyroidism. Which signs are characteristic of hyperthyroidism? Select all that apply. 1. _____ Diaphoresis 2. _____ Weight loss 3. _____ Constipation 4. _____ Protruding eyes 5. _____ Cold intolerance (Nugent 30) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Answer: 1, 2, 4 1 Diaphoresis occurs with hyperthyroidism because of increased metabolism, resulting in hyperthermia. 2 Weight loss occurs with hyperthyroidism because of increased metabolism. 3 Diarrhea occurs because of increased body processes, specifically increased gastrointestinal peristalsis. 4 Bulging eyes occur with hyperthyroidism and are thought to be related to an autoimmune response of the retro-orbital tissue, which causes the eyeballs to enlarge and push forward. 5 Heat intolerance occurs because of the increased metabolism associated with hyperthyroidism. (Nugent 112) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply. 1. _____ Fever 2 _____ Tachypnea 3. _____ Hypertension 4. _____ Abdominal rigidity 5. _____ Increased bowel sounds
Answer: 1, 2, 4 1 The metabolic rate will be increased and the temperature-regulating center in the hypothalamus resets to a higher than usual body temperature because of the influence of pyrogenic substances related to the peritonitis. 2 Tachypnea results as the metabolic rate increases and the body attempts to meet cellular oxygen needs. 3 Hypovolemia and therefore hypotension, not hypertension, results because of a loss of fluid, electrolytes, and protein into the peritoneal cavity. 4 With increased intra-abdominal pressure, the abdominal wall will become rigid and tender. 5 Peristalsis and associated bowel sounds will decrease or be absent in the presence of increased intra-abdominal pressure.
A nurse teaches a client, who has had a thyroidectomy for thyroid cancer, to observe for signs of surgically induced hypothyroidism. What should be included in the teaching plan? Select all that apply. 1. _____ Dry skin 2. _____ Lethargy 3. _____ Insomnia 4. _____ Tachycardia 5. _____ Sensitivity to cold (Nugent 31) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Answer: 1, 2, 5 1 This is a response to hypothyroidism that is related to the associated decreased metabolic rate. 2 This is a symptom related to hypothyroidism that is associated with a decreased metabolic rate. 3 This is related to hyperthyroidism, not hypothyroidism. 4 This is related to hyperthyroidism, not hypothyroidism. 5 This is a symptom reflective of hypothyroidism that is associated with a decreased metabolic rate. (Nugent 113) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client develops internal bleeding after abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit? Select all that apply. 1. _____ Pallor 2. _____ Polyuria 3. _____ Bradypnea 4. _____ Tachycardia 5. _____ Hypertension (Nugent 20) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Answer: 1, 4 1 Pallor occurs with hemorrhage as the peripheral blood vessels constrict in an effort to shunt blood to the vital organs in the center of the body. 2 Urinary output decreases with hemorrhage because of a lowered glomerular filtration rate secondary to hypovolemia. 3 Respirations increase and become shallow with hemorrhage as the body attempts to take in more oxygen. 4 Heart rate accelerates in hemorrhage as the body attempts to increase blood flow and oxygen to body tissues. 5 Hypotension occurs in response to hemorrhage as the person experiences hypovolemia. (Nugent 100) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A client has just undergone a subtotal gastrectomy. Part of discharge teaching includes information about dumping syndrome. What instructions by the nurse will best minimize dumping syndrome? Select all that apply. 1. _____ Drink fluids with meals 2. _____ Eat small frequent meals 3. _____ Lie down for 1 hour after eating 4. _____ Chew food five times before swallowing 5. _____ Increase the carbohydrate component of the diet
Answer: 2, 3 1 Fluids should be taken between meals to decrease the volume within the stomach at one time. 2 Small, frequent meals keep the volume within the stomach to a minimum at any one time, limiting dumping syndrome. Dumping syndrome occurs after eating because of the rapid movement of food into the jejunum without the usual digestive mixing in the stomach and processing in the duodenum. 3 Lying down delays emptying of the stomach contents, which will limit dumping syndrome. 4 Chewing a set number of times before swallowing is not pertinent to solving this problem. 5 A low-carbohydrate, high-protein, high-fat diet and avoidance of fluids with meals help delay stomach emptying, minimizing this problem.
A female client who has recurrent urinary tract infections (UTIs) is inquiring about the prevention of future UTIs. What information should the nurse include when teaching the client? Select all that apply. 1. _____ Avoid fluid intake after 6 pm 2. _____ Drink 8 to 10 glasses of water each day 3. _____ Urinate immediately after sexual intercourse 4. _____ Increase the daily intake of carbonated beverages 5. _____ Clean the perineal area with an astringent soap twice a day
Answer: 2, 3 1 Limiting fluid intake contributes to stasis of urine. 2 Drinking 8 to 10 glasses of water spaced throughout the day flushes the urinary tract and minimizes urinary stasis. 3 Urination flushes the urethra and urinary meatus limiting the presence of microorganisms. 4 Carbonated and caffeinated beverages irritate the bladder and should be avoided. 5 Cleaning the perineum with harsh soaps is irritating to the skin and mucous membranes, and can contribute to the development of UTIs in susceptible women.
The nurse concludes that a client with type 1 diabetes is experiencing hypoglycemia. Which responses support this conclusion? Select all that apply. 1. _____ Vomiting 2. _____ Headache 3. _____ Tachycardia 4. _____ Cool clammy skin 5. _____ Increased respirations (Nugent 33) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Answer: 2, 3, 4 1 Vomiting occurs with hyperglycemia because of the effects of metabolic acidosis. 2 Headache is a neuroglycopenic response directly related to brain glucose deprivation. 3 Tachycardia occurs with hypoglycemia because of a neurogenic adrenergic response; it is a sympathetic nervous system response precipitated by a low blood glucose level. 4 Cool, clammy skin is a neurogenic cholinergic response; it is a sympathetic nervous system response precipitated by a low serum glucose level. 5 Increased respirations are a sign of hyperglycemia and are related to metabolic acidosis; this is a compensatory response in an attempt to blow off carbon dioxide and increase the pH level. (Nugent 115) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
A nurse is assisting a client to plan a therapeutic diet that is high in vitamin C. What excellent sources of vitamin C should be included in the plan? Select all that apply. 1. _____ Lettuce 2. _____ Oranges 3. _____ Broccoli 4. _____ Apricots 5. _____ Strawberries
Answer: 2, 3, 5 1 An entire head of lettuce contains 13 mg of vitamin C. 2 One cup of fresh orange sections contains 96 mg of vitamin C. 3 Vitamin C (ascorbic acid), an antioxidant, is found in vegetables such as broccoli, tomatoes, and potatoes; 1 cup of broccoli contains 140 mg of vitamin C. 4 Apricots contain 11 mg of vitamin C; they are a source of beta-carotene. 5 A cup of strawberries contains 106 mg of vitamin C.
383. A nurse is assisting a client to plan a therapeutic diet that is high in vitamin C. What excellent sources of vitamin C should be included in the plan? Select all that apply. 1. Lettuce 2. Oranges 3. Broccoli 4. Apricots 5. Strawberries
Answer: 2, 3, 5 2. One cup of fresh orange sections contains 96 mg of vitamin C. 3. Vitamin C (ascorbic acid), an antioxidant, is found in vegetables such as broccoli, tomatoes, and potatoes; 1 cup of broccoli contains 140 mg of vitamin C.
A client with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The nurse is monitoring the client for manifestations of complications associated with peritoneal dialysis. Select all that apply. 1. _____ Pruritus 2. _____ Oliguria 3. _____ Tachycardia 4. _____ Cloudy outflow 5. _____ Abdominal pain
Answer: 3, 4, 5 1 Severe itching (pruritus) is caused by metabolic waste products that are deposited in the skin; dialysis removes metabolic waste products, preventing this adaptation associated with kidney failure. 2 The production of abnormally small amounts of urine (oliguria) is a sign of kidney failure, not a complication of peritoneal dialysis. 3 Tachycardia can be caused by peritonitis, a complication of peritoneal dialysis; the heart rate increases to meet the metabolic demands associated with infection. 4 Cloudy or opaque dialysate outflow (effluent) is the earliest sign of peritonitis; it is caused by the constituents associated with an infectious process. 5 Abdominal pain is associated with peritonitis, a complication of peritoneal dialysis; pain results from peritoneal inflammation, abdominal distention, and involuntary muscle spasms.
A client with the diagnosis of cancer of the transverse colon is transferred from the postanesthesia care unit to a room on a surgical unit after a colon resection with an anastomosis. The nurse on the unit receives the client from the transporting nurse and observes that an IV is in progress and the client has a nasogastric tube and an indwelling urinary catheter. Place the nursing actions in order of priority when receiving this client on the unit. 1. Assess the airway 2. Take the vital signs 3. Check the abdominal dressing 4. Receive the report from the nurse Answer: _______________
Answer: 4, 1, 3, 2 The first step is for the nurse to receive report from the transporting nurse. The receiving nurse should be informed about the type of surgery performed, important events that occurred during surgery, and the client's response and current status. Once the report is completed, the next step is for the receiving nurse to ensure that the client has a patent airway. Vital signs are then taken to assess the client's current cardiopulmonary status and to assess for signs of hemorrhage or other postoperative complications. This assessment follows the ABCs (airway, breathing, circulation) of assessment. After the client's vital signs are determined to be stable, the nurse should assess and monitor the dressing, IV, and the indwelling urinary catheter.
A client is hospitalized with a tentative diagnosis of pancreatic cancer. On admission the client asks the nurse, "Do you think I have anything serious, like cancer?" What is the nurse's best reply? A) "What makes you think you have cancer?" B) "I don't know if you do; let's talk about it." C) "Why don't you discuss this with your healthcare provider?" D) "You needn't worry now; we won't know the answer for a few days."
B) "I don't know if you do; let's talk about it."
A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which client manifestations should alert the nurse to the possible development of the life-threatening response of thrombocytopenia? Select all that apply. 1. _____ Fever 2. _____ Diarrhea 3. _____ Headache 4. _____ Hematuria 5. _____ Ecchymosis (Nugent 19) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Answer: 4, 5 1 Fever is unrelated to thrombocytopenia. Fever is a sign of infection; infection results when the white blood cells are reduced (leukopenia). 2 Diarrhea is unrelated to thrombocytopenia; diarrhea may result from the effects of chemotherapy on the rapidly dividing cells of the gastrointestinal system. 3 Headache is unrelated to thrombocytopenia; headache may be caused by the effects of chemotherapy on central nervous system cells or indicate that the leukemia has invaded the central nervous system. 4 Hematuria is blood in the urine. Thrombocytes are involved in the clotting mechanism; thrombocytopenia is a reduced number of thrombocytes in the blood. 5 Ecchymosis is a superficial bruise caused by bleeding under the skin or mucous membrane. With thrombocytopenia, bleeding occurs because there are insufficient platelets. (Nugent 99) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.
Genetic testing is being discussed with a couple at the fertility clinic. What is the nurse's best response when they express concerns? A) "You should be tested because it will be to your benefit." B) "Environmental factors can have an impact on genetic factors." C) "This type of testing will determine if you'll need in vitro fertilization." D) "If you have a gene for a disease there is a probability that your children will inherit it."
B) "Environmental factors can have an impact on genetic factors."
A client with schizophrenia, paranoid type, is readmitted involuntarily to the hospital because family members state that he has threatened to harm them physically. When exploring feelings about the readmission, the client angrily shouts, "You're one of them. Leave me alone!" How should the nurse respond? A) "Try not to be afraid. I will not hurt you." B) "I can see you are upset. We can talk more later." C) "I am not one of them, and I am here to help you." D) "Your family and the staff are trying to help you."
B) "I can see you are upset. We can talk more later."
A registered nurse is teaching the student nurse the precautions to follow when blood samples are collected. Which statement made by the student nurse indicates effective learning? A) "I can place the specimen with other samples." B) "I can use a single-lumen line to obtain samples." C) "I should not reveal the test procedure to the client." D) "I should not place the blood samples collected for adrenaline on ice."
B) "I can use a single-lumen line to obtain samples." - Usage of double- or triple-lumen lines for obtaining samples may contaminate the sample. Therefore, only single-lumen lines should be used. The samples should be stored separately to avoid contamination. The procedure of testing should be discussed with the client to obtain proper results. Blood samples drawn for catecholamines must be placed on ice and taken to the laboratory immediately.
After being medicated for anxiety, a client says to a nurse, "I guess you are too busy to stay with me." How should the nurse respond? A) "I'm so sorry, but I need to see other clients." B) "I have to go now, but I will come back in 10 minutes." C) "You'll be able to rest after the medicine starts working." D) "You'll feel better after I've made you more comfortable."
B) "I have to go now, but I will come back in 10 minutes." - The response "I have to go now, but I will come back in 10 minutes" demonstrates that the nurse cares about the client and will have time for the client's special emotional needs. This approach allays anxiety and reduces emotional stress. Saying "I'm so sorry, but I need to see other clients" indicates that the nurse's other tasks are more important than the client's needs. Telling the client "you'll be able to rest after the medicine starts working" is false reassurance and not therapeutic. Saying "you'll feel better after I've made you more comfortable" does not respond to the client's need and cuts off communication.
The registered nurse is teaching a nursing student about nursing care principles for cognitively impaired older adults. Which statement made by the nursing student indicates a need for further education? A) "I should encourage fluid intake." B) "I should provide conditional positive support." C) "I should promote social interaction based on abilities." D) "I should provide ongoing assistance to family caregiver."
B) "I should provide conditional positive support." - When caring for cognitively impaired older adult, the nurse should provide unconditional positive support and respect. The nurse should encourage the client to drink fluids. The nurse should promote social interactions based on abilities. The nurse should provide ongoing assistance to family caregivers, educate them in nursing care techniques, and inform them about community resources.
Parents are considering a bone marrow transplant for the child who has recurrent leukemia. THe parents ask the nurse for clarification about the procedure. What is the best response by the nurse? A) "It is rarely performed in children." B) "The immune system must be destroyed before a transplant can take place." C) "The hematopoietic stem cells are surgically implanted in the bone marrow." D) "It is a simple procedure with little preparation needed, and the stem cells are infused as in a blood transfusion."
B) "The immune system must be destroyed before a transplant can take place."
During the postpartum period a client with heart disease and type 2 diabetes asks a nurse, "Which contraceptives will I be able to use to prevent pregnancy in the near future?" How should the nurse respond? A) "You may use oral contraceptives because they are almost completely effective in preventing pregnancy." B) "You should use foam with a condom to prevent pregnancy because this is the safest method for women with your illness." C) "You will find that the intrauterine device is best for you because it prevents a fertilized ovum from implanting in the uterus." D) "You do not need to worry about becoming pregnant in the near future because women with your illness usually become infertile."
B) "You should use foam with a condom to prevent pregnancy because this is the safest method for women with your illness."
A client on a psychiatric unit who has been hearing vices is receiving a neuroleptic medication for the first time. The client takes the cup of water and the pill and stares at them. What is the most therapeutic statement the nurse can make? A) "You have to take your medicine." B) "Your doctor wants you to have this medicine. Swallow it." C) "There must be a reason why you don't want to take your medicine." D) "This is the medication that your doctor ordered for you to make you well."
B) "Your doctor wants you to have this medicine. Swallow it."
The charge nurse working the 3 to 11 shift of a 24-bed medical unit in a large acute care hospital is making assignments. Currently, there are 20 clients on the unit and 4 admissions are scheduled to arrive during the shift. Besides the charge nurse, the staff consists of two experienced practical nurses (PN) and one unlicensed assistive personnel (UAP) who has worked on the unit for 10 years. Taking into consideration the acuity of each client, which distribution of clients is the best assignment for the nurse to make? A) 10 clients and 2 admissions to each of the PNs. Have the UAP take all vital signs and collect all I&Os. B) 10 clients to each of the PNs. Have the UAP take vital signs. The charge nurse takes the 4 new admissions. C) 8 clients to each of the PNs, 4 clients to the charge nurse, and the 4 admissions to the UAP. D) 8 clients to each of the PNs, 4 admissions to the charge nurse, and 4 low-acuity clients to the UAP.
B) 10 clients to each of the PNs. Have the UAP take vital signs. The charge nurse takes the 4 new admissions. - Considering acuity level, it is best for the nurse to assign 10 clients to each of the PNs, have the UAP take vial signs and collect I&Os and the charge nurse care for the new admissions since they will all require assessment by the RN (B). The charge nurse should take admissions (A). The UAP is not qualified to conduct an admission assessment (C). The UAP, even with 10 years experience, is not qualified to take responsibility for total care of clients (D).
A client with cellulitis is recovering at home after experiencing a severe reaction to a new prescription for ampicillin (Unisyn) that was administered by a home health nurse. The client's allergies to penicillin and sulfonamide are noted in all critical areas of the home health record. What consequence can occur based on the nurse's action? A) None since the action did not result in the client's wrongful death. B) A malpractice suit based on lack of reasonable and prudent care. C) Disciplinary action initiated by the state's nurse licensing board. D) An intentional tort based on failure to note the client's allergies.
B) A malpractice suit based on lack of reasonable and prudent care. - Medication errors involving failure to provide reasonable and prudent care, including improper documentation of medication administration, failure to recognize side effects or contraindications, and negligence in verifying a client's allergies, may result in a malpractice suit against the nurse (B). (A) does not take into account the client's documented allergies and reaction. Actions of discipline by licensing agencies (C) focus on repeated incompetent practice or substance abuse, not single error occurrences. An intentional tort (D) is a civil wrong made against a person that willfully violates another's rights, such as assault, battery, and/or false imprisonment.
When assessing an adolescent who recently overdosed on acetaminophen (Tylenol), it is most important for the nurse to assess for pain in which area of the body? A) Flank. B) Abdomen. C) Chest. D) Head.
B) Abdomen. - Acetaminophen toxicity can result in liver damage; therefore, it is especially important for the nurse to assess for pain in the right upper quadrant of the abdomen (B), which might indicate liver damage. (A, C, and D) are not areas where pain would be anticipated.
A client is admitted with a tentative diagnosis of pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolyte balance, and decreasing anxiety. Which interventions should the nurse implement? Select all that apply. A) Provide a low-fat diet B) Administer analgesics C) Teach relaxation exercises D) Encourage walking in the hall E) Monitor cardiac rate and rhythm F) Observe for signs of hypercalcemia
B) Administer analgesics C) Teach relaxation exercises E) Monitor cardiac rate and rhythm
Which nursing interventions require the use of standard precautions? A) Giving a back rub B) Administering the first bath to a newborn C) Emptying a portable wound drainage system D) Interviewing a client in the ED E) Obtaining the BP of a client who is HIV positive
B) Administering the first bath to a newborn C) Emptying a portable wound drainage system
A male client gives a copy of his living will to the nurse upon admission to the hospital. What action should the nurse implement if the client is unable to express his desire about life-prolonging measures? A) Ask the spouse to make decisions regarding life-saving measures. B) Allow the client to die with dignity and without life-prolonging techniques. C) Administer medications to ensure a painless death and end the client's suffering. D) Implement all measures of technical assistance and equipment to prolong life.
B) Allow the client to die with dignity and without life-prolonging techniques. - A living will is an advance directive that is prepared when an individual is competent to make decisions about end-of-life care that specifies withholding resuscitative measures that prolong life (B). The spouse can make decisions regarding the client's care (A) if there is a legal power-of-attorney document, not a living will. (C) is not a function of a living will. An individual should be provided life-support (D) unless a living will is available to define a client's wishes to withhold treatment that prolongs life.
A client has a diagnosis of hemorrhoids. Which signs and symptoms does the nurse expect the client to report. Select all that apply. A) Flatulence B) Anal itching C) Blood in stool D) Rectal pressure E) Pain when defecating
B) Anal itching C) Blood in stool D) Rectal pressure E) Pain when defecating
Which class of antineoplastic chemotherapy agents resembles the essential elements required for DNA and RNA synthesis and inhibits enzymes necessary for cellular function and replication? A) Alkylating agents B) Antimetabolites C) Antitumor antibiotics D) Plant alkaloids
B) Antimetabolites - Antimetabolites (B) exert their action by inhibiting the enzymes necessary for cellular function and replication. (A, C, and D) have a different mechanism of action.
The nurse is assessing a 13-year-old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview? A) Have you lost any weight in the last month? B) Are you experiencing any type of nervousness? C) When was the last time you took your synthroid? D) Are you having any problems with your vision?
B) Are you experiencing any type of nervousness? - Assessing the client's physiological state upon admission is a priority, and nervousness, apprehension, hyperexcitability, and palpitations are signs of hyperthyroidism (B). Weight loss (even with a hearty appetite) (A) occurs in those with hyperthyroidism, but assessing the client's neurological state has a higher priority. Hormone replacement is not administered to a client who is already producing too much thyroid (C). The client may have exophthalmus (bulging eyes) but hyperthyroidism does not cause vision problems (D).
A primiparous client has been in labor for 15 hours. Two hours ago, vaginal examination revealed the cervix dilated to 5 cm, 100% effaced, and the presenting part at station 0. Five minutes ago, the vaginal examination reveals no change in the cervix or decent of the fetus. Which labor pattern should the nurse document to describe the client's progress? A) Protracted descent. B) Arrest of active phase. C) Prolonged latent phase. D) Protracted active phase.
B) Arrest of active phase. - Arrest of active phase (B) is indicated if there is no change in the dilation of the cervix for 2 hours or more in a primigravida. Prolonged latent phase (C) is labor lasting longer than 20 hours in a primigravida. Protracted active phase (D) occurs when dilatation of the cervix is less than 1.2 cm/hour. Protracted descent (A) occurs when the fetus decends less than 1 cm/hour into the pelvis.
Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; Paco2, 30 mm Hg; HCO3, 25 mEq/L; Pao2, 96 mm Hg. Which intervention should the nurse implement based on these results? A) Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B) Assess the client for pain and administer pain medication as prescribed. C) Encourage the client to take short shallow breaths for 5 minutes. D) Prepare to administer sodium bicarbonate IV over 30 minutes.
B) Assess the client for pain and administer pain medication as prescribed. - These ABGs reveal respiratory alkalosis (B), and treatment depends on the underlying cause. Because the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain will correct the underlying problem. A Pao2 of 96 mm Hg does not indicate the need for an increase in oxygen administration (A). The Paco2 indicates mild hyperventilation, so (C) is not indicated. In addition, it is very difficult to change one's breathing pattern. The use of sodium bicarbonate (D) is indicated for the treatment of metabolic acidosis, not respiratory alkalosis.
A client is in the ICU after sustaining a T2 spinal cord injury. Which priority interventions should the nurse include in the client's plan of care? Select all that apply. A) Minimizing environmental stimuli B) Assessing for respiratory complications C) Monitoring and maintaining blood pressure D) Initiating a bowel and bladder training program E) Discussing long-term treatment plans with the family
B) Assessing for respiratory complications C) Monitoring and maintaining blood pressure
A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? A) Analysis B) Assessment C) Nursing interventions D) Proposed nursing care
B) Assessment
A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications? A) 3+ protein in the urine B) Blood urea nitrogen >25 mg/dL C) Blood pH >7.45 D) Urine output, 2500 mL/day
B) Blood urea nitrogen >25 mg/dL - Rhabdomyolysis is characterized by destruction of muscles that release myoglobin, causing myoglobinuria, which places the client at risk for acute renal failure, so an increased blood urea nitrogen (BUN) level (B) indicates a decrease in renal function. Blood in the urine from the accompanying breakdown of red blood cells contributes to proteinuria (A), an expected finding. Metabolic acidosis is the potential complication, not alkalosis (C). During the diuretic phase of acute renal failure, there can be a normal output volume (D) (approximately 2000 mL/day), which can result from IV fluid hydration.
A nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selected by the client indicates to the nurse that dietary teaching about thiazide diuretics was effective? A) Apples B) Broccoli C) Cherries D) Cauliflower
B) Broccoli - Thiazide diuretics get rid of potassium, so the patient should select a food high in potassium such as broccoli.
The nurse enters a client's room to complete discharge preparations and finds the client in tears. The client states that someone from the business office insisted that a payment for the hospital bill be made before the client could leave. After providing comfort to the client, what is the best nursing action? A) Call the family to ask about the payment. B) Continue the client's discharge process. C) Resume the discharge when payment occurs. D) Notify the healthcare provider of the situation.
B) Continue the client's discharge process. - Detaining someone against one's wishes, such as physically or emotionally preventing a client from leaving a healthcare facility, is false imprisonment, which is an intentional tort. To prevent infringement of the clients' rights, the best action for the nurse is to continue the client's discharge preparations (B). Although (A, C, and D) may be options made by the client, the nurse should convey that the client is free to be discharged as prescribed.
A 3-year-old boy is brought to the emergency room because he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first? A) Insert N/G tube for gastric lavage. B) Determine the child's pulse and respirations. C) Assess the child's level of consciousness. D) Administer an IV D5/0.25 NS as prescribed.
B) Determine the child's pulse and respirations. - The most important principle in dealing with a poisoning is to treat the child first, not the poison. Initiate immediate life support measures with assessment of vital signs (B), in particular, respirations. Inserting an airway or initiating mechanical ventilation may be necessary. Assessment and identification of the poison should occur prior to (A). (C and D) should occur after assessing the airway.
An older client is receiving a water-soluble drug that is more than the average dose for a young adult. Which action should the nurse implement first? A) Obtain a prescription for lower medication dosages. B) Determine the drug's serum levels for toxicity. C) Start IV fluids to decrease the serum drug levels. D) Hold the next dosage and notify the health care provider.
B) Determine the drug's serum levels for toxicity. - Older clients usually have a decline in lean body mass and total body water that causes water-soluble drugs to become distributed in fluid compartments, resulting in an increased concentration, so determining the drug's serum level for toxicity should be implemented first (B). Although (A, C, and D) may be indicated, an increased plasma drug level should be the determining factor to consider when water-soluble drugs warrant a reduced dosage in the older client.
What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? A) Rapid, thready pulse B) Distended jugular veins C) Elevated hematocrit level D) Increase serum sodium level
B) Distended jugular veins
A client with congestive heart failure (CHF) is being discharged with a new prescription for the angiotensin-converting enzyme (ACE) inhibitor captopril (Capoten). The nurse's discharge instruction should include reporting which problem to the healthcare provider? A) Weight loss. B) Dizziness. C) Muscle cramps. D) Dry mucous membranes.
B) Dizziness. - Angiotensin-converting enzyme (ACE) inhibitors are used in CHF to reduce afterload by reversing vasoconstriction common in heart failure. This vasodilation can cause hypotension and resultant dizziness (B). (A) is desired if fluid overload is present, and may occur as the result of effective combination drug therapy such as diuretics with ACE inhibitors. (C) often indicates hypokalemia in the client receiving diuretics. Excessive diuretic administration may result in fluid volume deficit, manifested by symptoms such as (D).
The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he "has a tummy ache." After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question? A) If the child's tongue darkens, discontinue the Pepto Bismol immediately. B) Do not give if the child has chickenpox, the flu, or any other viral illness. C) Avoid the use of Pepto Bismol until the child is at least 16 years old. D) Pepto Bismol may cause a rebound hyperacidity, worsening the "tummy ache."
B) Do not give if the child has chickenpox, the flu, or any other viral illness. - Pepto Bismol contains aspirin and there is the potential of Reye's syndrome (B). (A) is a common effect of Pepto Bismol and does not warrant discontinuation. Pepto Bismol can be used by children (C). Pepto Bismol does not cause rebound hyperacidity (D), which is a complication of antacids containing calcium.
A client is admitted with anorexia, weight loss, abdominal distension, and abnormal stools. A diagnosis of malabsorption syndrome is made. What nursing action should the nurse implement to best meet this client's needs? A) Allow the client to eat food preferences B) Encourage the consumption of high-protein foods C) Institute IV therapy to improve the client's hydration D) Maintain NPO status because food precipitates diarrhea
B) Encourage the consumption of high-protein foods
During her sixth month of pregnancy, a woman visits the prenatal clinic for the first time. As part of the initial assessment, a CBC and a urinalysis are performed. Which laboratory finding should alert the nurse that further assessment is required? A) WBC count of 90000/mm B) Hemoglobin level of 10 g/dL C) Urine specific gravity of 1.020 D) Glucose level of 1+ in the urine
B) Hemoglobin level of 10 g/dL - This hemoglobin level is abnormally low. The WBC count and urine specific gravity are normal values. A glucose level of 1+ in the urine is normal during pregnancy.
Which dosing schedule should the nurse teach the client to observe for a controlled-release oxycodone prescription? A) As needed. B) Every 12 hours. C) Every 24 hours. D) Every 4 to 6 hours.
B) Every 12 hours. - A controlled-release oxycodone provides long-acting analgesia to relieve moderate to severe pain, so a dosing schedule of every 12 hours (B) provides the best around-the-clock pain management. Controlled-release oxycodone is not prescribed for breakthrough pain on a PRN or as needed schedule (A). (C) is inadequate for continuous pain management. Using a schedule of every 4 to 6 hours (D) may jeopardize patient safety due to cumulative effects.
What type of interview is most appropriate when the nurse admits a client to the clinic? A) Directive B) Exploratory C) Problem solving D) Information giving
B) Exploratory
A nurse is planning a community health program about screening for cancer. Which information recommended by the American Cancer Society (ACS) should the nurse include? A) Mammography should be performed annually after age 35 years for women B) Fecal occult blood testing should be performed yearly beginning at age 50 years C) Breast self-examination should be performed monthly beginning at age 30 years D) Digital rectal exams and PSA testing should be done yearly after age 40 for men
B) Fecal occult blood testing should be performed yearly beginning at age 50 years
What clinical indicators should a nurse identify when assessing a client with pyrexia (fever)? Select all that apply. A) Dyspnea B) Flushed face C) Precordial pain D) Increased pulse rate E) Increased blood pressure
B) Flushed face D) Increased pulse rate
A nurse is caring for a client who is receiving serum albumin. What therapeutic effect does the nurse anticipate? A) Improved clotting of blood B) Formation of RBC C) Activation of WBC D) Maintenance of oncotic pressure
B) Formation of RBC
The nurse is preparing to administer dalteparin (Fragmin) subcutaneously to an immobile client who has been receiving the medication for 5 days. Which finding indicates that the nurse should hold the prescribed dose? A) Tachypnea B) Guaiac-positive stool C) Multiple small abdominal bruises D) Dependent pitting edema
B) Guaiac-positive stool - Fragmin is an anticoagulant used to prevent deep vein thrombosis (DVT) in the at-risk client. If the client develops overt signs of bleeding, such as guaiac-positive stool (B) while receiving an anticoagulant, the medication should be held and coagulation studies completed. (A) is not an indication to hold the medication unless accompanied by signs of bleeding. (C) is an expected result. (D) is related to fluid volume, rather than anticoagulant therapy.
A 15-year-old adolescent tells the school nurse, "I have persistent pain during my periods." What should the nurse encourage her to do? A) Continue daily activities B) Have a gynecologic exam C) Eat a nutritious diet containing iron D) Practice relaxation of the abdominal muscles
B) Have a gynecologic exam
An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of Clostridium difficile. While planning care, which nursing goal should the nurse establish as the priority? A) Fluid and electrolyte balance is maintained. B) Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. C) Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. D) Normal bowel patterns are reestablished.
B) Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. - A priority goal for the client with infectious diarrhea caused by Clostridium difficile is infection control precautions and the prevention of health care-associated infection (HAI) transmission (B). (A and C) are goals dependent on the return of the client's normal bowel pattern (D).
A child is being treated with mebendazole (Vermox) for pinworms. Which type of diet should the mother be instructed to feed the child while the child is receiving this medication? A) Lactose-free foods B) High-fat diet C) Vitamin C-enriched foods D) High-fiber diet
B) High-fat diet - A high-fat diet increases the absorption of mebendazole (Vermox), which boosts the effectiveness of the medication in eliminating the pinworms (B). (A, C, and D) are not related to the administration of this medication.
A male client with degenerative arthritis of the knees and hips takes an over-the-counter (OTC) nonsteroidal antiinflammatory drug (NSAID) for pain. During a routine clinic visit, the client tells the nurse, "For the past month I've been having a lot of trouble sleeping. I can't seem to fall asleep, and when I finally do get to sleep, I find that I wake up a number of times during the night." Which information should the nurse obtain first? A) Does the client snore or experience sleep apnea? B) How intense does the client rate his pain on a scale of 1 to 10? C) What type of medications does the client take before bedtime? D) Are there any white noise or lights on during the night?
B) How intense does the client rate his pain on a scale of 1 to 10? - A client with degenerative arthritis may have sleep disturbances related to chronic pain, so the client's pain intensity (B) should be determined. Other factors that may affect the client's sleep patterns (A, C, and D) should be considered after assessing the client's arthritic pain and how it is managed.
A client is admitted to the hospital with a diagnosis of chronic kidney failure. For signs of what electrolyte imbalance should the nurse monitor in this client? A) Hypokalemia B) Hypocalcemia C) Hypernatremia D) Hyperglycemia
B) Hypocalcemia
During a routine prenatal visit, a client tells a nurse that she gets leg cramps. What condition does the nurse suspect and what suggestion is made to correct it? A) Hypercalcemia and tell her to avoid eating hard cheese B) Hypocalcemia and tell her to increase her intake of milk C) Hyperkalemia and tell her to consult with her HCP D) Hypokalemia and tell her to increase her intake of green, leafy vegetables
B) Hypocalcemia and tell her to increase her intake of milk - Low calcium causes leg cramps.
A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time? A) Diabetes insipidus B) Hypotension C) Hyperkalemia D) Uremia
B) Hypotension - During the transition from oliguria to the diuretic phase of acute renal failure, the tubule's inability to concentrate the urine causes osmotic diuresis, which places the client at risk for hypovolemia and hypotension (B). (A) is related to the secretion of antidiuretic hormone (ADH) and not specifically to the kidney function. Because of the excessive fluid loss, the client is at risk for potassium loss, not (C). (D) is characteristic of chronic renal failure with multiple body system involvement.
The nurse recognizes which behavior(s) in a client as warning sign(s) of an impending suicide attempt? (Select all that apply.) A) Reports feelings of sadness B) Mood changes from depressed to happy C) Begins giving away possessions D) Becomes compliant with medication regimen E) Independently joins a support group
B) Mood changes from depressed to happy C) Begins giving away possessions - Feelings of elation and giving away possessions are common characteristics of those who have made a plan to commit suicide (B and C). Feelings of sadness are signs of depression but not impending suicide (A). (D and E) are not typically indicative of impending suicide
A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care? A) Exploring the client's emotional conflict B) Identifying personal feelings toward this client D) Planning to discuss this with the client's family D) Developing a rapport with the client's healthcare provider
B) Identifying personal feelings toward this client - Nurses must identify their own feelings and prejudices because these may affect the ability to provide objective, nonjudgmental nursing care. Exploring a client's emotional well-being can be accomplished only after the nurse works through one's own feelings. The focus should be on the client, not the family. Health team members should work together for the benefit of all clients, not just this client.
Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? A) Decreased blood supply B) Impaired neural functioning C) Perforation of the bowel wall D) Obstruction of the bowel lumen
B) Impaired neural functioning
Based on the client's reported pain level, the nurse administers 8 mg of the prescribed morphine. The medication is available in a 10 mg syringe. Wasting of the remaining 2 mg of morphine should be done by the nurse and a witness. Who should be the witness? A) Nursing supervisor B) LPN C) Client's health care provider D) Designated nursing assistant
B) LPN - The wasting of controlled substances should be witnessed by two licensed personnel according to federal regulations; this can be done by an RN or a LPN.
A client is receiving an IV infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. What nutritional problem notifies the nurse to notify the HCP? A) Excessive carbohydrate intake B) Lack of protein supplementation C) Insufficient intake of water-soluable vitamins D) Increased concentration of electrolytes in cells
B) Lack of protein supplementation
The nurse educator is teaching the nursing staff about a new computerized documentation system that is recently implemented. What information is the best indication that the education is effective? A) A decrease in number of calls to the technology department. B) Less time for nursing staff to complete the daily charting. C) An increase in staff acceptance of computerized charting. D) An improvement from pretest scores of the training session.
B) Less time for nursing staff to complete the daily charting. - Being able to use the system to accomplish charting more efficiently and in less time (B) compared to previous documentation techniques indicates the staff has learned how to use the system effectively. (A) may be related to technology functionality and is not related to effective user learning. Acceptance (C) does not indicate that the staff understand or can use the system correctly. (D) measures cognition but not application.
An older adult with dementia has recently started to make mistakes regarding the time, place, and person. Which action of the nurse would be appropriate in this situation? A) Minimize environmental stress to reduce confusion B) Let the client continue to think in his or her own way C) Prompt the client to recognize the correct date and time D) Ask the client to recall the past to understand the present situation
B) Let the client continue to think in his or her own way - Mistaking the date and time are possible signs of dementia. In this situation, the client would benefit from validation therapy, which involves the adult continuing to think in his or her own way. Minimizing environmental stress can help to reduce confusion, but this is not the appropriate action for the given client's situation. Recognizing the inner needs and feelings of the client is more important than reinforcing the confused older adult's misperceptions. Reminiscence is a therapeutic approach that involves recalling the past to resolve present conflicts.
A nurse is obtaining a history and performing a physical assessment of a client who has cancer of the tongue. Which clinical findings should the nurse expect to identify? Select all that apply. A) Halitosis B) Leukoplakia C) Bleeding gums D) Substernal pain E) Alterations in taste F) Enlarged cervical lymph nodes
B) Leukoplakia E) Alterations in taste F) Enlarged cervical lymph nodes
A client with HIV who was recently diagnosed with tuberculosis (TB) asks the nurse, "Why do I need to take all of these medications for TB?" What information should the nurse provide? A) Antiretroviral medications decrease the efficacy of the TB drugs. B) Multiple drugs prevent the development of resistant organisms. C) Duration of the medication regimen is shortened. D) Potential adverse drug reactions are minimized.
B) Multiple drugs prevent the development of resistant organisms. - A multidrug regimen is prescribed for a client with HIV and TB to prevent the development of resistance of the tubercle bacilli (B). Although antitubercular medications can inhibit some antiretrovirals (A), a multidrug regimen is needed to inhibit the proliferation of the virulent tubercle bacilli. The duration of antitubercular therapy is typically 6 to 9 months and is not shortened (C) by the use of multiple medications. A client who is receiving HIV and TB therapy is at an increased risk of adverse reactions (D) because of the complex medication regimens and complications secondary to immunosuppression.
When receiving hemodialysis, the complication of the removal of too much sodium may occur. For which clinical findings associated with hyponatremia should the nurse assess the client? Select all that apply. A) Chovek sign B) Muscle cramps C) Extreme fatigue D) Cardiac dysrhythmias E) Increased temperature
B) Muscle cramps C) Extreme fatigue
The apical heart rate of an infant receiving digoxin (Lanoxin) for congestive heart failure is 80 beats/min. Which intervention should the nurse implement first? A) Administer the next dose of digoxin as scheduled. B) Obtain a serum digoxin level. C) Administer a PRN dose of atropine sulfate. D) Assess for S3 and S4 heart sounds.
B) Obtain a serum digoxin level. - Sinus bradycardia (rate < 90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level is the highest priority (B). Further doses of digoxin should be withheld until the serum level is obtained (A). (C) is not indicated unless the client exhibits symptoms of diminished cardiac output. (D) provides information about cardiac function but is of less priority than (B).
A nurse determines that a postpartum client is gravida 1 and para 1. Her blood type is B negative, and her baby's blood type is O positive. What should the nurse include in the plan of care? A) Type and crossmatch blood B) Obtain an order for RhoGAM C) Determine the father's blood type D) Observe for signs of ABO incompatibility
B) Obtain an order for RhoGAM
After a needlestick occurs while removing the cap from a sterile needle, which action should the nurse implement? A) Complete an incident report. B) Select another sterile needle. C) Disinfect the needle with an alcohol swab. D) Notify the supervisor of the department immediately
B) Select another sterile needle. - After a needlestick, the needle is considered used, so the nurse should discard it and select another needle (B). Because the needle was sterile when the nurse was stuck and the needle was not in contact with any other person's body fluids, the nurse does not need to complete an incident report (A) or notify the occupational health nurse (D). Disinfecting a needle with an alcohol swab (C) is not in accordance with standards for safe practice and infection control.
A client at 16 weeks' gestation calls the nurse at the prenatal clinic and states that her partner just told her he has genital herpes. What should the nurse include when teaching the client about sexual activity? A) Condoms must be used when having intercourse B) Sexual abstinence should be practiced during the last six weeks C) It will be necessary to refrain from sexual contact during pregnancy D) Meticulous cleaning of the vaginal area after intercourse is essential
B) Sexual abstinence should be practiced during the last six weeks - This will help prevent transmission to the baby.
A client with the diagnosis of cancer of the stomach expresses aversion to meals and eats only small amounts. What should the nurse provide? A) Nourishment between meals B) Small portions more frequently C) Supplementary vitamins to stimulate the client's appetite D) Only foods the client likes in small portions at mealtimes
B) Small portions more frequently
A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome? A) Low-residue, bland diet B) Small, frequent feeding schedule C) Fluid intake less than half a quart D) Low-protein, high-carbohydrate diet
B) Small, frequent feeding schedule
A client asks a nurse about the most common problem associated with the use of an intrauterine device (IUD)? A) Perforation of the uterus B) Spontaneous device expulsion C) Discomfort associated with coitus D) Development of vaginal infections
B) Spontaneous device expulsion
The nurse in the emergency department is caring for a client with type 1 diabetes mellitus in diabetic ketoacidosis (DKA). Which action should the nurse take first? A) Administer regular insulin IV B) Start an IV infusion of NS C) Check serum electrolyte levels D) Give a potassium supplement
B) Start an IV infusion of NS - The patient in DKA experiences severe dehydration and must be rehydrated before insulin is administered (B). The other actions will follow rehydration (A, C, and D).
While supervising a smallpox vaccination program, a nurse manager observes a nurse cleansing the arm of a client with an alcohol swab before giving the vaccination. What should the nurse manager's first reaction be? A) Continue observing the vaccination. B) Stop the nurse from giving the vaccination C) Give the nurse a povidone-iodine (Betadine) swab to use instead. D) Notify the members of the team about the need to use antiseptic swabs.
B) Stop the nurse from giving the vaccination - Alcohol deactivates the smallpox vaccine. Cleansing of the arm should not be done before the immunization is given unless the arm is dirty; if dirty, only water should be used to cleanse the site. Observation is insufficient; the nurse manager must intervene to ensure that the vaccine is given using the correct technique. Povidone-iodine will deactivate the smallpox vaccine. The site should be dry before administering the vaccine.
A nurse is teaching a client with diabetes about the treatment of hypoglycemia. The nurse knows that teaching was effective if the client picks which foods to treat a hypoglycemic attack? A) Fruit juice and a lollipop. B) Sugar and a slice of bread. C) Chocolate candy and a banana. D) Peanut butter crackers and a glass of milk.
B) Sugar and a slice of bread. - The suggested treatment of hypoglycemia in a conscious client is a simple sugar (such as two packets of sugar), followed by a complex carbohydrate (such as a slice of bread), and finally a protein (such as milk); the simple sugar elevates the blood glucose level rapidly; the complex carbohydrates and protein produce a more sustained response. Fruit juice and a lollipop are fast-acting sugars, and neither of them will provide a sustained response. The fat content of chocolate candy decreases the rate of absorption of glucose. Neither peanut butter crackers nor a glass of milk is a fast-acting sugar; peanut butter crackers and milk can be used to maintain the glucose level after it is raised.
After many years of coping with colitis, a client makes the decision to have a colectomy as advised by the HCP. Which is most likely the significant factor that impacted the client's decision? A) It is temporary until the colon heals B) Surgical treatment cures UC C) UC can progress to Crohn's disease D) Without surgery, eating table foods is contraindicated
B) Surgical treatment cures UC
The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse implement first? A) Inspect the dressing over the puncture site and under the client for bleeding. B) Take the vital signs to determine the client's response for a potential blood loss. C) Use caution when changing the dressing to avoid dislodging a clot at the puncture site. D) Assess the client's pain level to determine the need for analgesic medication.
B) Take the vital signs to determine the client's response for a potential blood loss. - After bone marrow aspiration, pressure is applied at the aspiration site, which is critical for a client with pancytopenia because of a decrease in the platelet count. The client's baseline vital signs should be obtained first to determine changes indicating bleeding caused by the procedure (B). Although (A, C, and D) should be implemented after the procedure, the first action is to obtain a baseline assessment.
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention? A) The cuff wraps around the girth of the leg. B) The UAP auscultates the popliteal pulse with the cuff on the lower leg. C) The client is placed in a prone position. D) The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
B) The UAP auscultates the popliteal pulse with the cuff on the lower leg. - When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg (B). (A) ensures an accurate assessment, and (C) provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher (D) than in the brachial artery.
A toddler screams and cries nosily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 - 45 minutes. Legally, how should this behavior be interpreted? A) Limits had to be set to control the child's crying B) The child had a right to remain in the room with the other children C) The child had to be removed because the other children needed to be considered D) Segregation of the child for more than half an hour was too long a period of time
B) The child had a right to remain in the room with the other children
The nurse is reviewing the use of the patient-controlled analgesia (PCA) pump with a client in the immediate postoperative period. The client will receive morphine 1 mg IV per hour basal rate with 1 mg IV every 15 minutes per PCA to total 5 mg IV maximally per hour. What assessment has the highest priority before initiating the PCA pump? A) The expiration date on the morphine syringe in the pump. B) The rate and depth of the client's respirations. C) The type of anesthesia used during the surgical procedure. D) The client's subjective and objective signs of pain.
B) The rate and depth of the client's respirations. - A life-threatening side effect of intravenous administration of morphine sulfate, an opiate narcotic, is respiratory depression (B). The PCA pump should be stopped and the healthcare provider notified if the client's respiratory rate falls below 12 breaths per minute, and the nurse should anticipate adjustments in the client's dosage before the PCA pump is restarted. (A, C, and D) provide helpful information, but are not as high a priority as the assessment described in (B).
A nurse is responding to the needs of victims at a collapsed building. WHat principle guides the nurse's priorities during this disaster? A) Hemorrhage necessitates immediate care to save the most lives B) Those requiring minimal care are treated first so they can help others C) Victims with head injuries are treated first because they are the most complex D) Children receive the higher priority because they have the greatest life expectancy
B) Those requiring minimal care are treated first so they can help others
A client with a family history of goiter is experiencing changes in voice and breathing. Which diagnostic study does the nurse consider to be beneficial in confirming a diagnosis? A) Thyroglobulin B) Thyroid antibodies C) Thyroxine (free T4), total D) Thyroid-stimulating hormone (TSH)
B) Thyroid antibodies - Changes in voice and breathing can be seen in Hashimoto's thyroiditis if the thyroid gland enlarges rapidly and constricts the trachea and laryngeal nerves. Clients with a family history of goiter may have this condition. A thyroid antibody test is used diagnose Hashimoto's thyroiditis by differentiating thyroid dysfunction from thyroiditis. Thyroglobulin is used to detect thyroid cancer. Thyroxine (free T4), total and TSH are used to evaluate thyroid function.
The nurse is developing the plan of care for an older client who is immobile and at risk for pressure ulcers. Which contributing factor should the nurse include in the nursing diagnosis, "Risk for altered skin integrity?" A) Poor nutrition. B) Tissue ischemia. C) Prolonged illness or disease. D) Nitrogen build-up in the underlying tissues.
B) Tissue ischemia. - Prolonged, intense pressure affects cellular metabolism by impeding capillary blood flow to tissue over weight-bearing bony prominences, resulting in tissue ischemia (B), skin breakdown, and tissue death. Although key factors contributing to pressure ulcers include poor nutrition (A), prolonged illness or disease (C), and build-up of metabolic nitrogen in underlying tissues (D), tissue ischemia is the primary factor in pressure ulcer development.
A nurse is caring for a client with diarrhea. In which clinical indicator does the nurse anticipate a decrease? A) Pulse rate B) Tissue turgor C) Specific gravity D) Body temperature
B) Tissue turgor
A nurse is caring for a client who has had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery? A) Femoral pulse B) Toes for mobility C) Condition of the pin D) Range of motion of the knee
B) Toes for mobility
The nurse assigning care for a 5-year-old child with otitis media is concerned about the child's increasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift? A) An RN should be assigned to take temperatures frequently. B) Tympanic and oral temperatures are equally accurate. C) The PN should take rectal temperatures on this child. D) The pediatrician should decide how to assess the temperature.
B) Tympanic and oral temperatures are equally accurate. - A tympanic membrane sensor approximates core temperatures because the hypothalamus and eardrum are perfused by the same circulation. Tympanic readings obtained using proper technique correlated moderately to strongly with oral temperatures in recent research studies (B). The sensor is unaffected by cerumen or the presence of suppurative or unsuppurative otitis media. An RN is not required to take the child's temperature, but must assess readings received from assistive personnel (A). Although rectal readings are highly accurate (C), such an invasive procedure is unnecessary. (D) is not required.
A person sustains deep-partial thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encourages the client to seek medical attention, but the client refuses. THe nurse advises the person to go to a HCP if: A) Blisters appear B) Urinary output decreases C) Edema and redness occur D) Low-grade fever develops
B) Urinary output decreases - A decrease in urinary output in a patient with burns indicates hypovolemia and must be treated immediately. Blisters, and edema and redness are expected. A low-grade fever is not as concerning as a decreased urinary output.
An older adult with a history of small cell lung carcinoma reports muscle cramping, thirst, and fatigue. The primary healthcare provider diagnoses the client with a pituitary disorder and is treating the client accordingly. Which is an effective outcome of the treatment? A) Urine output of 10 L/day B) Urine specific gravity less than 1.025 C) Urine osmolarity of 80 mOsm/kg (80 mmol/kg) D) Serum osmolarity of 600 mOsm/kg (600 mmol/kg)
B) Urine specific gravity less than 1.025 - Because the specific gravity is less than 1.025 after treatment, the outcome is considered positive. In syndrome of inappropriate antidiuretic hormone (SIADH), the specific gravity is greater than 1.025. Small cell lung cancer is a risk factor of SIADH. Muscle cramping, thirst, and fatigue are clinical manifestations of SIADH. A serum osmolarity of 600 mOsm/kg indicates central diabetes insipidus. A urine output 10 L/day and a urine osmolarity of 80 mOsm/kg indicate diabetes insipidus.
A psychiatric client is discharged from the hospital with a prescription for haloperidol (Haldol). Which instruction should the nurse include in the discharge teaching plan for this client? A) Take with antacids to reduce gastrointestinal irritation. B) Use sunglasses and sunscreen when outdoors. C) Eat foods low in fiber and salt. D) Count the pulse before each dose.
B) Use sunglasses and sunscreen when outdoors. - Photosensitivity is a common adverse effect of haloperidol (Haldol); therefore, the use of sunglasses and sunscreen (B) should be included in the discharge teaching for this client. (A, C, and D) are not pertinent to client teaching regarding the use of haloperidol (Haldol).
A client has a fractured mandible that is immobilized by wires. For which life-threatening postoperative problem should the nurse monitor this client? A) Infection B) Vomiting C) Osteomyelitis D) Bronchospasm
B) Vomiting
A male client has a prescription for disulfiram (Antabuse). Which adverse reaction should the nurse caution the client about while taking the medication? A) Euphoria. B) Vomiting. C) Hypertension. D) Hypoventilation.
B) Vomiting. - A disulfiram reaction includes nausea and severe vomiting (B), if alcohol is ingested while taking disulfiram (Antabuse). (A, C, and D) are not typically associated with the combined use of disulfiram and alcohol.
Which symptoms are serious adverse effects of beta-adrenergic blockers such as propranolol (Inderal)? A) Headache, hypertension, and blurred vision. B) Wheezing, hypotension, and AV block. C) Vomiting, dilated pupils, and papilledema. D) Tinnitus, muscle weakness, and tachypnea.
B) Wheezing, hypotension, and AV block. - (B) represents the most serious adverse effects of beta-blocking agents. AV block is generally associated with bradycardia and results in potentially life-threatening decreases in cardiac output. Additionally, wheezing secondary to bronchospasm and hypotension represent life-threatening respiratory and cardiac disorders. (A, C, and D) are not associated with beta-blockers.
A client who has acromegaly and insulin-dependent diabetes undergoes a hypophysectomy. The nurse identifies further teaching about the hypophysectomy is necessary when the client states, "I know I will.. A) be sterile for the rest of my life." B) require larger doses of insulin than I did preoperatively." C) have to take cortisone or a similar drug for the rest of my life." D) have to take thyroxine or a similar medication for the rest of my life"
B) require larger doses of insulin than I did preoperatively." - The hypophysis (pituitary gland) does not directly regulate insulin release. This is controlled by serum glucose levels. Because somatotropin release will stop after the hypophysectomy, any elevation of blood glucose level caused by somatotropin will also stop.
123. Ms. Norfolk Is to receive 3000 mL of solution Intravenously in each 24-hour period. If there Is a drop factor of 15 drops/mL, at approximately how many drops per minute should the nurse regulate the IV? A. 22 drops. B. 31 drops. C. 42 drops. D. 51 drops.
B. 31 drops. To determine the number of drops per minute, the nurse uses the following calculation: (total amount of solution x drop factor) + (total time x minutes) (3000 x 15) + (24 x 60) = 31 drops.
125. Because of Ms. Norfolk's weight and the location of her incision, the nurse' can anticipate that the most likely complication will be: A. Fluid and electrolyte imbalance. B. Atelectasis. C. Infection. D. Nausea and vomiting.
B. Atelectasis. Respiratory complications are the most probable due to the unwillingness of the client to cough and deep breathe because of the high incision. This inhibits ventilatory movement, and the incidence of postoperative pneumonia is very high. A, C, and D are all possible complications, but respiratory complications are the most common.
35. Which neurologic assessment parameter(s) would least likely indicate to the nurse the occurrence of impending hepatic coma? A. Flapping tremors. B. Decorticate rigidity. C. Hyperactive reflexes. D. Irritability and drowsiness.
B. Decorticate rigidity. B is correct because decorticate rigidity is a neurologic manifestation Indicative of lesions In the cerebral white matter, internal capsules, and thalamus - not impending hepaticcoma. Flexion of the fingers, wrists, and arms is seen in the client with this neurologic dysfunction. A, C, and D are incorrect answers because In the presence of advanced hepatocellular disease, these parameters do indicate impending hepatic coma.
127. Ms. Norfolk develops a paralytic ileus postoperatlvely. The nurse should question which medical order before carrying it out? A Begin intermittent nasogastric suction. B. Encourage the client to take carbonated beverages. C. Neostigmine (Prostigmin), 500mcg IM. D. Continuous IV therapy, 3000 mL in 24 hours; alternate 5% dextrose in water with Ringer's lactate.
B. Encourage the client to take carbonated beverages. B Is the order that should be questioned because nothing should be given by mouth when nonfunctioning bowel is suspected. A, C, and D are all appropriate actions for such a client and are therefore not the answers.
113. The nurse needs to teach Mr. Williams that if he is having bleeding from his stomach ulcer, his stools will be: A. Claylike in color. B. Tarry. C. Bright red. D. Light brown.
B. Tarry The tarry color indicates digested blood. Stools that are the color of clay, A, indicate a diet with excess fat. Bright red stools, C, indicate bleeding low in the large intestine or rectum. Light brown stools, D, indicate a diet too high in milk and low in meat.
153. A Sengstaken-Blakemore (S-B) tube was Inserted in Mr. Mesta to control bleeding of esophageal varices. On entering the room, the nurse notices that he is gasping for breath. His color has become cyanotic and his respirations are rapid and shallow. What should the nurse first suspect? A. A pulmonary embolus has probably developed. B. The S-B tube has dislodged and one of its balloons is obstructing the airway. C. The client Is air hungry due to anemia. D. The client is anxious and this can cause changes in respiratory status.
B. The S-B tube has dislodged and one of its balloons is obstructing the airway. Each of the answers given could conceivably cause respiratory distress in a client like Mr. Mesta. A and B are the most likely to cause a sudden respiratory crisis. B should first be considered since Mr. Mesta has a S-B tube in place. Displacement of the tube constitutes a medical emergency. A is a less correct response since the case study makes no reference to chest pain or hemoptysis, classic signs of a pulmonary embolus. Also, the client's history does not suggest prolonged immobility or long bone fractures, conditions that often precipitate an embolus. C is incorrect because Mr. Mesta's anemia is unlikely to cause such a sudden respiratory change. D is incorrect because the case situation states that the client is lethargic and disoriented-not especially anxious.
A child has cystic fibrosis. Which statement by the parents about their plan for the child's dietary regimen provides evidence that they understand the nurse's instructions? A) "I will restrict fluids during mealtimes." B) "I will discontinue the use of salt while cooking." C) "I should provide high-calorie foods between meals." D) "I should eliminate whole milk products from the diet."
C) "I should provide high-calorie foods between meals." - Children with cystic fibrosis require 150% more calories than the average child. Fluids should not be restricted because patients with CF have thick secretions and fluids will thin them out. There is no need to eliminate salt or dairy from the diet.
While awaiting the biopsy report before removal of a tumor, the client reports being afraid of a diagnosis of cancer. How should the nurse respond? A) "Worrying is not going to help the situation." B) "Let's wait until we hear what the biopsy report says." C) "It is very upsetting to have to wait for a biopsy report." D) "Operations are not performed unless there are no other options."
C) "It is very upsetting to have to wait for a biopsy report."
A client asks the nurse if glipizide (Glucotrol) is an oral insulin. Which response should the nurse provide? A) "Yes, it is an oral insulin and has the same actions and properties as intermediate insulin." B) "Yes, it is an oral insulin and is distributed, metabolized, and excreted in the same manner as insulin." C) "No, it is not an oral insulin and can be used only when some beta cell function is present." D) "No, it is not an oral insulin, but it is effective for those who are resistant to injectable insulins."
C) "No, it is not an oral insulin and can be used only when some beta cell function is present." - An effective oral form of insulin has not yet been developed (C) because when insulin is taken orally, it is destroyed by digestive enzymes. Glipizide (Glucotrol) is an oral hypoglycemic agent that enhances pancreatic production of insulin. (A, B, and D) do not provide accurate information.
Which pediatric client requires immediate intervention by the nurse? A) A 2-year-old with a twenty-four hour urinary output of 500 ml. B) A 3-year-old with several episodes of nocturnal enuresis. C) A 4-year-old with an easily palpable bladder and frequency. D) A 5-year-old with diuresis following furosemide (Lasix) administration
C) A 4-year-old with an easily palpable bladder and frequency. - Frequency and bladder distention (C) are indications of urinary retention, which requires immediate intervention by the nurse. (A) is the normal output for a child of this age. (B) describes bed-wetting, not uncommon in a child of this age, although if the problem persists in a child older than 5 years of age, further assessment and intervention is warranted. (D) is an expected response to the medication, which requires routine monitoring, but does not indicate a need for immediate intervention.
Uric acid levels
Concurrent use of anti gout meds and aspirin causes elevated ________. Client should be instructed to take acetaminophen rather than aspirin.
A client is comatose upon arrival to the emergency department after falling from a roof. The client flexes with painful stimuli, and the nurse determines the client's Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client's airway? A) Tracheostomy tube insertion. B) An endotracheal tube. C) A nasopharyngeal tube. D) An oral airway.
C) A nasopharyngeal tube. - If head and neck injuries are suspected, a client with a GCS of 6 who demonstrates motor flexion in response to painful stimuli requires airway maintenance without risk of compromise to spinal cord function. Nasal intubation using a nasopharyngeal tube (C) is the airway of choice for a client with suspected spinal cord injury because less cervical spine manipulation is needed during insertion, as compared with endotracheal intubation (B). A tracheostomy (A) is an option if long-term artificial airway maintenance is needed. Although (D) maintains an open airway by keeping the tongue out of the way, neck hyperextension and spinal manipulation pose a risk for spinal cord damage.
The family of an older adult who is aphasic reports to the nurse manager that the primary care nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding? A) Procedure for a client's benefit do not require a signed consent B) Clients who are aphasic are incapable of signing informed consent C) A separate signed informed consent for routine treatments is necessary D) A specific intervention without a client's signed consent is an invasion of rights
C) A separate signed informed consent for routine treatments is necessary - This is considered a routine procedure to meet basic physiologic needs and is covered by a consent signed at the time of admission.
Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop a stress ulcer (Curling). Which of these is evidence of a stress ulcer? A) Unexplained shock B) Melena for several days C) A sudden massive hemorrhage D) A gradual drop in the hematocrit value
C) A sudden massive hemorrhage - Stress ulcers are asymptomatic until they produce massive hematemesis and rectal bleeding. Shock is the outcome of massive hemorrhage; it is not unexplained because the sudden gastrointestinal bleeding will be identified. Sudden massive bleeding occurs, not the slow oozing that causes melena. A gradual drop in the hematocrit value indicates slow blood loss.
Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate? A) A trial of adrenocorticotrophic hormone injections. B) Frequent stimulation of the cremasteric reflex. C) A trial of human chorionic gonadotrophic hormone. D) Frequent warm baths to gently dilate the scrotal area.
C) A trial of human chorionic gonadotrophic hormone. - A trial of HCG (human chorionic gonadotrophic hormone) (C) may aid in testicular descent, but does not replace surgical repair for true undescended testes. Undescended testes (cryptorchidism) may be found in the inguinal canal due to exaggerated cremasteric reflex. (A) is not indicated. Stimulation of the cremasteric reflex causes the testes to ascend rather than descend in the scrotum (B). (D) may relax the cremasteric muscle, but may not cause the testes to descend.
A nurse is caring for a client admitted to the hospital for DKA. Which clinical findings related to this event should the nurse document in the client's clinical record? Select all that apply. A) Sweating B) Retinopathy C) Acetone breath D) Increased arterial bicarbonate level E) Decreased arterial CO2 level
C) Acetone breath E) Decreased arterial CO2 level
A client's dose of isosorbide dinitrate (Imdur) is increased from 40 mg to 60 mg PO daily. When the client reports the onset of a headache prior to the next scheduled dose, which action should the nurse implement? A) Hold the next scheduled dose of Imdur 60 mg and administer a PRN dose of acetaminophen (Tylenol). B) Administer the 40 mg of Imdur and then contact the healthcare provider. C) Administer the 60 mg dose of Imdur and a PRN dose of acetaminophen (Tylenol). D) Do not administer the next dose of Imdur or any acetaminophen until notifying the healthcare provider.
C) Administer the 60 mg dose of Imdur and a PRN dose of acetaminophen (Tylenol). - Imdur is a nitrate which causes vasodilation. This vasodilation can result in headaches, which can generally be controlled with acetaminophen (C) until the client develops a tolerance to this adverse effect. (A and B) may result in the onset of angina if a therapeutic level of Imdur is not maintained. Lying down (D) is less likely to reduce the headache than is a mild analgesic.
For which client(s) should the nurse withhold the initial dose of a cyclooxygenase 2 (COX-2) inhibitor until notifying the health care provider? (Select all that apply.) A) A middle-aged adult with a history of tinnitus while taking aspirin B) A middle-aged adult with a history of polycystic ovarian disease C) An older adult with a history of a skin rash while taking glyburide (DiaBeta) D) An adolescent with a history of an anaphylactic reaction to penicillin E) An older adult with a history of gastrointestinal upset while taking naproxen sodium (Naprosyn) F) An adolescent at 34 weeks of gestation experiencing 1+ pitting edema
C) An older adult with a history of a skin rash while taking glyburide (DiaBeta) D) An adolescent with a history of an anaphylactic reaction to penicillin F) An adolescent at 34 weeks of gestation experiencing 1+ pitting edema - COX-2 inhibitors are contraindicated for those who are allergic to sulfa drugs (C), aspirin, and nonsteroidal antiinflammatory drugs (NSAIDs). Drug safety for adolescents (D and F) is not yet established, and COX-2 inhibitors, as well as NSAIDs, are contraindicated during the third trimester of pregnancy (F) because they can cause a premature closure of the patent ductus arteriosus. Tinnitus, an adverse reaction of aspirin (A), and ovarian disease (B) are not contraindications for the use of COX-2 inhibitors. Gastrointestinal upset is a common adverse reaction of NSAIDs (E) but is not a contraindication for the use of a COX-2 inhibitor.
A client has an anaphylactic reaction after receiving IV penicillin. What does the nurse conclude is the cause of this reaction? A) An acquired atopic sensitization occurred B) There was passive immunity to the penicillin allergies C) Antibodies to penicillin developed after a previous exposure D) Potent antibodies were produced when the infusion was instituted
C) Antibodies to penicillin developed after a previous exposure
A client with a third-degree uterine prolapse is scheduled for a vaginoplasty. What should the nurse anticipate the surgeon will order? A) Encourage ambulation B) Elevate the foot of the bed C) Apply moist compresses to the uterus D) Support the prolapsed uterus with a sanitary pad
C) Apply moist compresses to the uterus
A client with cancer of the colon had surgery for a resection of the tumor and the creation of a colostomy. During the 6-week postoperative checkup, the nurse teaches the client about nutrition. The nurse evaluates that learning has taken place when the client states, "I should follow a diet that is: A) Rich in protein B) Low in fiber content C) As close to usual as possible D) Higher in calories than before
C) As close to usual as possible
A client with ARDS is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? A) Regulate the PEPP according to the rate and depth of the client's respirations B) Deflate the cuff on the endotracheal tube for a few minutes every one to two hours C) Assess the need for suctioning when the high pressure alarm is activated D) Adjust the temperature of fluid in the humidification chamber, depending on the volume of gas delivered
C) Assess the need for suctioning when the high pressure alarm is activated
The nurse is preparing to apply a surface anesthetic agent for a client. Which action should the nurse implement to reduce the risk of systemic absorption? A) Apply the anesthetic to mucous membranes. B) Limit the area of application to inflamed areas. C) Avoid abraded skin areas when applying the anesthetic. D) Spread the topical agent over a large surface area.
C) Avoid abraded skin areas when applying the anesthetic. - To minimize systemic absorption of topical anesthetics, the anesthetic agent should be applied to the smallest surface area of intact skin (C). Application to the mucous membranes poses the greatest risk (A) of systemic absorption because absorption occurs more readily through mucous membranes than through the skin. Inflamed areas generally have an increased blood supply, which increases the risk of systemic absorption, so (B) should be avoided. A large surface area increases the amount of topical drug that is available for transdermal absorption, so the smallest area should be covered, not (D).
A HCP orders a GI endoscopy with a capsule endoscopic device. What should the nurse instruct the client to do? A) Check the recorder every hour B) Avoid eating food and fluid during the test C) Avoid stooping and bending during the test D) Swallow the capsule as soon as it is placed in the mouth
C) Avoid stooping and bending during the test
A comatose client is admitted to the critical care unit and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids? A) Pain scale B) Vital signs C) Breath sounds D) Level of consciousness
C) Breath sounds - Before administering IV fluids through a central line, the nurse must first ensure that the catheter did not puncture the vessel or lungs. A chest radiograph should be obtained STAT, and the nurse should auscultate the client's breath sounds (C). (A, B, and D) are important assessment data but are not specifically related to insertion of a central venous catheter.
The nurse performs tracheostomy suctioning on a comatose client. Place the interventions in order from first to last. A) Gently insert the catheter without suction using sterile technique. B) Hyperoxygenate using a manual reservoir-equipped resuscitation bag (MRB). C) Check the suction regulator and adjust suction pressure to 120 to 150 mm Hg. D) Apply suction intermittently while withdrawing the catheter.
C) Check the suction regulator and adjust suction pressure to 120 to 150 mm Hg. B) Hyperoxygenate using a manual reservoir-equipped resuscitation bag (MRB). A) Gently insert the catheter without suction using sterile technique. D) Apply suction intermittently while withdrawing the catheter. - Equipment should be set up and adjusted prior to beginning the procedure (C). Hyperoxygenation using an MRB should be completed prior to inserting the catheter (B). After preoxygenation, the catheter can be inserted (A) and suction can be applied intermittently (D).
During a colostomy irrigation, a client reports feeling abdominal cramps. What should the nurse do in response to the client's statement? A) Discontinue the irrigation B) Lower the container of fluid C) Clamp the catheter for a few minutes D) Advance the catheter approximately an inch
C) Clamp the catheter for a few minutes
Which factor is most important to ensure compliance when planning to teach a client about a drug regimen?A. A) Genetics B) Client age C) Client education D) Absorption rate
C) Client education - The client's educational level (C) is the most important factor when planning teaching to ensure a client's compliance with taking a prescribed drug. (A and D) are physiologic responses that do not relate to a client's compliance. Although maturity level and age (B) contribute to compliance, the client's basic understanding of instructions, which is best indicated by educational level, is more significant.
A nurse is caring for two clients newly diagnosed with diabetes. One client has type 1 diabetes and the other has type 2 diabetes. The nurse determines that the main difference between newly diagnosed type 1 and type 2 diabetes is that in type 1 diabetes: A) Onset of the disease is slow B) Excessive weight is a contributing factor C) Complications are not present at the time of diagnosis D) Treatment involves diet, exercise and oral medications
C) Complications are not present at the time of diagnosis - Clinical presentation of type 1 diabetes is characterized by ACUTE (ABRUPT) onset, and therefore there is no time to develop the long-term complications that are common with long-standing disease.
A postoperative client has been receiving a continuous IV infusion of meperidine (Demerol) 35 mg/hr for four days. The client has a PRN prescription for Demerol 100 mg PO q3h. The nurse notes that the client has become increasingly restless, irritable and confused, stating that there are bugs all over the walls. What action should the nurse take first? A) Administer a PRN dose of the PO meperidine (Demerol). B) Administer naloxone (Narcan) IV per PRN protocol. C) Decrease the IV infusion rate of the meperidine (Demerol) per protocol. D) Notify the healthcare provider of the client's confusion and hallucinations.
C) Decrease the IV infusion rate of the meperidine (Demerol) per protocol. - The client is exhibiting symptoms of Demerol toxicity, which is consistent with the large dose of Demerol received over four days. (C) is the most effective action to immediately decrease the amount of serum Demerol. (A) will increase the toxic level of medication in the bloodstream. Naloxone (B) is an opioid antagonist that is used during an opioid overdose, but it is not beneficial during Demerol toxicity and can precipitate seizures. The healthcare provider should be notified (D), but that is not the initial action the nurse should take; first the amount of drug infusing should be decreased.
A client with viral influenza is receiving vitamin C, 1000 mg PO daily, and acetaminophen elixir, 650 mg PO every 4 hours PRN. The nurse calls the health care provider to report that the client has developed diarrhea. Which change in prescriptions should the nurse anticipate? A) Change the acetaminophen to ibuprofen. B) Change the elixir to an injectable route. C) Decrease the dose of vitamin C. D) Begin treatment with an antibiotic.
C) Decrease the dose of vitamin C. - Diarrhea is an adverse effect of high doses of vitamin C, so the nurse should anticipate a reduction in the dose of vitamin C (C). Acetaminophen does not cause diarrhea (A) and is not available in an injectable form (B). Because the client has a viral infection, (D) will not be beneficial.
Which drug can cause diabetes insipidus? A) Cabergoline B) Metyrapone C) Demeclocycline D) Aminoglutethimide
C) Demeclocycline - Prolonged administration of demeclocycline may cause diabetes insipidus, as this drug decreases the production of antidiuretic hormone by the kidneys. Cabergoline inhibits the release of growth hormone and prolactin by stimulating dopamine receptors in the brain. Metyrapone and aminoglutethimide decrease cortisol production.
A nurse is teaching a client with a permanent colostomy about self-care in preparation for discharge from the hospital. Which intervention should the nurse discuss with the client? A) Limiting activity B) Wearing special clothing C) Dilating the stoma periodically D) Maintaining a low-residue diet
C) Dilating the stoma periodically
A nurse is caring for a client with ascites. What does the nurse consider to be the cause of the ascites? A) Portal hypertension B) Kidney malfunction C) Diminished plasma protein level D) Decreased production of potassium
C) Diminished plasma protein level
Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis? A) Perform cough and deep breathing exercises hourly. B) Turn from side to side in bed at least every 2 hours. C) Dorsiflex and plantarflex the feet 10 times each hour. D) Drink approximately 4 ounces of water every hour.
C) Dorsiflex and plantarflex the feet 10 times each hour. - To reduce the risk of venous thrombosis, the nurse should instruct the client in measures that promote venous return, such as dorsiflexion and plantar flexion (C). (A, B, and D) are helpful to prevent other complications of immobility but are less effective in preventing venous thrombus formation than (C).
The nurse is suctioning the tracheostomy for a child who is experiencing rhonchi and unable to expel mucus. Which action should the nurse implement to provide effective pulmonary toileting? A) Encourage child to cough to raise the secretions before suctioning. B) Allow child to rest after every five times the suction catheter is passed. C) Each pass of the suction catheter should take no longer than five seconds. D) Select a catheter 3/4 the size of the diameter of the tracheostomy tube.
C) Each pass of the suction catheter should take no longer than five seconds. - To ensure the child's O2 saturation returns to normal, suctioning of the tracheostomy should last no more than five seconds per aspiration (C) and rest periods provided after each aspiration, not (B). (A) is not effective. To facilitate ease of insertion and prevent tracheal wall abrasion, the suction catheter should be half the diameter of the tracheostomy tube, not (D).
When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity? A) Encourage the client to turn from side to side every 2 hours. B) Elevate the foot of the client's bed at least 6 inches. C) Encourage the client to ambulate every 3 hours. D) Teach the client how to perform leg exercises while in bed.
C) Encourage the client to ambulate every 3 hours. - Ambulation is the best way to increase peripheral vascular activity (C). (A, B, and D) will increase peripheral vascular activity but are not as effective as ambulation.
Which intervention(s) should the nurse use when interacting with a client with Alzheimer's disease? (Select all that apply). A) Adhere to strict time limits for activities. Incorrect B) Give all instructions at the start of the activity. C) Encourage verbal and nonverbal communication. Correct D) Speak to the client in a loud and clear voice. E) Maintain a calm demeanor during all interactions. Correct
C) Encourage verbal and nonverbal communication. E) Maintain a calm demeanor during all interactions. - Alzheimer's causes the client to experience cognitive deficits and memory impairment, so frequent communication (C) and a calm affect (E) should be maintained with the client. (A, B, and D) increases the client's frustration.
A nurse is caring for a child with a very low platelet count related to chemotherapy. The nurse should monitor this child's urine for the presence of which consistent? A) Protein B) Glucose C) Erythrocytes D) Lymphocytes
C) Erythrocytes - Patients with low platelet counts are at an increased risk for bleeding and will have erythrocytes (RBC) in the urine.
A nurse is collecting information about a client who has type 1 diabetes and who is being admitted because of diabetic ketoacidosis coma. Which factors can predispose a client to this condition? Select all that apply. A) Taking too much insulin B) Getting too much exercise C) Excessive emotional stress D) Running a fever with the flu E) Eating fewer calories than prescribed
C) Excessive emotional stress D) Running a fever with the flu -
A client with cancer of the cervix has an intracavitary radioactive sealed implant in place. What precaution should the nurse take to protect against excessive exposure to radiation? A) Dispose of body fluids in special marked containers B) Cohort two clients who have implanted radiation therapy C) Exit the room walking backward while wearing an apron D) Limit visitors to individuals who are 13 years and older
C) Exit the room walking backward while wearing an apron
The nurse is preparing to administer the disease-modifying antirheumatic drug (DMARD) methotrexate (Rheumatrex) to a client diagnosed with rheumatoid arthritis. Which intervention is most important to implement prior to administering this medication? A) Assess the client's liver function test results. B) Monitor the client's intake and output. C) Have another nurse check the prescription. D) Assess the client's oral mucosa.
C) Have another nurse check the prescription. - Double-checking the prescription (C) is an important intervention because death can occur from an overdose. This medication is administered weekly and in low doses for rheumatoid arthritis and should not be confused with administration of the drug as a chemotherapeutic agent. (A and B) are appropriate interventions for those who are receiving this drug, but they are not the most important interventions. Stomatitis (D) is an expected side effect of this medication.
Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s) is(are) most likely to maintain client safety? (Select all that apply.) A) Direct the client to sign a liability release form. B) Restrict the client's ability to leave the unit. C) Explain the benefits of remaining in the hospital. D) Instruct the client to take medications as prescribed. E) Provide the client with names of local support groups. F) Notify the health care provider of the client's intention.
C) Explain the benefits of remaining in the hospital. D) Instruct the client to take medications as prescribed. F) Notify the health care provider of the client's intention. - Correct responses are (C, D, and F). To maintain safety and to provide information, the nurse should explain the potential benefits of continuing treatment in the hospital (C) and the need to take prescribed medications (D). This client, who is very likely self-destructive, should remain on the unit and the health care provider should be notified (F). Signing a release form (A) before leaving the hospital does not contribute to safety. The nurse may ask the client not to leave the hospital (B), but pressuring clients is unethical behavior. (E) may be helpful at a later time in this client's treatment program.
What clinical indicator is important for the nurse to assess after a client undergoes a submucosal resection for a deviated septum? A) Occipital headache B) Periorbital edema C) Exportation of blood D) Changes in vocalization
C) Exportation of blood
A nurse provides dietary teaching about a low-sodium diet for a client with HTN. Which nutrient selected by the client indicates an understanding about foods that are low in natural sodium? A) Milk B) Meat C) Fruits D) Vegetables
C) Fruits
A nurse is evaluating a client who has been receiving medical intervention for the diagnosis of Crohn disease. What expected outcome is most important for this client? A) Does skin care B) Takes oral fluids C) Gains a half pound per week D) Experiences less abdominal cramping
C) Gains a half pound per week
A nurse is caring for a newly admitted client with a diagnosis of Cushing syndrome. Why should the nurse monitor this client for clinical indicators of diabetes mellitus? A) Cortical hormones stimulate rapid weight loss. B) Tissue catabolism results in a negative nitrogen balance. C) Glucocorticoids accelerate the process of gluconeogenesis. D) Excessive adrenocorticotropic hormone (ACTH) secretion damages pancreatic tissue.
C) Glucocorticoids accelerate the process of gluconeogenesis. - Excess glucocorticoids cause hyperglycemia, and signs of diabetes mellitus may develop ACTH, which causes sodium retention and subsequent weight gain. Although muscle wasting is associated with excessive corticoid production, this will not cause diabetes mellitus. ACTH affects the adrenal cortex, not the pancreas.
A medication that is classified as a beta-1 agonist is most commonly prescribed for a client with which condition? A) Glaucoma. B) Hypertension. C) Heart failure. D) Asthma.
C) Heart failure. - Beta-1 agonists improve cardiac output by increasing the heart rate and blood pressure and are indicated in heart failure (C), shock, atrioventricular block dysrhythmias, and cardiac arrest. Glaucoma (A) is managed using adrenergic agents and beta-adrenergic blocking agents. Beta-1 blocking agents are used in the management of hypertension (B). Medications that stimulate beta-2 receptors in the bronchi are effective for bronchoconstriction in respiratory disorders, such as asthma (D).
Which nursing intervention is most important when caring for a client receiving the antimetabolite cytosine arabinoside (Arc-C) for chemotherapy? A) Hydrate the client with IV fluids before and after infusion. B) Assess the client for numbness and tingling of extremities. C) Inspect the client's oral mucosa for ulcerations. D) Monitor the client's urine pH for increased acidity.
C) Inspect the client's oral mucosa for ulcerations. - Cytosine arabinoside (Arc-C) affects the rapidly growing cells of the body, therefore stomatitis and mucosal ulcerations are key signs of antimetabolite toxicity (C). (A, B, and D) are not typical interventions associated with the administration of antimetabolites.
The nurse is caring for a client with diabetes mellitus. What is the primary fluid shift that occurs with this condition? A) Intravascular to interstitial because of glycosuria B) Interstitial to extracellular because of hypoproteinemia C) Intracellular to intravascular because of hyperosmolarity D) Intercellular to intravascular because of increased hydrostatic pressure
C) Intracellular to intravascular because of hyperosmolarity - The osmotic effect of hyperglycemia pulls fluid from the intracellular and interstitial compartments, resulting in dehydration. Hyperglycemia pulls fluid from the interstitial to the intravascular compartment, eventually spilling into the urine. Interstitial fluid is part of the extracellular compartment; the osmotic pull of glucose exceeds other osmotic forces. An increase in hydrostatic pressure results in an intravascular to interstitial shift.
Why is it important for a nurse to support the parents' decision to abort a fetus with a birth defect even if the nurse is morally against abortion? A) Supporting them will eliminate feelings of guilt B) The parents are legally responsible for the decision C) It is essential for maintenance of the family equilibrium D) The nurse's support will relieve the pressure caused by this decision
C) It is essential for maintenance of the family equilibrium
A client has a urinary retention catheter in place after surgery. What should the nurse do when planning the client's safety needs in relation to this device? A) Empty the bag every 6 hour s B) Maintain the tension on the tubing C) Keep the system closed at all times D) Attach the bag to the side rail of the bed
C) Keep the system closed at all times - Urinary catheter systems should be kept closed at all times. The bag should be emptied more frequently than every 6 hours. Tension should be relieved not maintained. The bag should not be attached to the side rail of the bed because if the side rail is moved the catheter may detach.
A client has severe diarrhea, and the HCP prescribes IV fluids, sodium bicarbonate, and an antidiarrheal medication. Which most frequently ordered antidiarrheal drug does the nurse expect the HCP to prescribe? A) Bisacodyl B) Psyllium C) Loperamide D) Docusate sodium
C) Loperamide
An antacid (Maalox) is prescribed for a client with peptic ulcer disease. The nurse knows that the purpose of this medication is to: A) Decrease production of gastric secretions. B) Produce an adherent barrier over the ulcer. C) Maintain a gastric pH of 3.5 or above. D) Decrease gastric motor activity.
C) Maintain a gastric pH of 3.5 or above. - The objective of antacids is to neutralize gastric acids and keep pH of 3.5 or above (C) which is necessary for pepsinogen inactivity. (A) is the purpose of H2 receptor antagonists (cimetidine, ranitidine). (B) is the purpose of sucralfate (Carafate). (D) is the purpose of anticholinergic drugs which are often used in conjunction with antacids to allow the antacid to remain in the stomach longer.
The health care provider prescribes carbamazepine (Tegretol) for a child whose tonic-clonic seizures have been poorly controlled. The nurse informs the mother that the child must have blood tests every week. The mother asks why so many blood tests are necessary. Which complication is assessed through frequent laboratory testing that the nurse should explain to this mother? A) Nephrotoxicity B) Ototoxicity C) Myelosuppression D) Hepatotoxicity
C) Myelosuppression - Myelosuppression (C) is the highest priority complication that can potentially affect clients managed with carbamazepine (Tegretol) therapy. The client requires close monitoring for this condition by weekly laboratory testing. Hepatic function may be altered (D), but this complication does not have as great a potential for occurrence as (C). (A and B) are not typical complications of carbamazepine (Tegretol) therapy.
A client who had an I+D of an oral abscess is to be discharged. For which clinical finding, if it should occur, should the nurse instruct the client to notify the HCP? A) Foul odor to the breath B) Pain associated with swallowing C) Pain with swelling after one week D) Tenderness in the mouth when chewing
C) Pain with swelling after one week - Pain and swelling should subside before one week. Continued pain and swelling may indicate infection.
A client has myxedema, which results from a deficiency of thyroid hormone synthesis in adults. The nurse knows that which medication should be contraindicated for this client? A) Liothyronine (Cytomel) to replace iodine. B) Furosemide (Lasix) for relief of fluid retention. C) Pentobarbital sodium (Nembutal Sodium) for sleep. D) Nitroglycerin (Nitrostat) for angina pain.
C) Pentobarbital sodium (Nembutal Sodium) for sleep. - Persons with myxedema are dangerously hypersensitive to narcotics, barbiturates (C), and anesthetics. They do tolerate liothyronine (Cytomel) (A) and usually receive iodine replacement therapy. These clients are also susceptible to heart problems such as angina for which nitroglycerin (Nitrostat) (D) would be indicated, and congestive heart failure for which furosemide (Lasix) (B) would be indicated.
An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome? A) Stop the flow of unoxygenated blood into systemic circulation. B) Increase the flow of unoxygenated blood to the lungs. C) Prevent the return of oxygenated blood to the lungs. D) Reduce peripheral tissue hypoxia and nailbed clubbing.
C) Prevent the return of oxygenated blood to the lungs. - Closure of VSDs stops oxygenated blood from being shunted from the left ventricle to the right ventricle (C). VSDs are acyanotic defects, which means that no unoxygenated blood enters the systemic circulation (A and B). (D) is common with Tetrology of Fallot, which is a cyanotic defect.
In developing a teaching plan for a 5-year-old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first? A) Food planning and selection. Incorrect B) Administering insulin injections. C) Process of glucose testing. D) Drawing up the correct insulin dose.
C) Process of glucose testing. - Developmentally, a 5-year-old has the cognitive and psychomotor skills to use a glucometer (C) and to read the number (it is especially helpful if the nurse presents this activity as a game). (A, B, and D) require more advanced cognitive and psychomotor skills and have greater potential for errors.
A client with a history of gambling has legal difficulties for embezzling money and is required to obtain counseling. During an intake interview, the client says, "I never would have done this if I had been paid what I am worth." What factor will create the greatest difficulty when assisting this client to develop insight? A) Feelings of boredom and emptiness B) Grandiosity related to personal abilities C) Projection of reasons for difficulties onto others D) Anger toward those who are in authority positions
C) Projection of reasons for difficulties onto others
A nurse is caring for a client with an undescended testicle. The nurse teaches the client that the main reason why the testicles are suspended in the scrotum is to: A) Protect the sperm from the acidity of urine B) Facilitate the passage of sperm through the urethra C) Protect the sperm from high abdominal temperatures D) Facilitate their maturation during embryonic development
C) Protect the sperm from high abdominal temperatures
A client is admitted to a medical unit with a diagnosis of Addison disease. The client is emaciated and reports muscular weakness and fatigue. Which disturbed body process does the nurse determine is the root cause of the client's clinical manifestations? A) Fluid balance B) Electrolyte levels C) Protein anabolism D) Masculinizing hormones
C) Protein anabolism - Glucocorticoids help maintain blood glucose and liver and muscle glycogen content. A deficiency of glucocorticoids causes hypoglycemia, resulting in the breakdown of protein and fats as energy sources.
A client at the women's health clinic tells the nurse she has endometriosis. What factors associated with endometriosis does the nurse anticipate the client will report? Select all that apply. A) Insomnia B) Ecchymoses C) Rectal pressure D) Abdominal pain E) Skipped periods F) Pelvic infections
C) Rectal pressure D) Abdominal pain
Which nursing diagnosis is important to include in the plan of care for a client receiving the angiotensin-2 receptor antagonist irbesartan (Avapro)? A) Fluid volume deficit. B) Risk for infection. C) Risk for injury. D) Impaired sleep patterns.
C) Risk for injury. - Avapro is an antihypertensive agent, which acts by blocking vasoconstrictor effects at various receptor sites. This can cause hypotension and dizziness, placing the client at high risk for injury (C). Avapro does not act as a diuretic (A), impact the immune system (B), or alter sleep patterns (D).
A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit? A) Participating in telephone consultations with clients B) Identifying oneself by name and title to clients in telehealth communications C) Sending medical records to health care providers via the Internet D) Answering a client-initiated health question via electronic mail
C) Sending medical records to health care providers via the Internet - Sending medical records over the Internet, even with the latest security protection, creates the greatest risk for liability because of the high potential of breaching client confidentiality and the amount of information being transferred (C). Client confidentiality is protected by federal wiretapping laws making telephone consultation (A) a private and protected form of communication. By stating one's name and credentials in telehealth communication (B), one is taking responsibility for the encounter. E-mail initiated by the client (D) poses less risk than sending records via the Internet.
A preschool-age child has been restricted to bed rest since admission to the hospital. As a response to the improvement, the child becomes interested in playing. Based on the child's developmental level and activity restriction, what should the nurse provide? A) Television viewing time B) Squeaky stuffed animals C) Small farm animals and a little barn D) Simple three-or four-piece wooden puzzles
C) Small farm animals and a little barn
What gross motor skills should the nurse expect a developmentally appropriate 3-year-old child to perform? Select all that apply. A) Skipping on alternate feet B) Riding alone on a small bicycle C) Standing on one foot for a few seconds D) Alternating feet when walking up the stairs E) Jumping rope by lifting both feet simultaneously
C) Standing on one foot for a few seconds D) Alternating feet when walking up the stairs
A client who is receiving chlorpromazine HCl (Thorazine) to control his psychotic behavior also has a prescription for benztropine (Cogentin). When teaching the client and/or significant others about these medications, what should the nurse explain about the use of benztropine (Cogentin) in the treatment plan for this client? A) This medication will reduce the side effect of urinary retention. B) This drug potentiates the effect of chlorpromazine HCl (Thorazine). C) The benztropine (Cogentin) is used to control extrapyramidal symptoms. D) The combined effect of these drugs will modify psychotic behavior.
C) The benztropine (Cogentin) is used to control extrapyramidal symptoms. - Benztropine (Cogentin), an anticholinergic drug, is used to control extrapyramidal symptoms (C) associated with chlorpromazine HCl (Thorazine) use. (A, B, and D) are not accurate statements regarding the use of benztropine (Cogentin) for clients who are treated with Thorazine for the control of psychosis.
A client with coronary artery disease has a sudden episode of cyanosis and a change in respirations. The nurse starts oxygen administration immediately. Legally, should the nurse have administered the oxygen? A) The oxygen had not been ordered and therefore should not have been administered B) The symptoms were too vague for the nurse to determine a need for administering oxygen C) The nurse's observations were sufficient, and the oxygen should have been administered D) The HCP should have been called for an order before the nurse administered the oxygen
C) The nurse's observations were sufficient, and the oxygen should have been administered - The Nurse Practice Act states that nurses diagnose and treat human responses to actual or potential health problems. Administration of oxygen is an emergency situation and is within the scope of nursing practice.
A nurse is teaching a client how to self-administer a medicated douche. In which direction should the nurse instruct the client to direct the douche nozzle? A) To the left B) To the right C) Toward the sacrum D) Toward the umbilicus
C) Toward the sacrum
Which food selected by a client with osteoporosis indicates that the nurse's dietary teaching was effective? A) Red meat B) Soft drinks C) Turnip greens D) Enriched grains
C) Turnip greens - Turnip greens are high in calcium.
Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence? A) Adjustment of orthodontic appliances or braces B) Loss of deciduous teeth (baby teeth) C) Urinary catherization D) Insect bites
C) Urinary catherization - Prophylactic antibiotics are usually prescribed prior to any invasive procedure for children who have valvular damage. Of the choices listed, only urinary catheterization (C) is an invasive procedure. (A, B, and D) are not invasive and do not require administration of prophylactic antibiotics.
A nurse is caring for a client after surgical creation of a conduit diversion. What is the major disadvantage of a conduit diversion that the nurse should consider when caring for this client? A) Peristalsis is greatly decreased B) Stool continuously oozes from it C) Urine continuously drains from it D) Absorption of nutrients is diminished
C) Urine continuously drains from it
Two clients with polydipsia and polyuria arrived at the hospital. Both were having similar symptoms but were diagnosed with different types of diabetes insipidus. Which assessment finding helped to differentiate the diagnosis? A) Urine output B) Specific gravity C) Urine osmolarity D) Serum osmolarity
C) Urine osmolarity - Polydipsia and polyuria are signs of diabetes insipidus. When a water deprivation test is performed, urine osmolarity is increased dramatically from 100 to 600 mOsm (mmol)/kg in clients with central diabetes insipidus. But in nephrogenic diabetes insipidus, the urine osmolarity may not be greater than 300 mOsm (mmol)/kg. The urine output is 2 L to 20 L/day in all types of diabetes insipidus. The specific gravity is less than 1.005 in all types of diabetes insipidus and the serum osmolarity is also greater than 295 mOsm (mmol)/kg in all types of diabetes insipidus.
The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents? A) Administer a nonsteroidal antiinflammatory drug (NSAID) to the child prior to getting the child out of bed in the morning. B) Apply ice packs to edematous or tender joints to reduce pain and swelling. C) Warm the child with an electric blanket prior to getting the child out of bed. D) Immobilize swollen joints during acute exacerbations until function returns.
C) Warm the child with an electric blanket prior to getting the child out of bed. - Early morning stiffness and pain are common symptoms of rheumatoid arthritis. Warming the child (C) in the morning helps reduce these symptoms. Although moist heat is best, an electric blanket could also be used to help relieve early morning discomfort. (A) on an empty stomach is likely to cause gastric discomfort. Warm (not cold) packs or baths are used to minimize joint inflammation and stiffness (B). (D) is contraindicated, because joints should be exercised, not immobilized.
A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide? A) Remove all blackheads and follow with an alcohol scrub. B) Use medicated cosmetics only to help hide the blemishes. C) Wash the hair and skin frequently with soap and hot water. D) Encourage her to see a dermatologist as soon as possible.
C) Wash the hair and skin frequently with soap and hot water. - Washing the hair and skin with soap and hot water (C) removes oil and debris from the skin and helps prevent and treat acne. Oily skin is especially bothersome during adolescence when hormones cause enlargement of sebaceous glands and increased glandular secretions which predispose the teenager to acne. (A) is contraindicated. Cosmetics ("medicated" or not) should be used sparingly to avoid further blocking sebaceous gland ducts (B). (D) might be indicated at a later time, if healthcare recommendations are not successful.
The nurse is assessing a client who is receiving risperidone (Risperdal). The nurse should monitor the client for which common side effect that is most likely to occur during therapy? A) Dystonia. B) Akathisia. C) Weight gain. D) Photosensitivity.
C) Weight gain. - Risperidone (Risperdal, Consta) is an atypical antipsychotic agent with a lower potential for extrapyramidal effects, but cause common side effects, such as weight gain (C), insomnia, hypotension, and headache. Atypical antipsychotics are less likely to induce extrapyramidal side effects (EPS) (movement disorders), such as pseudoparkinsonism and tardive dyskinesia, where as (A, B, and D) are more likely to occur during therapy with conventional phenothiazine antipsychotics.
149. Which goal of care is inappropriate when a lowered blood ammonia level Is the desired outcome? A. Prevention of GI bleeding. B. Reduction of dietary protein Intake. C. Avoidance of enemas and cathartics. D. Decrease in bacterial flora in the intestine.
C. Avoidance of enemas and cathartics. C is not indicated if a lowering of blood ammonia is desired, so it is the correct answer. Enemas and cathartics may be given to hasten the removal of protein materials from the intestine, thereby lowering blood ammonia. A and B lower ammonia levels by decreasing Intestinal protein. D lowers ammonia levels by reducing the bacterial production of this substance.
30. Based on the data given, the most common nursing problem is: A. Depression related to feelings of guilt. B. Anxiety related to a fear of impending doom. C. Body Image change related to altered skin appearance. D. Anger and hostility related to restriction of physical activity.
C. Body Image change related to altered skin appearance. C is cqriect because the appearance of Ms. Bee's jaundice and her insistence on visitor restrictions occurred concurrently. Because of the jaundice, she became more self-conscious of her appearance, suggesting a change in her perception of her body image. A, B, and D are Incorrect. The data do not reflect the presence of depression, A; anxiety, B; or anger and hostility, D. It is possible, however, that the nurse may encounter these nursing problems during the hospitalization of a client with hepatitis.
120. Ms. Norfolk Is discharged from the hospital. She must follow a low-fat diet until her readmission for surgery. The nurse knows that the client is demonstrating her dietary knowledge when she eliminates: A. fruit juices. B. Broiled chicken. C. Chocolate pudding. D. Carrots and spinach.
C. Chocolate pudding. Chocolate and milk are eliminated from the diet because of their fat content. A, B, and D are allowed in a fat-free diet.
RA
Chronic systemic inflammatory disease that leads to destruction of connective tissue and synovial membrane within joints; weakens joint, leading to dislocation and permanent deformity in the joint.
118. Which drug may Increase biliary colic pain if given to a client with cholecystitis? A. Meperidine (Demerol). B. Nitroglycerin. C. Morphine. D. Ibuprofen.
C. Morphtne. Morphine is thought to stimulate the sphincter of Oddi, causing biliary pain; therefore, it is usually avoided. A, meperidine, is the drug of choice for pain. B, nitroglycerin, is given to relax smooth muscle and decrease colic pain. D, ibuprofen, an NSAID, most likely will have no significant effect on biliary colic.
116. Mr. Williams complains of postoperative pain. The nurse administers the analgesic as ordered. What nursing actions will help reduce the pain while the analgesic is taking its effect? A. Move the client quickly; administer stimulating backrub. B. Encourage the client to discuss his feelings. C. Position comfortably; subdue the lighting. D. Give the client a bath; change bed linens.
C. Position comfortably; subdue the lighting. These actions encourage relaxation and provide a quiet environment, which should help reduce pain until the analgesic takes effect. A, B, and D produce a stimulating effect and are unlikely to help alleviate the client's pain.
126. Ms. Norfolk has a T-tube Inserted in the surgical wound. The most important nursing function In caring for this tube is: A. Recording quantity and color of drainage. B. Changing the dressing every shift. C. Preventing the tube from kinking. D. Teaching the client about the reason for the tube.
C. Preventing the tube from kinking. For any tube to function properly, the opening must remain patent for drainage of fluid. A and D are important functions but do not have the highest priority. B is incorrect because dressings should be changed only when necessary due to wetness.
119. Ms. Norfolk Is having an oral cholecystogram. She asks the nurse If there are any special preparations for this type of x-ray. The nurse tells her that she will: A. Have a regular diet the evening before the test. B. Eat a full meal the morning of the test. C. Take Iodine dye capsules by mouth the evening before the test. D. Have this test done after her scheduled GI series.
C. Take iodine dye capsules by mouth the evening before the test. Telepaque capsules, usually six, are administered the evening prior to the test. It takes about 13 hours for the dye to reach the liver and be excreted into the bile, where it is stored in the gallbladder. A is incorrect; the diet should be fat free, since fat is the principal cause of contraction of the diseased organ and should be avoided. B is incorrect; the client is given no food after the evening meal, to prevent contraction of the gallbladder and expulsion of the dye. D is incorrect; barium studies should be performed after, not before, the gallbladder series because the barium may shadow normal structures if it Is not excreted completely.
When assessing a client during peritoneal dialysis, a nurse observes that drainage of the dialysate from the peritoneal cavity has ceased before the required volume has returned. What should the nurse instruct the client to do? 1 Turn from side to side 2 Deep breathe and cough 3 Drink a glass of water 4 Rotate the catheter periodically
CORRECT 1 Turning from side to side will change the position of the catheter, thereby freeing the drainage holes of the tubing, which may be obstructed. Drinking a glass of water and deep breathing and coughing do not influence drainage of dialysate from the peritoneal cavity. The position of the catheter should be changed only by the primary healthcare provider
Arterial steal syndome
Can develop in a client with an internal arteriovenous fistula. In this complication, too much blood is diverted to the vein and arterial perfusion to the hand is compromised
MRI
Contraindicated in pregnant women because the increase in amniotic fluid temperature that occurs during the procedure may be harmful to the fetus
A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she was 12 years of age. To provide health teaching, which question is most important for the nurse to ask this mother? A) "Is your son's short stature a social embarrassment to him or the family?" B) "What types of foods do both your children eat now and what did they eat when they were infants?" C) "Did any significant trauma occur with the birth of your son?" D) "Did your daughter also start her menstrual period at 12 years of age?"
D) "Did your daughter also start her menstrual period at 12 years of age?" - Girls are expected to mature sexually and grow physically sooner than boys. Furthermore, girls only grow an average of 2 inches after menses begins (D). (A) is not appropriate at this time. The mother is worried that something is wrong with her son physically. (B) has less to do with stature than growth and development. (C) is not related to growth hormone deficiencies, which are idiopathic (without known causes).
After a hysterosalpingo-oophorectomy, a client wants to know whether it would be wise for her to take hormones right away to prevent symptoms of menopause. WHat is the nurse's most appropriate response? A) "It is best to wait because you may not have any symptoms." B) "It is comforting to know that hormones are available if you should ever need them." C) "You have to wait until symptoms are severe; otherwise, hormones will have no effect." D) "Discuss this with your HCP, because it is important to know your concerns."
D) "Discuss this with your HCP, because it is important to know your concerns."
A client with type 2 diabetes, who is taking an oral hypoglycemic agent, is to have a serum glucose test early in the morning. The client asks the nurse, "What do I have to do to prepare for this test?" Which statement by the nurse reflects accurate information? A) "Eat your usual breakfast." B) "Have clear liquids for breakfast." C) "Take your medication before the test." D) "Do not ingest anything before the test."
D) "Do not ingest anything before the test." - Fasting before the test is indicated for accurate and reliable results; food before the test will increase serum glucose levels through metabolism of the nutrients. Food should not be ingested before the test; food will increase the serum glucose level, negating accuracy of the test. Instructing the client to have clear liquids for breakfast is inappropriate; some clear fluids contain simple carbohydrates, which will increase the serum glucose level. Medications are withheld before the test because of their influence on the serum glucose level.
A parent whose newborn infant son has a cleft lip and palate asks the nurse, "How should I feed my baby because he has difficulty sucking?" What information should the nurse provide concerning a safe feeding technique for the infant? A) "Since he tires easily, it is best to have him lying in bed while he is being fed." B) "He should be held in a horizontal position and fed slowly to avoid aspiration." C) "Try using a soft nipple with an enlarged opening so he can get milk through a chewing motion." D) "Give him brief rest periods and frequent burpings during feedings so that he can get rid of swallowed air."
D) "Give him brief rest periods and frequent burpings during feedings so that he can get rid of swallowed air." - Infants with cleft lips and palates tend to swallow a lot of air, so frequent rest periods and burping are the best teaching for this client.
A client is taking famotidine (Pepcid). Which client statement should the nurse further assess because it may indicate that the client is experiencing a side effect of this drug? A) "I have heartburn whenever I lie down." B) "I am never hungry. I've lost weight in the past 2 weeks." C) "I have a funny metallic taste in my mouth." D) "I seem to be having difficulty thinking clearly."
D) "I seem to be having difficulty thinking clearly." - A common side effect of Pepcid is confusion (D). (A, B, and C) are not side effects of this medication.
The nurse is evaluating a client's understanding of the prescribed antilipemic drug lovastatin (Mevacor). Which client statement indicates that further teaching is needed? A) "My bowel habits should not be affected by this drug." B) "This medication should be taken once a day only." C) "I will still need to follow a low-cholesterol diet." D) "I will take the medication every day before breakfast."
D) "I will take the medication every day before breakfast." - The enzyme that helps metabolize cholesterol is activated at night, so this medication should be taken with the evening meal (D). (A, B, and C) reflect correct information about lovastatin.
A nurse is caring for a client who is cachexic. What information about the function of adipose tissue in fat metabolism is necessary to better address the needs of this client? A) Releases glucose for energy B) Regulates cholesterol production C) Uses lipoproteins for fat transport D) Stores triglycerides for energy reserves
D) Stores triglycerides for energy reserves
A client is diagnosed with uterine fibroids, and the HCP advises a hysterectomy. The client expresses concern about having a hysterectomy at age 45 because she has heard from friends that she will undergo severe symptoms of menopause after surgery. What is the nurse's most appropriate response? A) "You are correct, but there are medicines you can take that will ease the symptoms." B) "This sometimes occurs in women of your age, but you needn't worry about it at this time." C) "Perhaps you should talk to your surgeon because I am not allowed to discuss this with you." D) "Some women may experience symptoms of menopause if their ovaries are removed with their uterus."
D) "Some women may experience symptoms of menopause if their ovaries are removed with their uterus."
A nurse is monitoring a client's fasting plasma glucose. At which FPG level should the nurse identify that the client has prediabetes? A) 70 mg/dL B) 100 mg/dL C) 130 mg/dL D) 160 mg/dL
D) 160 mg/dL
A 15-year-old sexually active girl diagnosed with pelvic inflammatory disease (PID) is admitted to the hospital with a temperature of 101.6° F and a purulent vaginal discharge. She has no insurance and tells the nurse she enjoys small children. Which room should the nurse assign this client? A) A semi-private room with a 4-year-old girl who is currently receiving chemotherapy. B) A semi-private room with an older adolescent girl who had surgery yesterday. Incorrect C) A room close to the nurse's station. D) A private room.
D) A private room. - Despite the fact that the client has no insurance and enjoys small children, she is infected and should be placed in a private room (D). This client is infected, which is a priority consideration, so (A and B) would not be the best room assignment for this client because they would put the roommates at serious, unnecessary risk. This client is not acutely ill and does not need to be assigned to a room next to the nurse's station (C).
The charge nurse is assigning a room for a newly-admitted client, diagnosed with acute Pneumocystis carinii pneumonia, secondary to acquired immunodeficiency syndrome (AIDS). Which room would be best to assign to this client? A) A private room fully equipped with an outside air ventilation system. B) A semi-private room shared with an bed-ridden elder who would enjoy the company. C) A semi-private room with a bed available nearest to the bathroom. D) A semi-private room that does not have a client in the other bed at this time.
D) A semi-private room that does not have a client in the other bed at this time. - A semi-private room without a roommate (D) is the best assignment because the room can be easily blocked to create a private room should the client require isolation measures due to the pneumonia (the AIDS diagnosis alone does not affect the type of room assignment). A client with pneumonia should not be exposed to an outside air ventilation system (A). The client should not be assigned to a room with a client who is at risk for pneumonia (B). Mobility is not a factor for this client, therefore (C) is not indicated.
Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? A) Anger B) Denial C) Depression D) Acceptance
D) Acceptance - In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs.
The nurse is preparing to administer a secondary infusion of a dobutamine solution to a client. The nurse notes that the solution is brown in color. Which action should the nurse implement? A) Verify the prescribed dose with the health care provider. B) Discard the solution and reorder from the pharmacy. C) Dilute the solution with more normal saline until it becomes lighter in color. D) Administer the drug if the solution's reconstitution time is less than 24 hours.
D) Administer the drug if the solution's reconstitution time is less than 24 hours. - The color of the dobutamine solution is normal (D), and it should administered within 24 hours after reconstitution, so the time of reconstitution should be verified before administering the solution of medication. (A) is not indicated. (B) is not necessary. Additional dilution of a drug in solution is stated in the manufacturer's reconstitution instructions, but (C) is not needed.
A client with acute kidney failure becomes confused and irritable. Which does the nurse determine is the most likely cause of this behavior? A) Hyperkalemia B) Hypernatremia C) A limited fluid intake D) An increased BUN
D) An increased BUN
A mother brings her 18-month-old child to the community health center because the child has had "bad diarrhea" for the last 3 days. She states, "I bought some of this liquid at the pharmacy and gave my daughter a half-ounce." The nurse sees that the bottle contains loperamide (Imodium AD). Which intervention is most important for the nurse to implement initially? A) Tell the mother never to give this drug to her toddler. B) Ask if any other siblings have experienced diarrhea. C) Take the child's oral and tympanic temperatures. D) Ask the mother when the child last voided.
D) Ask the mother when the child last voided. - Determining when the child last voided (D) is most important because urine output is decreased with dehydration and an 18-month-old with a 3-day history of diarrhea could be severely dehydrated. Although the manufacturer states that loperamide (Imodium AD) should not be given to a child younger than 2 years except under the direction of a health care provider (A), this information is not the best answer for this question. In addition, loperamide (Imodium AD) causes an anticholinergic effect of urinary retention. Data obtained in (B and C) are not as high a priority as (D) in this situation.
A HCP prescribes tolterodine for a client with an overactive bladder. What is most important for the nurse to teach the client to do? A) Maintain a strict record of fluid intake and urinary output B) Chew the extended release capsule thoroughly before swallowing C) Report episodes of diarrhea or any increase in respiratory secretions D) Avoid activities requiring alertness until the response to the medication is known
D) Avoid activities requiring alertness until the response to the medication is known - Tolterodine is a urinary antispasmodic and may cause dizziness.
Which information is most accurate for the nurse to use when calculating safe drug dosages for a child? A) Age. B) Height. C) Weight. D) Body surface area.
D) Body surface area. - The most accurate method of calculating pediatric doses is based on a child's body surface area (BSA) (D). Drug calculations are not consistently precise when made on the basis of a child s age (A) since children vary widely in size and maturity for chronologic age. Although the calculation of a child's BSA utilizes a child's height and weight, (B and C) alone do not correlate with the distribution or metabolism of a drug due to the variance in each child's growth and development
A client's laboratory values demonstrate an increased serum calcium level, and further diagnostic tests reveal hyperparathyroidism. What clinical manifestations might the nurse identify when assessing this client? Select all that apply. A) Muscle tremors B) Abdominal cramps C) Increased peristalsis D) Cardiac dysrhythmias E) Hypoactive bowel sounds
D) Cardiac dysrhythmias E) Hypoactive bowel sounds - When the serum calcium level is increased, initially it causes tachycardia; as it progresses, it depresses electrical conduction in the heart, causing bradycardia. Hypercalcemia causes decreased peristalsis identified by constipation and hypoactive or absent bowel sounds. Muscle tremors occur with hypocalcemia, not hypercalcemia. Abdominal cramps occur with hypocalcemia, not hypercalcemia. Increased intestinal peristalsis occurs with hypocalcemia, not hypercalcemia.
Which nursing action can best prevent infection from a urinary retention catheter? A) Cleansing the perineum B) Encouraging adequate fluids C) Irrigating the catheter once daily D) Cleansing around the meatus routinely
D) Cleansing around the meatus routinely
A client's problem with ineffective control of type 1 diabetes is pinpointed as a sudden decrease in blood glucose level followed by rebound hyperglycemia. What should the nurse do when this event occurs? A) Give the client 8 oz (240 mL) of orange juice. B) Seek a prescription to increase the insulin dose at bedtime. C) Encourage the client to eat smaller, more frequent meals. D) Collaborate with the primary healthcare provider to alter the insulin prescription
D) Collaborate with the primary healthcare provider to alter the insulin prescription - The client is experiencing the Somogyi effect. It is a paradoxical situation in which sudden decreases in blood glucose are followed by rebound hyperglycemia. The body responds to the hypoglycemia by secreting glucagon, epinephrine, growth hormone, and cortisol to counteract the low blood sugar; this results in an excessive increase in the blood glucose level. It most often occurs in response to hypoglycemia when asleep. The primary healthcare provider may choose to decrease the insulin dose and then reassess the client. Giving the client 8 oz (240 mL) of orange juice will further increase the serum glucose level and is contraindicated. Increasing the insulin dose at bedtime will further worsen the problem. Encouraging the client to eat smaller, more frequent meals will not address the hypoglycemia and rebound hyperglycemia that occurs when sleeping. However, a bedtime snack may help minimize this event.
The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam hydrochloride (Versed). In assessing the client, the nurse determines that the client has slurred speech with diplopia. Based on this finding, what action should the nurse take? A) Open the airway with a chin lift-head tilt maneuver. B) Obtain a fingerstick glucose reading. C) Administer flumazenil (Romazicon). D) Continue to monitor the client
D) Continue to monitor the client - The desired level III in conscious sedation includes slurred speech, glazed eyes, and marked diplopia. Because this is the desired outcome of the medication regimen, no action is needed but continuing to monitor the client (D). The airway is open if the client is able to talk (A). There are no signs of hypoglycemia (B). No reversal is necessary for the benzodiazepine (Versed) without signs of oversedation, such as respiratory depression (C).
A client who had an organ transplant is receiving cyclosporine. For what should the nurse monitor to identify a serious adverse effect of cyclosporine? A) Skin for hirsutism B) Stools for constipation C) Heart rhythm for dysrhythmias D) Creatinine level for an increase
D) Creatinine level for an increase - Cyclosporine causes nephrotoxicity.
When developing a written nursing care plan for a client receiving chemotherapy for treatment of cancer, the nurse writes, "Assess each voiding for hematuria." The administration of which type of chemotherapeutic agent would prompt the nurse to add this intervention? A) Vincristine B) Bleomycin sulfate C) Chlorambumacil D) Cyclophosphamide
D) Cyclophosphamide Hemorrhagic cystitis is the characteristic adverse reaction of cyclophosphamide (Cytoxan) (D). Administration of (A, B, and C) does not typically cause hemorrhagic cystitis.
A nurse is teaching an athletic teenager about nutrients that provide the quickest source of energy. Which food selected from the menu indicates to the nurse that the adolescent understands the teaching? A) Glass of milk B) Slice of bread C) Chocolate candy bar D) Glass of orange juice
D) Glass of orange juice
During the first prenatal visit of a woman who is at 23 weeks' gestation, the nurse discovers that the client has a history of pica. What is the most appropriate nursing action? A) Seek a physiologic referral B) Explain the danger this poses to the fetus C) Obtain a prescription for an iron supplement D) Determine whether the diet is nutritionally adequate
D) Determine whether the diet is nutritionally adequate - Patients who have a history of pica typically have a nutritionally INADEQUATE diet, so the nurse should assess the patient's regular diet.
A female client with myasthenia gravis is taking a cholinesterase inhibitor and asks the nurse what can be done to remedy her fatigue and difficulty swallowing. What action should the nurse implement? A) Explore a plan for development of coping strategies for the symptoms with the client. B) Explain to the client that the dosage is too high, so she should skip every other dose of medication. C) Advise the client to contact her health care provider because of the development of tolerance to the medication. D) Develop a teaching plan for the client to self-adjust the dose of medication in response to symptoms.
D) Develop a teaching plan for the client to self-adjust the dose of medication in response to symptoms. - Maintaining optimal dosage for cholinesterase inhibitors can be challenging for clients with myasthenia gravis. Clients should be taught to recognize signs of overmedication and undermedication so that they can modify the dosage themselves (D) based on a prescribed sliding scale. (A, B, and C) do not adequately address the client's concerns.
A client has a transverse loop colostomy. What should the nurse do when inserting a catheter for the colostomy irrigation? A) Use an oil-based lubricant B) Instruct the client to gently bear down C) Apply gentle but continuous pressure D) Direct it toward the client's right side
D) Direct it toward the client's right side
When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A) Use the normal saline solution once more and then discard. B) Obtain a new sterile syringe to draw up the labeled saline solution. C) Use the saline solution and then relabel the bottle with the current date. D) Discard the saline solution and obtain a new unopened bottle.
D) Discard the saline solution and obtain a new unopened bottle. - Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded (D). (A, B, and C) describe incorrect procedures.
The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A) Only refer to the client by gender. B) Identify the client only by age. C) Avoid using the client's name. D) Discuss the client another time.
D) Discuss the client another time. - The best nursing action is to discuss the client another time (D). Confidentiality must be observed at all times, so the nurse should not discuss the client when the conversation can be overheard by others. Details can identify the client when referring to the client by gender (A) or age (B), and even when not using the client's name (C).
An adult female who presents at the mental clinic trembling and crying becomes distressed when the nurse attempts to conduct an assessment. She complains about the number of questions that are being asked, which she is convinced are going to cause her to have a heart attack. What action should the nurse take? A) Take the client's blood pressure and reassure her that the questioning will not cause a heart attack B) Explain that treatment is based on the information obtained in the assessment C) Encourage the client to relax so that she can provide the information requested D) Empower the client to share her story of why she is here at the mental health clinic
D) Empower the client to share her story of why she is here at the mental health clinic - The client is exhibiting signs of moderate anxiety, which include voice tremors, shakiness, somatic complaints, and selective inattention. (D) is the best method for addressing this client's level of anxiety by creating a shared understanding of the client's concerns. Although assessment of her blood pressure (A) might be a worthwhile intervention, reassuring her that questioning will not cause a heart attack (A) is argumentative. (B) suggests that treatment cannot be provided without the information, which is manipulative. Asking the client to relax (C) is likely to increase her anxiety.
During a group therapy session, a client with hypomania threatens to strike another client. What intervention is best for the nurse to implement? A) Summon assistance of several other staff. B) Send the other clients out of the group setting. C) Tell the client to leave the group to gain control of the behavior. D) Firmly inform the client that acting out anger is not acceptable.
D) Firmly inform the client that acting out anger is not acceptable. - A client with hypomania may demonstrate a varying degree of feelings, rapid thoughts, speech patterns, and impulsive acts. The client should be informed firmly that threats or behavior to act out feelings of anger is not acceptable (D). Staff assistance should be summoned (A) only if the client becomes aggressive and out of control. If a client persists with threats or aggressive behavior, changing the client's environment should be implemented before (B). Although personal time away from the group (C) may allow the client time out, the client should be confronted to recognize that the behavior is unacceptable.
During a home visit to a client, the nurse identifies tremors of the client's hands. When discussing this assessment, the client reports being nervous, having difficulty sleeping, and feeling as if the collars of shirts are getting tight. Of the additional assessment findings, which one should the nurse report to the practitioner? A) Increased appetite B) Recent weight loss C) Feelings of warmth D) Fluttering in the chest
D) Fluttering in the chest - Many of these problems are associated with hyperthyroidism; palpitations may indicate cardiovascular changes requiring prompt intervention. The increased metabolism associated with hyperthyroidism can lead to heart failure. Although an increased appetite becomes a compensatory mechanism for the increased metabolism associated with hyperthyroidism, it is not life threatening. Although unexplained weight loss can result from catabolism associated with hyperthyroidism, it is not life threatening. Although a feeling of warmth caused by the increased metabolism associated with hyperthyroidism is uncomfortable, it is not life threatening.
The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. What action should the nurse take? A) Institute the ordered blood transfusion because the client's surgical depends on volume replacement B) Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion C) Phone the HCP for an administrative order to give the transfusion under these circumstances D) Give the spouse a treatment refusal form to sign and notify the HCP that a court order can now be sought
D) Give the spouse a treatment refusal form to sign and notify the HCP that a court order can now be sought - The client is unconcious. Although the spouse can give consent, there is no legal power to refuse treatment for the client unless previously authorized to do so by the power of attorney or a health care proxy ; the court can make a decision for the client.
A nurse is transferring a client with a diagnosis of pheochromocytoma from a bed to a chair. What is the MOST important nursing intervention associated with this procedure for this client? A) Supporting the client on the weak side B) Ensuring that the chair is close to the client's bed C) Placing sturdy shoes with rubber soles on the client's feet D) Having the client sit on the side of the bed for a few minutes before the transfer
D) Having the client sit on the side of the bed for a few minutes before the transfer - Having the client sit on the side of the bed for several minutes allows time for the blood pressure to adjust to the vertical position; this avoids dizziness and the potential for fainting or falling.
Dobutamine (Dobutrex) is an emergency drug most commonly prescribed for a client with which condition? A) Shock. B) Asthma. C) Hypotension. D) Heart failure.
D) Heart failure. - Dobutamine is a beta-1 adrenergic agonist that is indicated for short term use in cardiac decompensation or heart failure (D) related to reduced cardiac contractility due to organic heart disease or cardiac surgical procedures. Alpha and beta adrenergic agonists, such as epinephrine and dopamine, are sympathomimetics used in the treatment of shock (A). Other selective beta-2 adrenergic agonists, such as terbutaline and isoproterenol, are indicated in the treatment of asthma (B). Although dobutamine improves cardiac output, it is not used to treat hypotension (C).
A nurse is assessing two clients. One client has UC and the other client has Crohn disease. Which is more likely to be identified in the client with UC? A) Inclusion of transmural involvement of the small bowel wall B) Correlation with increased malignancy because of malabsorption syndrome C) Pathology beginning proximally with intermittent plaques found along the colon D) Involvement starting distally with rectal bleeding that spreads continually up the colon
D) Involvement starting distally with rectal bleeding that spreads continually up the colon
A nurse administers the prescribed regular insulin (Novolin R) to a client in DKA. In addition, the nurse anticipates that the IV solution prescribed will contain potassium to replenish potassium ions in the extracellular fluid that are being: A) Rapidly lost from the body by copious diaphoresis present during coma B) Carried with glucose to the kidneys to be excreted in the urine in increased amounts C) Quickly used up during the rapid series of catabolic reactions stimulated by insulin and glucose D) Moved into the intracellular fluid compartment because of the generalized anabolism induced by insulin and glucose
D) Moved into the intracellular fluid compartment because of the generalized anabolism induced by insulin and glucose - Insulin stimulates cellular uptake of glucose and also stimulates the sodium/potassium pump, leading to the influx of potassium into cells. The resulting hypokalemia is offset by parenteral administration of potassium.
Which action should the nurse implement to assess for jugular vein distention (JVD) in a client with heart failure (HF)? A) Ask the client to perform the Valsalva maneuver while lying in a supine position. B) Palpate the jugular veins, comparing the volume and pressure of one with those of the other. C) Measure in centimeters the distance that the jugular veins are distended outward from the neck. D) Observe the vertical distention of the veins as the client is gradually elevated to an upright position.
D) Observe the vertical distention of the veins as the client is gradually elevated to an upright position. - An indicator of elevated right atrial pressure in HF is jugular distention of greater than 3 cm vertical distance between the intersection of the angle of Louis and the level of the jugular distention, which occurs when the client is gradually elevated to an upright position (D). (A, B, and C) do not provide the best evaluation of JVD in a client with HF.
A client had a mastectomy asks about ERP-positive. The nurse explains that tumors cells are evaluated for estrogen receptor protein to determine the: A) Need for supplemental oxygen B) Feasibility of breast reconstruction C) Degree of metastasis has occurred D) Potential response to hormone therapy
D) Potential response to hormone therapy
An older adult with dementia is admitted to a nursing home. The client is confused, agitated, and at times unaware of the presence of others. What is the best nursing approach to help this client adapt to the unit? A) Initiate a program of planned interaction B) Explain the nature and routines of the unit C) Explore in depth the reasons for admission D) Provide for the continuous presence of staff members
D) Provide for the continuous presence of staff members
Which response best supports the observations that the nurse identifies in a client who is experiencing a placebo effect? A) Beneficial response or cure for disease B) Behavioral or psychotropic responses C) Malingering or drug-seeking behaviors D) Psychological response to inert medication
D) Psychological response to inert medication - The placebo effect is a response in the client that is caused by the psychological impact (D) of taking an inert drug that has no biochemical properties. A placebo effect can be therapeutic, negative, or ineffective but provides no cure or benefit (A) to the client's progress. The placebo effect may evoke behavioral changes but does not affect neurochemical psychotropic changes (B). Malingering and drug seeking (C) are behaviors that a client exhibits to obtain treatment for nonexistent disorders or obtain prescription medications.
A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? A) Alkalosis B) Renal failure C) Hypervolemia D) Pulmonary edema
D) Pulmonary edema
A nurse is caring for a child with spasmodic croup. Which clinical finding alerts the nurse that immediate nursing intervention is required? A) Irritability B) Hoarseness C) Barking cough D) Rapid respirations
D) Rapid respirations
A HCP orders intermittent NG tube feeding to supplement a client's oral nutritional intake. Which hazard associated with NG tube feeding will be reduced if the nurse administers this feeding over 60 minutes? A) Distension B) Flatulence C) Indigestion D) Regurgitation
D) Regurgitation
A mother asks the nurse to explain how using time-out to discipline her 2-year-old child is an effective method. Which rationale should the nurse provide? A) Offers positive reinforcement. B) Provides a consequence to behavior. C) Extinguishes the behavior by ignoring it. D) Removes a reinforcer that a child is receiving.
D) Removes a reinforcer that a child is receiving. - Time-out is a disciplinary approach that removes a reinforcer, such as the satisfaction or attention the child receives from a behavior or activity (D). When placed in an unstimulating and isolated place, the child becomes bored and consequently agrees to behave in order to reenter the family group. Positive reinforcement (A) uses rewards that encourages a child to behave in another specified way, which reduces the unacceptable behavior. Time-out avoids physical punishment, which is a negative reinforcement (B) that may reinforce behavior because it brings attention. Although no reasoning or scolding is given with time-out, ignoring behavior allows the child to continue the behavior until it is eventually extinguished or minimized.
A client who is experiencing an acute attack of gouty arthritis is prescribed colchicine (Colcrys) USP, 1 mg PO daily. Which information is most important for the nurse to provide the client? A) Take the medication with meals. B) Limit fluid intake until the attack subsides. C) Stop the medication when the pain resolves. D) Report any vomiting to the clinic.
D) Report any vomiting to the clinic. - The client should be instructed to report signs of colchicine toxicity, such as nausea, diarrhea, vomiting (D), and/or abdominal pain, to the health care provider. Food inhibits the absorption of colchicine when ingested concurrently (A). Limited fluid intake (B) decreases the excretion of the uric acid crystals, which contributes to painful attacks. Typically, a client should remain on a daily dose of colchicine to decrease the number and severity of acute attacks, so stopping the medication after the pain resolves (C) is not indicated.
A nurse is giving discharge instructions to a client who had an aspiration abortion by suction curettage. What should the client be told? A) Avoid showering for 2 days B) Tampons may be used after 1 day C) Sexual intercourse should be delayed for 3 weeks D) Report bleeding that requires pad changes every 2 hours
D) Report bleeding that requires pad changes every 2 hours
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A) Encourage the client to use a nicotine patch. B) Reassure the client that it is almost time for another break. C) Have the client leave the unit with another staff. D) Review the schedule of outdoor breaks with the client.
D) Review the schedule of outdoor breaks with the client. - The best nursing action is to review the schedule of outdoor breaks (D) and provide concrete information about the schedule. (A) is contraindicated if the client wants to continue smoking. (B) is insufficient to encourage a trusting relationship with the client. (C) is preferential for this client only and is inconsistent with unit rules.
A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? A) Accept the client's crying B) Encourage unrestricted family visitors C) Explain details of the care being given D) Stay nearby without initiating conversation
D) Stay nearby without initiating conversation
A nurse is teaching a class about hepatitis, specifically hepatitis A. Which food should the nurse explain will most likely remain contaminated with hepatitis A virus after being cooked? A) Canned tuna B) Broiled shrimp C) Baked haddock D) Steamed lobster
D) Steamed lobster
A client is experiencing chronic constipation and the nurse discusses how to include more bulk in the diet. The nurse concludes that learning has occurred when the client states, "Bulk in the diet promotes defecation by: A) Irritating the bowel wall B) Stimulating the intestinal mucosa chemically C) Acting on the microorganisms in the large intestine D) Stretching intestinal smooth muscle, which causes it to contract
D) Stretching intestinal smooth muscle, which causes it to contract
A client is admitted with diarrhea, anorexia, weight loss, and abdominal cramps. What clinical manifestations of an electrolyte deficit should the nurse report immediately? Select all that apply. A) Diplopia B) Skin rash C) Leg cramps D) Tachycardia E) Muscle weakness
D) Tachycardia E) Muscle weakness
The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first? A) Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client. B) Sit quietly in the client's room until the client leaves the bathroom. C) Allow the client to cry alone and leave the client in the bathroom. D) Talk to the client and attempt to find out why the client is crying.
D) Talk to the client and attempt to find out why the client is crying. - The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed (D). (A) is incorrect; the nurse should implement the intervention. The nurse may offer to stay nearby after first assessing the situation more fully (B). Although (C) may be correct, the nurse should determine if the client's safety is compromised and offer assistance, even if it is refused.
The nurse expects a clinical finding of cyanosis in an infant with which condition(s)? (Select all that apply.) A) Ventircular septal defect (VSD) B) Patent ductus arteriosis (PDA) C) Coarction of the aorta D) Tetrology of Fallot E) Transposition of the great vessels
D) Tetrology of Fallot E) Transposition of the great vessels - Both tetralogy of Fallot and transposition of the great vessels are classified as cyanotic heart disease, in which unoxygenated blood is pumped into the systemic circulation, causing cyanosis (D and E). The others are all abnormal cardiac conditions, but are classified as acyanotic and involve left-to-right shunts, increased pulmonary blood flow, or obstructive defects. (A, B, and C).
When administering an intramuscular (IM) injection to an adult client using the ventrogluteal site, which landmarks should the nurse identify to locate the area for injection? A) The greater trochanter and the knee. B) The acromion process and the dorsal surface of the upper arm. C) The greater trochanter and the posterior iliac spine. D) The anterosuperior iliac spine and the greater trochanter.
D) The anterosuperior iliac spine and the greater trochanter. - The heel of the hand is placed on the greater trochanter and the fingers spread to palpate the anterosuperior iliac spine, which are the landmarks used to give an injection in the ventrogluteal site (D). (A) locates the vastus lateralis, (B) locates the deltoid, and (C) locates the gluteus maximus, which is no longer recommended as an IM site.
A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how it provides passive immunity? A) It increases production of short-lived antibodies B) It accelerates antigen-antibody union at the hepatic sites C) The lymphatic system is stimulated to produce antibodies D) The antigen is neutralized by the antibodies it supplies
D) The antigen is neutralized by the antibodies it supplies
The registered nurse teaches a nursing student about the implementation process of nursing. Which example does the registered nurse use while describing indirect care interventions using his or her knowledge? A) The nurse counseling a client at the time of grief B) The nurse administering an intravenous infusion to a client C) The nurse teaching the client about an appropriate nutrition plan D) The management of the client's environment to prevent infections
D) The management of the client's environment to prevent infections - Nursing interventions are based on clinical judgment and knowledge and performed by the nurse for enhancing the client's outcomes. Indirect care interventions are treatments which are performed away from the client but will benefit the client. Managing the client's environment to prevent infection control is an indirect care intervention. Direct care interventions are performed through interactions with the clients. Direct care interventions may include counselling the client at the time of grief, administering an intravenous infusion to the client, and teaching the client about an appropriate nutrition plan.
A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first? A) Clamp the nasogastric tube. B) Confirm placement of the tube. C) Use a syringe to instill the medications. D) Turn off the intermittent suction device.
D) Turn off the intermittent suction device. - The nurse should first turn off the suction (D) and then confirm placement of the tube in the stomach (B) before instilling the medications (C). To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped for a period of time (A) before reconnecting the suction.
What potential complication does the nurse anticipate when admitting a client with the diagnosis of severe prolapse of the uterus? A) Edema B) Fistulas C) Exudate D) Ulcerations
D) Ulcerations
In reviewing the medical record, the nurse notes that a client's last eye examination revealed an intraocular pressure (IOP) of 28 mmHg. What information should the nurse ask the client? A) Length of time the client has been wearing prescription lenses. B) Recent experience of seeing light flashes or floaters. C) Complaints of any blind spots in the client's field of vision. D) Use of prescribed eye drops since last exam by ophthalmologist.
D) Use of prescribed eye drops since last exam by ophthalmologist. - Normal intraocular pressures range between 10 and 21 mmHg, so the client's use of any prescribed eye drops should be determined to evaluate the client's intraocular pressure (D). Although (A, B, and C) should be determined to screen for other ophthalmic disorders, the use of an ophthalmic prescription for glaucoma focuses the evaluation of the client's IOP status.
A client who has been taking levodopa PO TID to control the symptoms of Parkinson's disease has a new prescription for sustained release levodopa/carbidopa (Sinemet 25/100) PO BID. The client took his levodopa at 0800. Which instruction should the nurse include in the teaching plan for this client? A) Take the first dose of Sinemet today, as soon as your prescription is filled. B) Since you already took your levodopa, wait until tomorrow to take the Sinemet. C) Take both drugs for the first week, then switch to taking only the Sinemet. D) You can begin taking the Sinemet this evening, but do not take any more levodopa.
D) You can begin taking the Sinemet this evening, but do not take any more levodopa. - Carbidopa significantly reduces the need for levodopa in clients with Parkinson's disease, so the new prescription should not be started until eight hours after the previous dose of levodopa (D), but can be started the same day (B). (A and C) may result in toxicity.
154. Mr. Mesta Is restless and uncooperative in the early days of his treatment. His wife asks the nurse If he could be medicated to "calm him down." Which statement should guide the nurse's response? A. Sedatives are never given to clients with liver disease because damaged liver cells cannot metabolize the drug. B. Sedatives are usually metabolized by the kidneys, so this request Is feasible. C. Sedatives have an excitant, rather than a calming, effect on clients with liver disease. D. A few sedatives that are not metabolized in the liver exist, but they should be used cautiously.
D. A few sedatives that are not metabolized in the liver exist, but they should be used cautiously. Clients with liver disease respond adversely to sedation. The inability of damaged liver cells to metabolize drugs Is generally given as a reason for this. A is incorrect in that a few drugs - namely, phenobarbital and paraldehyde - are given to clients if absolutely necessary. B is incorrect since most opiates, short-acting barbiturates, and major tranquilizers are metabolized primarily in the liver. C is incorrect because "excitant" effects with sedatives are rarely, if ever, reported.
34. Pruritus, caused by the accumulation of bile salts In the skin, can be relieved by administering prescribed: A. Valium to help the client relax. B. Benadryl to promote sleep during the night. C. Questran to stimulate the reabsorption of bile salts. D. Cholestyramine to bind bile salts in the intestines.
D. Cholestyramine to bind bile salts in the intestines. Cholestyramine, a bile add-sequestering resin, Increases fecal bile excretion, resulting In the reduction of excess bile salt deposits in the skin. Questran, C, Is another bile add sequestrant, but It stimulates the excretion, not the reabsorption, of bile salts, so C is incorrect. A and B are incorrect. As stated, they do not relieve the pruritus of the client with hepatitis.
117. Mr. Williams demonstrates that he is aware of dietary influences in the prevention of the dumping syndrome when he adjusts his intake by: A. Decreasing fats. B. Decreasing proteins. C. Increasing fluids at mealtimes. D. Decreasing carbohydrates.
D. Decreasing carbohydrates. The food mass is a concentrated hyperosmolar solution in relation to surrounding extracellular fluid. Water is drawn from the blood into the intestines, and symptoms of distress occur. A and B are incorrect; fats should be increased because they slow passage of food into the intestines, and protein should be increased. C is incorrect, as fluids with meals should be decreased or eliminated so that food will stay in the stomach longer.
32. The nurse observes that Ms. Bee has clay-colored stools. The reason is that: A. Hepatic uptake of bilirubin is impaired. B. Excretion of fecal urobilinogen is increased. C. Conjugated bilirubin reenters the bloodstream. D. Excretion of conjugated bilirubin into the intestines Is decreased.
D. Excretion of conjugated bilirubin into the intestines Is decreased. D is correct because decreased excretion of conjugated bilirubin Into the Intestines is a common occurrence in viral hepatitis. It causes lack of bile pigments in the stools-thus, the clay-colored stools seen. A and C are incorrect. Although both can also occur In hepatitis, they do not have any effect on the color of the stools. The life span of the RBCs In clients with liver diseases is shortened, causing an Jmpaired hepatic uptake of bilirubin, A. The reentry of conjugated bilirubin into the bloodstream, C, results in jaundice. B Is also incorrect. Increased excretion of fecal urobilinogen occurs in hemolytic anemia, not in hepatitis.
150. Which drug might the nurse be asked to give to decrease ammonia levels in a client with liver disease? A. Diazepam (Valium). B. Diphenoxylate hydrochloride and atropine sulfate (Lomotil). C. Furosemide (Lasix). D. Lactulose.
D. Lactulose. Lactulose is a drug that lowers the pH of the colon, which inhibits the diffusion of ammonia from the colon into the blood, reducing blood ammonia levels. A, B, and C do not have the desired effect on ammonia levels. Diazepam is a sedative and skeletal-muscle relaxant that should be used with much caution in a person with liver disease. Lomotil is an antidiarrheal drug that will slow the removal of protein materials from the ntestine and thereby increase ammonia levels. Furosemide is a diuretic drug that Inhibits reabsorption of sodium and water in renal tubules.
122. Ms. Norfolk returns from surgery. Which nursing action has the highest priority during the recovery room period? A. Checking vital signs every 15 minutes. B. Recording Intake and output. C. Explaining procedures to her family. D. Maintaining a patent airway.
D. Maintaining a patent airway. D is correct because life-threatening factors always have priority. A, B, and C are all important functions, but the airway has priority.
A client undergoing tuberculosis therapy reports eye pain that worsens when moving the eyes with decreased color vision. Which medication most likely is responsible for the client's condition? 1 Rifampin 2 Isoniazid 3 Ethambutol 4 Pyrazinamide
Ethambutol Eye pain that is worsened when the eyes are moved with decreased color vision may be indicative of optic neuritis. Ethambutol, especially at high dosages, can cause optic neuritis, a condition that can result in blindness. Rifampin reduces the effectiveness of oral contraceptives, increasing the risk of an unplanned pregnancy, and can change bodily fluid orange. Isoniazid can deplete the body of the B-complex vitamins. Pyrazinamide increases uric acid formation and worsens gout.
Graft rejection
Except for identical twin donors and recipients, the major postoperative complication following renal transplant is?
In which order should the nurse implement these actions when withdrawing a solution from an ampule?
Flick the stem several times with a finger. Wrap the neck with a protective device. Break the neck by pressing thumbs outward. Stabilize ampule on a firm surface. Withdraw the solution using a filter needle. - Flicking the stem ensures all medication is in the bottom of the ampule. Wrapping the neck with a protective device (such as a small gauze pad or alcohol prep pad) protects fingers from trauma as the glass tip is broken off. Snapping the neck of the ampule quickly and outwards minimizes the nurse's risk of injury from shattering glass. Stabilizing the ampule assists in maintaining sterility as the needle is placed to withdraw the solution. Withdrawing the solution with a filter needle protects against aspirating microscopic glass into the syringe.
Right side
Following a liver biopsy, place the client on the ______ with a pillow under the costal margin at the anatomical location of the liver to decrease the risk of hemorrhage
Gag reflux
Following endoscopic procedures, monitor for ____ before giving the client any oral substance.
SLE
For a client with ________, monitor the blood urea nitrogen and creatine levels frequently for signs of renal impairment
Leg elevation
For venous insufficiency, ________ is usually prescribed to assist with the return of blood to the heart
Bronchodilator, corticosteroid
If two diffract inhaled medications are prescribed and one of them contains a glucocorticoid, administer the ________ first and the ________ second
Gout
Results from abnormal amounts of Uric acid in the body
Flumazenil (Romazicon)
Reverses the effects of benzodiazepines
AMS
Sign of a UTI
Cerebral edema, increased BP, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, n/v
Signs of Transurethral resection syndrome
What is the function of the structure labeled in the given figure? picture wont copy onto here.... 1 Holds the fetus 2 Secretes ovum 3 Serves as entry to the sperm 4 Massages the ovaries
correct 4 The structure labeled in the figure represents the fallopian tubes, fingerlike projections that massage the ovaries to facilitate ovum extraction. The ovaries produce ovum. The uterus accommodates the fetus. The cervix serves as an entry to the sperm and is also involved in expulsion of menses.
Which drug prescribed to a client with a urinary tract infection (UTI) turns urine reddish-orange in color? 1 Nitrofurantoin 2 Ciprofloxacin 3 Phenazopyridine 4 Amoxicillin
correct:3 Phenazopyridine is a topical anesthetic that is used to treat pain or burning sensation associated with urination. It also imparts a characteristic orange or red color to urine. Amoxicillin is a penicillin form that could cause pseudomembranous colitis as a complication; it is not associated with reddish-orange colored urine. Ciprofloxacin is a quinolone antibiotic used for treating UTIs and can cause serious cardiac dysrhythmias and sunburns. It is not, however, responsible for reddish-orange colored urine. Nitrofurantoin is an antimicrobial medication prescribed for UTIs. This drug may affect the kidneys but is not associated with reddish-orange colored urine.
A nurse is caring for a client who had a splenectomy. For which complication should the nurse specifically assess in the immediate postoperative period? a. Infection b. Peritonitis c. Intestinal obstruction d. Abdominal distention
d. Abdominal distention
