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A nurse is planning care for a newly admitted client diagnosed with acute nephrotic syndrome. What interventions would the nurse include in the plan of care? You answered this questionCorrectly 1. Monitor triglyceride level 2. Educate client on a 3 gm sodium diet. 3. Auscultate lung sounds. 4. Monitor blood pressure. 5. Assess for venous thrombo-embolism (VTE).

1, 3, 4, & 5. Correct: The liver increases the release of cholesterol and triglycerides while producing more needed albumin. This client is at risk for heart failure, and pulmonary edema so the lungs should be auscultated and the blood pressure should be monitored. Without proteins, the blood can clot and put the client at risk for thrombosis or embolism. 2. Incorrect: The client should be on a low sodium diet (3 grams is too high). Carbohydrates are given liberally to provide energy.

A client is admitted with arterial disease of the lower extremities. Which client teachings would the nurse initiate? 1. Elevate extremities above the level of the heart. 2. Discourage use of caffeine. 3. Protect extremities from cold exposure. 4. Maintain a warm environment at home. 5. Encourage isometric exercise.

2., 3., 4., & 5. Correct: Caffeine, stress, and nicotine cause vasoconstriction and vasospasm, which impedes peripheral circulation. Warmth promotes arterial flow by preventing the vasoconstriction effects of chilling. Vasodilation will be increased by providing warmth in the environment. Cold causes vasoconstriction. Isometric exercise and walking promote the development of collateral circulation. 1. Incorrect: Lower the extremities below the level of the heart for arterial problems. Dependent extremities enhance arterial blood supply.

A client who was admitted to coronary care unit with a diagnosis of myocardial infarction is on continuous cardiac monitoring. Which cardiac change noted on the monitor would be of greatest concern? 1. Ventricular tachycardia > 100 bpm 2. Atrial fibrillation with atrial rate > 300 per minute 3. Four premature ventricular contractions within one minute 4. ST segment depression of 0.5 mm

1. Correct: Ventricular tachycardia with a ventricular rate greater than 100 per minute can be a precursor to ventricular fibrillation. This rhythm is the most life threatening and would be of greatest concern. 2. Incorrect: Clients diagnosed with atrial fibrillation are at high risk for formation of thrombus. This is a serious concern, but not as great a concern as ventricular tachycardia. 3. Incorrect: Premature ventricular contractions (PVCs) that are less than 6 are worrisome but not considered a precursor to ventricular tachycardia or ventricular fibrillation. 4. Incorrect: ST segment depression of 1 mm or more signifies myocardial ischemia.

The nurse is monitoring the client's heart rhythm. The monitor shows sinus tachycardia. What is expected with this assessment finding? 1. Regular rhythm 2. Rate of 101-200 3. Absent P wave 4. P-R interval not measurable 5. QRS complex greater than 0.20 seconds

1., & 2. Correct: Sinus tachycardia indicates a regular rhythm, although the rate is elevated. The term tachycardia is defined as a heart rate above 100. Sinus rhythms have a normal QRS complex. 3. Incorrect: There is a P-wave with a sinus rhythm and it is normal. 4. Incorrect: P-R interval is not measurable in atrial flutter, atrial fib, PVCs, V tach or V fib. 5. Incorrect: The QRS complex should be no more than 0.12 seconds

The nurse is planning care for a client who has incomplete emptying of the bladder with reports of dribbling, hesitancy, and frequency. Which intervention would the nurse include in this plan? 1. After voiding, instruct client to void a second time. 2. Encourage the client to void every 4 hours. 3. Teach client to perform the Credé method. 4. Pour warm water over perineum. 5. Insert indwelling urinary catheter if client unable to void.

1., 2., 3., & 4. Correct: Have client attempt to void again. This is called double voiding. This can improve bladder emptying. Encourage client to void every 4 hours. We do not want urine to sit in the bladder for long periods of time. Stagnant urine can create infection. Place bedpan, urinal, or bedside commode within reach. Perform Credé method over bladder to increase bladder pressure. Provide privacy. Have client listen to sound of running water or place hands in warm water and/or pour warm water over perineum to stimulate urination. Offer fluids before voiding. 5. Incorrect: If these methods are unsuccessful, the client will need education on intermittent catheterization.

A nurse is caring for a client post heart catheterization with a left femoral stick. What signs and symptoms would indicate to the nurse that the primary healthcare provider should be notified? 1. Capillary refill of 6 seconds to left toes. 2. Epigastric discomfort 3. Paresthesia to left leg 4. Left pedal pulse 0/4; Right pedal pulse 2+/4 5. Temperature of 99.9º F (37.72º C)

1., 2., 3., & 4. Correct: These signs and symptoms indicate an emergency with loss of circulation to the extremity. This is an emergency, and the primary healthcare provider is the only one that can save this foot from ischemia. Don't delay. Epigastric pain could indicate the client is having an MI. Always assume the worse! 5. Incorrect: Temperature of 101º F (38.3º C) or more indicates a problem.

The nurse is planning to teach a client about home peritoneal dialysis. What information should the nurse include? 1. After washing hands with soap and water, put on clean gloves to clean catheter site. 2. Apply a prescription antibiotic cream to the skin around the catheter with fingers. 3. Leave crust formed around the insertion site alone. 4. Gently rub the skin dry around the site dry after cleaning. 5. Wash the skin around the catheter site with antibacterial soap.

1., 3., & 5. Correct: Before cleaning the area, wash your hands with soap and water and put on clean gloves. Do not pick at or remove crusts or scabs at the site. The skin around the catheter site should be washed daily or every other day with antibacterial soap or an antiseptic (either povidone iodine or chlorhexidine). The soap should be stored in the original bottle (not poured into another container). 2. Incorrect: Apply a prescription antibiotic cream to the skin around the catheter with a cotton-tip swab every time the dressing is changed. 4. Incorrect: Pat the skin around the site dry after cleaning. A clean cloth or towel is suggested.

A manufacturing worker comes into the occupational health nurse's clinic reporting a squeezing pain in the chest. What additional signs and symptoms should the nurse monitor for in the client? 1. Dyspnea 2. Dry, flushed skin 3. Indigestion 4. Restlessness 5. Tachycardia

1., 3., 4. & 5. Correct: The nurse should be thinking myocardial infarction (MI)! All of these are signs of an MI. 2. Incorrect: The skin is not being perfused properly so the skin will be cool and clammy.

What information should the pre-operative nurse include when educating a client about preventing a deep vein thrombus (dvt) formation after abdominal surgery? 1. Anticoagulant medication may be prescribed. 2. Caffeinated beverages will be allowed once able to drink in order to promote hydration. 3. Bed rest will be required for at least 5 days. 4. Move feet in a circle 10 times an hour. 5. A sequential compression device (SCD) will be wrapped around the legs.

1., 4., & 5. Correct: Anticoagulants can prevent blood clots. Simple exercises while you are resting in bed or sitting in a chair can help prevent blood clots. Move your feet in a circle or up and down. Do this 10 times an hour to improve circulation. Sequential compression device (SCD) or intermittent pneumatic compression (IPC) are wrapped around your legs and connected to a pump that inflates and deflates the sleeves. This applies gentle pressure to promote blood flow in the legs and prevent blood clots. 2. Incorrect: Alcohol and coffee contribute to dehydration, which can lead to thickened blood and increased risk for clot formation. 3. Incorrect: After surgery, a nurse should help the client out of bed, as soon as pssible. Moving around improves circulation and helps prevent blood clots.

An elderly client with a history of coronary artery disease (CAD) has just been admitted to the telemetry unit following a syncopal episode at home. The admitting nurse places EKG leads on the client and notes the following rhythm on the monitor. When the client indicates the need to void, the nurse knows that what would be the safest action? 1. Request order for a foley catheter. 2. Assist client with the use of a bedpan. 3. Provide a bedside commode chair. 4. Perform in and out straight catherization.

2. CORRECT. The exhibit shows bradycardia with premature ventricular contractions (PVCs), and more specifically, bigeminy. The safest approach for a syncopal client with this rhythm is the use of a bedpan for bathroom needs. Even with assistance, this client would be at risk for falls when ambulating. 1. INCORRECT. Because the client has experienced syncope and is bradycardic, keeping the client in bed is safer than ambulating to the bathroom. However, a foley catheter is an invasive procedure that could place the client at risk of infection. There is a better option. 3. INCORRECT. The client has experienced syncope and is bradycardic. Keep the client in bed. This is a safety issue. 4. INCORRECT. This client is newly admitted with a diagnosis of syncope. The exhibit shows the heart rate is bradycardic with PVCs, which are non-perfusing beats. In and out straight catheterization is an invasive procedure that could place the client at risk for infection. There is a better option.

A client has sublingual (SL) nitroglycerin prn added to the medication regimen. Which statement made by the client indicates to the nurse that teaching has been effective? You answered this questionCorrectly 1. "If the medication burns in my mouth, it is old and should be discarded." 2. "I must keep this medication in its original dark, glass bottle." 3. "I can take one tablet every five minutes up to 3 doses for chest pain." 4. "I know that I must put this tablet under my tongue for it to work." 5. "My medication should be renewed yearly."

2., 3., & 4. Correct: These are true statements and would indicate that teaching has been effective. 1. Incorrect: Nitroglycerin may or may not burn or fizz in the client's mouth. It is normal. 5. Incorrect: Nitroglycerin should be renewed on average every three to five months. Two years for the spray.

The nurse is assessing a male client suspected of having a myocardial infarction (MI). What signs/symptoms would the nurse expect the client to exhibit? 1. Bradycardia 2. Chest pressure 3. Cough 4. Flu like symptoms 5. Vomiting

2., 3., & 5. Correct: These are symptoms commonly seen in a male client having an MI 1. Incorrect: Tachycardia rather than bradycardia will be noted with an MI 4. Incorrect: A woman, rather than a male, having an MI my exhibit flu like symptoms.

The nurse is caring for a client who is receiving enoxaparin after a diagnosis of deep vein thrombosis of the left leg. Which nursing interventions would be appropriate for this client? You answered this questionCorrectly 1. Monitor PT and aPTT 2. Initiate bedrest 3. Elevate left leg 4. Monitor closely for bleeding 5. Monitor complete blood count

2., 3., 4. & 5. Correct: The main complication of anticoagulant therapy is bleeding. Periodic complete blood counts, including platelet count, and stool occult blood tests are recommended during the course of treatment with enoxaparin sodium Injection. Bedrest will reduce the risk of a clot dislodging. Elevate left leg to decrease swelling and promote venous return. 1. Incorrect: When administered at recommended prophylaxis doses, routine coagulation tests such as Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are relatively insensitive measures of enoxaparin

As a member of the emergency preparedness planning team at the hospital, which action should the nurse encourage the team to implement? You answered this questionCorrectly 1. Develope a response plan for each potential disaster. 2. Provide education to employees on the response plan. 3. Practice the response plan on a regular basis. 4. Evaluate the hospital's level of preparedness. 5. Coordinate with neighboring hospitals regarding different emergency response plans.

2., 3., 4., & 5. Correct: Developing a single response plan, educating individuals to the specifics of the response plan, and practicing the plan and evaluating the facility's level of preparedness are effective means of implementing emergency preparedness. Consideration must be given to the proximity of chemical plants, nuclear facilities, schools, and areas where large groups gather. 1. Incorrect: One good response plan should be developed rather than multiple plans.

What should a nurse include when planning an educational program for a group of women on how to prevent a urinary tract infection (UTI)? 1. Empty bladder at least every 8 hours while awake 2. Take showers rather than prolonged baths 3. Use spemicidal jelly during intercourse 4. Use tampons rather than sanitary napkins 5. Wear cotton underwear

2., 4., & 5. Correct: Take showers and avoid prolonged baths. Sitting in a tub allows bacteria to reach the bladder opening area. Tampons are advised during the menstrual period rather than sanitary napkins or pads because they keep the bladder opening area drier than a sanitary pad, thereby limiting bacterial overgrowth. Cotton underwear for general use is suggested. 1. Incorrect: Avoid long intervals between urinating. Try to empty the bladder at least every 4 hours during the day while awake. 3. Incorrect: Avoid the use of spermicidal jelly. This kills sperm as well as normal vaginal flora, which are important in suppressing colonization with pathogenic bacteria.

The nurse sees the following rhythm on the cardiac monitor for a client recovering from a myocardial infarction. What would be the nurse's first action upon entering the client's room? ExhibitYou answered this questionCorrectly 1. Attempt defibrillation 2. Begin CPR 3. Assess for carotid pulse 4. Administer lidocaine

3. Correct: Although the rhythm strip looks like ventricular fibrillation, you must first check the client. Assess for consciousness, airway, breathing, circulation first. 1. Incorrect: Assess the client first. Do not rely on the strip alone. It may be artifact. If there is no pulse, then you defibrillate. 2. Incorrect: Assess the client first. Defibrillate, then CPR. 4. Incorrect: While CPR is in progress after defibrillation, start IV, if one is not available, then give lidocaine.

A client has been admitted with advanced cirrhosis. The nurse's assessment verifies an increase weight of 6 lbs. (2.71 kg) since yesterday's weight and an abdominal girth increase of 5 inches (12.7 cm). What is the priority assessment? You answered this questionIncorrectly 1. Urinary Output 2. Daily weight 3. Blood pressure 4. LOC

3. Correct: Blood Pressure. We said that all of this ascites is coming from the vascular space and it's getting worse, So what could happen to my blood pressure? It will drop! 1. Incorrect: SURE, you are going to watch the urinary output and the daily weight. LOC is very important as well and one of the first assessments we make, BUT if I can only do one of these assessments, I better take the BP because that is the one that says SHOCK. 2. Incorrect: SURE, you are going to watch the urinary output and the daily weight. LOC is very important as well and one of the first assessments we make, BUT if I can only do one of these assessments, I better take the BP because that is the one that says SHOCK. 4. Incorrect: SURE, you are going to watch the urinary output and the daily weight. LOC is very important as well and one of the first assessments we make, BUT if I can only do one of these assessments, I better take the BP because that is the one that says SHOCK.

A client returns to the unit after having extracorporeal lithotripsy. Which would be the best indicator that the treatment has been effective? 1. The client is relieved of the pain. 2. The urine is free of red blood cells. 3. The urinary output has increased since return to the unit. 4. There is sediment in the urinary catheter drainage bag.

4. Correct: This answer provides visible proof that the renal calculi has been broken up by the shock waves. 1. Incorrect: Pain can occur because of spasm of smooth muscle when the stone is moving. 2. Incorrect: There will be blood in the urine for several days after treatment. 3. Incorrect: Blocked urine flow from stone fragments may cause decreased urine output.

A nurse is attempting planning care for a client who has self-care difficulty due to left-sided hemiparesis. Which intervention should the nurse include? 1. Offer to take the client to the toilet every two hours. 2. Instruct client to use disposable razors once to prevent infection. 3. Encourage family members to comb hair for client. 4. Provide the client with a button hook for dressing. 5. Teach the client to rely on furniture for support when walking.

1., & 4. Correct: Offer bedpan or place client on toilet every 1 to 2 hours during the day and three times during the night. The use of a button hook or loop and pile closure on clothes may make it possible for a client to continue independence in this self-care activity. 2. Incorrect: The client can be helped by using an electric razor and toothbrush. These will improve client safety during self care. 3. Incorrect: Having client comb own hair helps maintain autonomy. This is a one handed task that will enable the client to maintain autonomy for as long as possible. 5. Incorrect: The client should use prescribed assistive devices for ambulation. Furniture may move or not be in the correct place for support while walking.

A client was admitted two days ago in the oliguric phase of acute kidney injury (AKI). What evaluation by the nurse would indicate that treatment has been effective? 1. Variable urine specific gravity 2. Serum K+ 5.5 mEq (5.5 mmol/L) 3. Serum Na+ 140 mEq (140 mmol/L) 4. Minimal crackles auscultated in bases of left lung 5. Urine output = 1250 mL/24 hours

1., 3. & 5. Correct: A fixed specific gravity indicates that the kidneys are not working properly. A variable specific gravity changes based on whether the urine is dilute or concentrated. This is a normal sodium level, which indicates that the client is improving. The serum sodium level would be low in the oliguric phase due to increased dilution of the blood. This urine output is adequate to indicate proper kidney perfusion. 2. Incorrect: The serum potassium is high. The serum potassium level is elevated when the client is still in the oliguric phase. 4. Incorrect: The lungs would need to be clear to verify that treatment has been effective.

A nurse, planning an educational seminar on chronic kidney disease, would invite clients with which medical conditions? 1. Diabetes 2. Frequent urinary tract infections (UTI) 3. Hyperlipidemia 4. Hypertension 5. Obesity

1., 3., 4 & 5. Correct: Polycystic kidney disease is a genetic condition that causes damage to the kidneys. Clients with diabetes and hypertension make up more than 67% of clients diagnosed with chronic kidney disease. Glomerulonephritis damages the kidneys and can lead to permanent damage. 2. Incorrect: Cystitis is an inflammation of the bladder. Inflammation is where part of your body becomes irritated, red, or swollen. In most cases, the cause of cystitis is a urinary tract infection (UTI).Acute UTIs do not generally lead to chronic kidney disease.

A client had a coronary artery bypass surgery (CABG) x 3 performed 24 hours ago. What assessment findings would make the nurse suspect cardiac tamponade? You answered this questionCorrectly 1. Bradycardia with wet lungs 2. Increased central venous pressure 3. Distended bilateral neck veins 4. A widening pulse pressure 5. Decreasing blood pressure

2, 3, and 5. CORRECT: Cardiac tamponade occurs when blood or fluid enters the pericardial sac, causing compression of the heart chambers. Such pressure prevents blood from either entering or leaving the heart, thus decreasing cardiac output. Central venous pressure (CVP) increases because of the compression of the right atria, but because no fluid is exiting the heart, blood pressure drops. Since the returning blood cannot enter the heart, neck veins become distended, though lungs remain clear. 1. INCORRECT: Because little blood is moving within the heart chambers, no fluid would back up into the lungs. The client's lungs remain clear, even though the cardiac output decreases and neck veins are distended. 4. INCORRECT: Widening pulse pressure is noted with increased intracranial pressure, not cardiac tamponade. Pulse pressure in tamponade would narrow since the heart is being compressed.

A client arrives to the emergency department with reports of palpitations, chest discomfort, and light-headedness. The nurse connects the client to a cardiac monitor and notes a weak, thready pulse, and a BP of 90/50. What actions should the nurse take? 1. Administer Atropine 0.5 mg intravenous push (IVP). 2. Prepare for immediate synchronized cardioversion. 3. Provide 100 percent oxygen. 4. Start large bore intravenous access. 5. Set up for endotracheal intubation.

2., & 4. Correct: This client has a rapid heart rate of 188/min. The actual rhythm is atrial tachycardia but can also be identified as supraventricular tachycardia because the heartrate is greater than 150/min. This client is considered unstable so requires oxygen therapy starting at 2 liters/nasal cannula, with O2 saturation monitoring, and synchronized cardioversion. IV access is needed prior to cardioversion incase medications are required. 1. Incorrect: Atropine is not indicated for an atrial or supraventricular dysrhythmia. 3. Incorrect: Oxygen therapy starting at 2 liters/nasal cannula, with O2 saturation monitoring is needed. 5. Incorrect: This client is awake with a patent airway. So intubation is not needed at this time.

the nurse is caring for a client with acute renal failure. The morning assessment findings indicate the client has become confused and irritable. Which finding is most likely responsible for the change in behavior? You answered this questionIncorrectly 1. Hyperkalemia 2. Hypernatremia 3. Elevated blood urea nitrogen (BUN) 4. Limited fluid intake

3. Correct: A client with acute renal failure will have an increased (BUN). Significant elevation in BUN may result in nausea, vomiting, lethargy, fatigue, impaired thought processes, and headache. 1. Incorrect: Hyperkalemia can result from acute renal failure. Symptoms of hyperkalemia do not include confusion and irritability. Hyperkalemia may cause muscle weakness, muscle twitching, and flaccid paralysis. 2. Incorrect: Clients with renal failure retain fluid and are at risk for dilutional hyponatremia. Increased or decreased sodium levels can cause confusion, but this client is not at risk for hypernatremia.4. Incorrect: Clients in acute renal failure should have limited fluid intake. This will not lead to confusion.

A small community has experienced a mudslide that hit a restaurant causing mass casualties. What would the nurse do first? 1. Assess the immediate area for electrical wires on the ground. 2. Attend to victim injuries as they are encountered. 3. Activate the community emergency response team. 4. Triage and tag victims according to injury.

3. Correct: With mass casualties, community response teams are needed. 1. Incorrect: This would be the second step so that further injuries are not encountered. 2. Incorrect: Triage must occur before treatment of anyone so that an accurate assessment of level of injuries can be made. With mass casualties, a color tag system is usually implemented. 4. Incorrect: This would be the third step.