final exam from med surg book

3. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment.

. A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.

3. Clients diagnosed with AIDS should be encouraged to discuss their end-of-life issue with the significant others and to put those wishes in writing. This is important for all clients, not just those diagnosed with AIDS.

. Which intervention is an important psychosocial consideration for the client diagnosed with AIDS? 1. Perform a thorough head-to-toe assessment. 2. Maintain the client's ideal body weight. 3. Complete an advance directive. 4. Increase the client's activity tolerance

3. The assistant can place the client on the bedside commode as part of bowel training; the nurse is responsible for the training but can delegate this task.

. Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel? 1. Teach Credé's maneuver to the client needing to void. 2. Administer the tube feeding to the client who is quadriplegic. 3. Assist with bowel training by placing the client on the bedside commode. 4. Observe the client demonstrating self-catheterization technique.

2. Type 2 diabetes is a disorder usually occurring around the age of 40, but it is now being detected in children and young adults as a result of obesity and sedentary lifestyles. Nonhealing wounds are a hallmark sign of type 2 diabetes. This client weighs 248.6 pounds and is short

An 18-year-old female client, 5′4′′ tall, weighing 113 kg, comes to the clinic for a nonhealing wound on her lower leg, which she has had for two (2) weeks. Which disease process should the nurse suspect the client has developed? 1. Type 1 diabetes. 2. Type 2 diabetes. 3. Gestational diabetes. 4. Acanthosis nigricans.

1. Headache and photophobia are expected clinical manifestations of meningitis. The new graduate could care for this client.

The charge nurse is making assignments. Which client should be assigned to the new graduate nurse? 1. The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes. 2. The client diagnosed with Parkinson's disease who fell during the night and is complaining of difficulty walking. 3. The client diagnosed with a cerebrovascular accident whose vitals signs are P 60, R 14, and BP 198/68. 4. The client diagnosed with a brain tumor who has a new complaint of seeing spots before the eyes.

1. The nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further injure the client.

The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first? 1. Administer 50% dextrose IVP. 2. Notify the health-care provider. 3. Move the client to the ICU. 4. Check the serum glucose level.

45mL/hr

The client in a code is now in ventricular bigeminy. The HCP orders a lidocaine drip at three (3) mg/min. The lidocaine comes prepackaged with two (2) grams of lidocaine in 500 mL of D5W. At which rate will the nurse set the infusion pump?

3. This is the main reason the HCP decreases the client's medication dose and is an explanation appropriate for the client.

The client is diagnosed with end-stage liver failure. The client asks the nurse, "Why is my doctor decreasing the doses of my medications?" Which statement is the nurse's best response? 1. "You are worried because your doctor has decreased the dosage." 2. "You really should ask your doctor. I am sure there is a good reason." 3. "You may have an overdose of the medications because your liver is damaged." 4. "The half-life of the medications is altered because the liver is damaged."

2. Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless.

The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.

3. A xenograft or heterograft consists of skin taken from animals, usually porcine.

The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best response? 1. "The doctor will graft skin from your back to your leg." 2. "The skin from a donor will be used to cover your burn." 3. "The graft will come from an animal, probably a pig." 4. "I think you should ask your doctor about the graft."

3. Uremic frost, which results when the skin attempts to take over the function of the kidneys, causes itching, which can lead to scratching possibly resulting in a break in the skin.

The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client? 1. Notify the HCP if oral temperature is 102˚F or greater. 2. Apply ice to the access site if it starts bleeding at home. 3. Keep fingernails short and try not to scratch the skin. 4. Encourage significant other to make decisions for the client.

3. The nurse must maintain a patent airway. Airway is the first step in resuscitation.

The nurse arrives at the site of a one-car motor-vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next? 1. Carefully remove the driver from the car. 2. Assess the client's pupils for reaction. 3. Assess the client's airway. 4. Attempt to wake the client up by shaking him

3. This is the first intervention the nurse should implement after finding the client unresponsive on the floor.

The nurse finds the client unresponsive on the floor of the bathroom. Which action should the nurse implement first? 1. Check the client for breathing. 2. Assess the carotid artery for a pulse. 3. Shake the client and shout. 4. Notify the Rapid Response Team.

. 1. The client has a malnutrition syndrome. The nurse assesses the body and what the client has been able to eat

The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention? 1. Assess the client's body weight and ask what the client has been able to eat. 2. Place in contact isolation and don a mask and gown before entering the room. 3. Check the HCP's orders and determine what laboratory tests will be done. 4. Teach the client about total parenteral nutrition and monitor the subclavian IV site.

1. Blood urea nitrogen (BUN) levels reflect the balance between the production and excretion of urea from the kidneys. Creatinine is a by-product of the metabolism of the muscles and is excreted by the kidneys. Creatinine is the ideal substance for determining renal clearance because it is relatively constant in the body and is the laboratory value most significant in diagnosing renal failure.

The nurse is caring for a client diagnosed with ARF. Which laboratory values are most significant for diagnosing ARF? 1. BUN and creatinine. 2. WBC and hemoglobin. 3. Potassium and sodium. 4. Bilirubin and ammonia level.

4. A collaborative intervention is an intervention in which another health-care discipline—in this case, occupational therapy—is used in the care of the client.

The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals. 4. Refer the client to an occupational therapist for evaluation.

4. The major goal of treating PD is to maintain the ability to function. Clients diagnosed with PD experience slow, jerky movements and have difficulty performing routine daily tasks.

The nurse is planning the care for a client diagnosed with Parkinson's disease. Which would be a therapeutic goal of treatment for the disease process? 1. The client will experience periods of akinesia throughout the day. 2. The client will take the prescribed medications correctly. 3. The client will be able to enjoy a family outing with the spouse. 4. The client will be able to carry out activities of daily living.

4. Fetal tissue transplantation has shown some success in PD, but it is an experimental and highly controversial procedure.

The nurse researcher is working with clients diagnosed with Parkinson's disease. Which is an example of an experimental therapy? 1. Sterotactic pallidotomy/thalamotomy. 2. Dopamine receptor agonist medication. 3. Physical therapy for muscle strengthening. 4. Fetal tissue transplantation.

3. Memory deficits are cognitive impairments. The client may also develop a dementia.

Which is a common cognitive problem associated with Parkinson's disease? 1. Emotional lability. 2. Depression. 3. Memory deficits. 4. Paranoia.

1. The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate.

. A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? 1. Administer a stool softener b.i.d. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90

1. Retroviruses never die; the virus may become dormant, only to be reactivated at a later time.

. The nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach? 1. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in. 2. The HIV virus can be eradicated from the host body with the correct medical regimen. 3. It is difficult for the HIV virus to replicate in humans because it is a monkey virus. 4. The HIV virus uses the client's own red blood cells to reproduce the virus in the body

4. Excess fluid volume is priority because of the stress placed on the heart and vessels, which could lead to heart failure, pulmonary edema, and death.

The nurse is developing a nursing care plan for the client diagnosed with CKD. Which nursing problem is priority for the client? 1. Low self-esteem. 2. Knowledge deficit. 3. Activity intolerance. 4. Excess fluid volume.

4. Standard Precautions are used for all contact with blood and body secretions.

Which type of isolation technique is designed to decrease the risk of transmission of recognized and unrecognized sources of infections? 1. Contact Precautions. 2. Airborne Precautions 3. Droplet Precautions. 4. Standard Precautions.

2. Diaphoresis (sweating) is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin.

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis. 2. Diaphoresis and cool clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema.

3. Multifocal PVCs, which are secondary to hypokalemia and can occur in clients with DKA, are a potentially life-threatening emergency. This client needs an experienced nurse

The charge nurse is making client assignments in the intensive care unit. Which client should be assigned to the most experienced nurse? 1. The client with type 2 diabetes who has a blood glucose level of 348 mg/dL. 2. The client diagnosed with type 1 diabetes who is experiencing hypoglycemia. 3. The client with DKA who has multifocal premature ventricular contractions. 4. The client with HHNS who has a plasma osmolarity of 290 mOsm/L.

3. Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac rehabilitation clinic, which includes progressive exercise, diet teaching, and classes on modifying risk factors.

The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client? 1. Social worker. 2. Physical therapy. 3. Cardiac rehabilitation. 4. Occupational therapy.

3. This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain with inspiration and a nonproductive cough.

1. Spinal shock associated with SCI represents a sudden depression of reflex activity below the level of the injury. T12 is just above the waist; therefore, no reflex activity below the waist would be expected.

In assessing a client with a T12 SCI, which clinical manifestations would the nurse expect to find to support the diagnosis of spinal shock? 1. No reflex activity below the waist. 2. Inability to move upper extremities. 3. Complaints of a pounding headache. 4. Hypotension and bradycardia.

2. "Cognitive" pertains to mental processes of comprehension, judgment, memory, and reasoning. Therefore, an appropriate goal would be for the client to stay on task for 10 minutes.

The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client? 1. The client will return to work within six (6) months. 2. The client is able to focus and stay on task for 10 minutes. 3. The client will be able to dress self without assistance. 4. The client will regain bowel and bladder control.

2. The rehabilitation commission of each state will help evaluate and determine if the client can receive training or education for another occupation after injury.

The 34-year-old male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement? 1. Refer the client to the American Spinal Cord Injury Association (ASIA). 2. Refer the client to the state rehabilitation commission. 3. Ask the social worker about applying for disability. 4. Suggest that the client talk with his significant other about this concern.

4. The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.

The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.

1. This is the correct statement explaining what an AED does when used in a code.

The CPR instructor is discussing an automated external defibrillator (AED) during class. Which statement best describes an AED? 1. It analyzes the rhythm and shocks the client in ventricular fibrillation. 2. The client will be able to have synchronized cardioversion with the AED. 3. It will keep the health-care provider informed of the client's oxygen level. 4. The AED will perform cardiac compressions on the client.

2. This client's dialysis access is compromised and he or she should be assessed first.

The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first? 1. The client who has hemoglobin of 9.8 g/dL and hematocrit of 30%. 2. The client who does not have a palpable thrill or auscultated bruit. 3. The client who is complaining of being exhausted and is sleeping. 4. The client who did not take antihypertensive medication this morning.

2. The client will not be compliant with the diet if he or she is still hungry. Therefore, the nurse should request the dietitian talk to the client to try to adjust the meals so the client will adhere to the diet.

The UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to eat for lunch. Which intervention should the nurse implement? 1. Instruct the UAP to get the client additional food. 2. Notify the dietitian about the client's request. 3. Request the HCP increase the client's caloric intake. 4. Tell the UAP the client cannot have anything else.

2. These crystals are uremic frost resulting from irritating toxins deposited in the client's tissues. Bathing in cool water will remove the crystals, promote client comfort, and decrease the itching resulting from uremic frost.

The UAP tells the nurse the client with ARF has a white crystal-like layer on top of the skin. Which intervention should the nurse implement? 1. Have the assistant apply a moisture barrier cream to the skin. 2. Instruct the UAP to bathe the client in cool water. 3. Tell the UAP not to turn the client in this condition. 4. Explain this is normal and do not do anything for the client.

2. Deep partial-thickness burns are scalds and flash burns that injure the epidermis, upper dermis, and portions of the deeper dermis. This causes pain, blistered and mottled red skin, and edema

The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial thickness. 3. Full thickness. 4. First degree.

3. The health-care team should meet to discuss ways to best help the client deal with the anger being expressed, and the staff should be consistent in working with the client.

The client diagnosed with AIDS is angry and yells at everyone entering the room, and none of the staff members wants to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving this situation? 1. Assign a different nurse every shift to the client. 2. Ask the HCP to tell the client not to yell at the staff. 3. Call a team meeting and discuss options with the staff. 4. Tell one (1) staff member to care for the client a week at a time.

2. This most likely is a fungal infection known as oral candidiasis, commonly called thrush. An antifungal medication is needed to treat this condition

The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement? 1. Teach the client to brush the teeth and patchy area with a soft-bristle toothbrush. 2. Notify the HCP for an order for an antifungal swish-and-swallow medication. 3. Have the client gargle with an antiseptic-based mouthwash several times a day. 4. Determine what types of food the client has been eating for the last 24 hours.

2. If the ventilator system malfunctions, the nurse must ventilate the client with a manual resuscitation (Ambu) bag until the problem is resolved.

The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag. 3. Request STAT arterial blood gases. 4. Auscultate the client's lung sounds.

1. When peak airway pressure is increased, the nurse should implement the intervention least invasive for the client. This alarm goes off with a plugged airway, "bucking" in the ventilator, decreasing lung compliance, kinked tubing, or pneumothorax.

The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first? 1. Check the tubing for any kinks. 2. Suction the airway for secretions. 3. Assess the lip line of the ET tube. 4. Sedate the client with a muscle relaxant.

3. Assessment is the first part of the nursing process and is the first intervention the nurse should implement when caring for a client on a ventilator.

The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that the ventilator alarms are functioning properly. 3. Assess the respiratory status and pulse oximeter reading. 4. Monitor the client's arterial blood gas results.

4. Normal potassium level is 3.5 to 5.5 mEq/L. A level of 6.8 mEq/L is life threatening and could lead to cardiac dysrhythmias. Therefore, the client may be dialyzed to decrease the potassium level quickly. This requires a health-care provider order, so it is a collaborative intervention.

The client diagnosed with ARF has a serum potassium level of 6.8 mEq/L. Which collaborative treatment should the nurse anticipate for the client? 1. Administer a phosphate binder. 2. Type and crossmatch for whole blood. 3. Assess the client for leg cramps. 4. Prepare the client for dialysis.

3. Carbohydrates are increased to provide for the client's caloric intake and protein is restricted to minimize protein breakdown and to prevent accumulation of toxic waste products.

The client diagnosed with ARF is admitted to the intensive care unit and placed on a therapeutic diet. Which diet is most appropriate for the client? 1. A high-potassium and low-calcium diet. 2. A low-fat and low-cholesterol diet. 3. A high-carbohydrate and restricted-protein diet. 4. A regular diet with six (6) small feedings a day.

3. Regular insulin, along with glucose, will drive potassium into the cells, thereby lowering serum potassium levels temporarily.

The client diagnosed with ARF is experiencing hyperkalemia. Which medication should the nurse prepare to administer to help decrease the potassium level? 1. Erythropoietin. 2. Calcium gluconate. 3. Regular insulin. 4. Osmotic diuretic.

2. Bedrest reduces exertion and the metabolic rate, thereby reducing catabolism and subsequent release of potassium and accumulation of endogenous waste products (urea and creatinine).

The client diagnosed with ARF is placed on bedrest. The client asks the nurse, "Why do I have to stay in bed? I don't feel bad." Which scientific rationale supports the nurse's response? 1. Bedrest helps increase the blood return to the renal circulation. 2. Bedrest reduces the metabolic rate during the acute stage. 3. Bedrest decreases the workload of the left side of the heart. 4. Bedrest aids in reduction of peripheral and sacral edema.

1. Carrying heavy objects in the left arm could cause the fistula to clot by putting undue stress on the site, so the client should carry objects with the right arm.

The client diagnosed with CKD has a new arteriovenous fistula in the left forearm. Which intervention should the nurse implement? 1. Teach the client to carry heavy objects with the right arm. 2. Perform all laboratory blood tests on the left arm. 3. Instruct the client to lie on the left arm during the night. 4. Discuss the importance of not performing any hand exercises.

4. Because the client is in ESRD, fluid must be removed from the body, so the output should be more than the amount instilled. These assessment data require intervention by the nurse

The client diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse? 1. Inability to auscultate a bruit over the fistula. 2. The client's abdomen is soft, is nontender, and has bowel sounds. 3. The dialysate being removed from the client's abdomen is clear. 4. The dialysate instilled was 1,500 mL and removed was 1,500 mL.

4. When the glucose level is decreased to around 300 mg/dL, the regular insulin infusion therapy is decreased. Subcutaneous insulin will be administered per sliding scale.

The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement? 1. Increase the regular insulin IV drip. 2. Check the client's urine for ketones. 3. Provide the client with a therapeutic diabetic meal. 4. Notify the HCP to obtain an order to decrease insulin.

3. Carbidopa enhances the effects of levodopa by inhibiting decarboxylase in the periphery, thereby making more levodopa available to the central nervous system. Sinemet is the most effective treatment for PD.

The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications? 1. There will be fewer side effects with this combination than with carbidopa alone. 2. Dopamine D requires the presence of both of these medications to work. 3. Carbidopa makes more levodopa available to the brain. 4. Carbidopa crosses the blood-brain barrier to treat Parkinson's disease.

2. Difficulty swallowing places the client at risk for aspiration. Immobility predisposes the client to pneumonia. Both clinical manifestations place the client at risk for pulmonary complications.

The client diagnosed with Parkinson's disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain these assessment data? 1. Masklike facies and shuffling gait. 2. Difficulty swallowing and immobility. 3. Pill rolling of fingers and flat affect. 4. Lack of arm swing and bradykinesia.

3. Scheduling appointments late in the morning gives the client a chance to complete ADLs without pressure and allows the medications time to give the best benefits.

The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions? 1. "All of my spouse's emotions will slow down now just like his body movements." 2. "My spouse may experience hallucinations until the medication starts working." 3. "I will schedule appointments late in the morning after his morning bath." 4. "It is fine if we don't follow a strict medication schedule on weekends."

2. Oxygen is a priority, especially with a client diagnosed with a respiratory illness.

The client diagnosed with Pneumocystis pneumonia (PCP) is being admitted to the intensive care unit. Which HCP's order should the nurse implement first? 1. Draw a serum for CD4 and complete blood count STAT. 2. Administer oxygen to the client via nasal cannula. 3. Administer trimethoprim-sulfamethoxazole, a sulfa antibiotic, IVPB. 4. Obtain a sputum specimen for culture and sensitivity

2. An osmotic diuretic would be ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation unit.

The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question? 1. A subcutaneous anticoagulant. 2. An intravenous osmotic diuretic. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.

1. Purposeless movement indicates that the client's cerebral edema is decreasing. The best motor response is purposeful movement, but purposeless movement indicates an improvement over decorticate movement, which, in turn, is an improvement over decerebrate movement or flaccidity

The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving? 1. Purposeless movement in response to painful stimuli. 2. Flaccid paralysis in all four extremities. 3. Decerebrate posturing when painful stimuli are applied. 4. Pupils that are 6 mm in size and nonreactive on painful stimuli.

1. Awakening the client every two (2) hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety—all signs of postconcussion syndrome—that would warrant the significant other's taking the client back to the emergency department.

The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other? 1. Awaken the client every two (2) hours. 2. Monitor for increased intracranial pressure. 3. Observe frequently for hypervigilance. 4. Offer the client food every three (3) to four (4) hours.

3. This result parallels a serum blood glucose level of approximately 180 to 200 mg/dL. An A1c is a blood test reflecting average blood glucose levels over a period of three (3) months; clients with elevated blood glucose levels are at risk for developing long-term complications.

The client diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1c) of 8.1%. Which interpretation should the nurse make based on this result? 1. This result is below normal levels. 2. This result is within acceptable levels. 3. This result is above recommended levels. 4. This result is dangerously high.

1. The heart tissue is dead, stress or activity may cause heart failure, and it does take about six (6) weeks for scar tissue to form.

The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? 1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal." 2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias." 3. "Your doctor has ordered bedrest. Therefore, you must stay in the bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger."

3. The nurse should praise and encourage UAPs to participate in the client's care. Clients on bedrest are at risk for deep vein thrombosis, and moving the legs will help prevent this from occurring

The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement? 1. Instruct the UAP to stop encouraging the leg movements. 2. Report this behavior to the charge nurse as soon as possible. 3. Praise the UAP for encouraging the client to move legs. 4. Take no action concerning the UAP's behavior.

3. Any neurovascular assessment data that are abnormal require intervention by the nurse; numbness may indicate decreased blood supply to the right foot.

The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? 1. The client is keeping the affected extremity straight. 2. The pressure dressing to the right femoral area is intact. 3. The client is complaining of numbness in the right foot. 4. The client's right pedal pulse is 3+ and bounding.

1. Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. 3. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising.

The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.

1. The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.

2. The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium.

The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. 2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. 3. Determine if the client has gained weight and instruct the client to keep the legs elevated. 4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily

2. While the balloons are inflated, the client must not be left unattended in case they become dislodged and occlude the airway. This is a safety issue.

The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (SengstakenBlakemore). Which nursing intervention should the nurse implement for this treatment? 1. Assess the gag reflex every shift. 2. Stay with the client at all times. 3. Administer the laxative lactulose (Chronulac). 4. Monitor the client's ammonia level.

4. Ammonia is a by-product of protein metabolism and contributes to hepatic encephalopathy. Reducing protein intake should decrease ammonia levels

The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? 1. Restrict sodium intake to 2 g/day. 2. Limit oral fluids to 1,500 mL/day. 3. Decrease the daily fat intake. 4. Reduce protein intake to 60 to 80 g/day

3. The client is at risk for hypovolemia; therefore, vital signs will be assessed frequently to monitor for signs of hemorrhaging.

The client diagnosed with end-stage renal failure and ascites is scheduled for a paracentesis. Which client teaching should the nurse discuss with the client? 1. Explain the procedure will be done in the operating room. 2. Instruct the client a Foley catheter will have to be inserted. 3. Tell the client vital signs will be taken frequently after the procedure. 4. Provide instructions on holding the breath when the HCP inserts the catheter

1. Hot water increases pruritus, and soap will cause dry skin, which increases pruritus; therefore, the nurse should discuss this with the UAP.

The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse? 1. The UAP is assisting the client to take a hot soapy shower. 2. The UAP applies an emollient to the client's legs and back. 3. The UAP puts mittens on both hands of the client. 4. The UAP pats the client's skin dry with a clean towel.

3. Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain.

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Obtain a STAT electrocardiogram. 3. Have the client sit down immediately. 4. Assess the client's vital signs.

3. Dry mucous membranes are a result of the hyperglycemia and occur with both HHNS and DKA.

The client diagnosed with type 2 diabetes is admitted to the intensive care unit with hyperosmolar hyperglycemic nonketonic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit? 1. Kussmaul's respirations. 2. Diarrhea and epigastric pain. 3. Dry mucous membranes. 4. Ketone breath odor.

4. Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.

The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.

1. Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy

The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy? 1. Gastrointestinal bleeding. 2. Hypoalbuminemia. 3. Splenomegaly. 4. Hyperaldosteronism.

1. After airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes.

The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? 1. Replace fluids and electrolytes. 2. Prevent contractures of extremities. 3. Monitor urine output hourly. 4. Prepare to assist with an escharotomy

3. Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure

The client has had a liver biopsy. Which postprocedure intervention should the nurse implement? 1. Instruct the client to void immediately. 2. Keep the client NPO for eight (8) hours. 3. Place the client on the right side. 4. Monitor BUN and creatinine level

3. If the client bends the leg, it could cause the insertion site to bleed. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention.

The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? 1. The client's BP is 110/70 and pulse is 90. 2. The client's groin dressing is dry and intact. 3. The client refuses to keep the leg straight. 4. The client denies any numbness and tingling

3. The cold caloric test, also called the oculovestibular test, is a test used to determine if the brain is intact or dead. No eye activity indicates brain death. If the client's eyes moved, that would indicate that the brainstem is intact.

The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is "brain dead." Which data support that the client is brain dead? 1. When the client's head is turned to the right, the eyes turn to the right. 2. The electroencephalogram (EEG) has identifiable waveforms. 3. There is no eye activity when the cold caloric test is performed. 4. The client assumes decorticate posturing when painful stimuli are applied.

1. Vitamin K deficiency causes impaired coagulation; therefore, rectal thermometers should be avoided to prevent bleeding. 2. Soft-bristle toothbrushes will help prevent bleeding of the gums. 3. Platelet count, PTT/PT, and INR should be monitored to assess coagulation status. 4. Injections should be avoided, if at all possible, because the client is unable to clot, but if they are absolutely necessarily, the nurse should use small gauge needles.

The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement? Select all that apply. 1. Avoid rectal temperatures. 2. Use only a soft toothbrush. 3. Monitor the platelet count. 4. Use small-gauge needles. 5. Assess for asterixis.

1. The nurse should always address the airway when a client is seriously ill. 2. The client must be assessed for fluid volume deficit and then for fluidvolume excess after fluid replacement is started. 3. The electrolyte imbalance of primary concern is depletion of potassium. 4. Ketones are excreted in the urine; levels are documented from negative to large amount. Ketones should be monitored frequently. 5. The nurse must ensure the client's fluid intake and output are equal.

The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply. 1. Maintain adequate ventilation. 2. Assess fluid volume status. 3. Administer intravenous potassium. 4. Check for urinary ketones. 5. Monitor intake and output.

1. Preventing and treating shock with blood and fluid replacement will prevent acute renal failure from hypoperfusion of the kidneys. Significant blood loss is expected in the client with a gunshot wound

The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should the nurse implement first to prevent ARF? 1. Administer normal saline IV. 2. Take vital signs. 3. Place client on telemetry. 4. Assess abdominal dressing.

4. The most important nursing goal in the management of a client with a head injury is to establish and maintain an adequate airway.

The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? 1. Assess neurological status. 2. Monitor pulse, respiration, and blood pressure. 3. Initiate an intravenous access. 4. Maintain an adequate airway.

1. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status.

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 90 and capillary refill time <3 seconds.

2. There is no instrument used at home to test daily ammonia levels. The ammonia level is a serum level requiring venipuncture and laboratory diagnostic equipment

The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client needs more teaching concerning this medication? 1. "I should have two to three soft stools a day." 2. "I must check my ammonia level daily." 3. "If I have diarrhea, I will call my doctor." 4. "I should check my stool for any blood."

1. The client needs sufficient nutrients for wound healing and increased metabolic requirements, and homemade nutritious foods are usually better than hospital food. This also allows the family to feel part of the client's recovery.

The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement? 1. Encourage the client's family to bring favorite foods. 2. Provide a low-fat, low-cholesterol diet for the client. 3. Monitor the client's weight weekly in the same clothes. 4. Make a referral to the hospital social worker.

3. The client needs to know that it will take time to adjust to life after burns and that returning to work, family role, sexual intimacy, and body image will take time.

The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client's mental health? 1. Encourage the client to stay at home as much as possible. 2. Discuss the importance of not relying on the family for needs. 3. Tell the client to remember that changes in lifestyle take time. 4. Instruct the client to discuss feelings only with the therapist.

1. Renal failure affects almost every system in the body. Neurologically, the client may have drowsiness, headache, muscle twitching, and seizures. In the recovery period, the client is alert and has no seizure activity. 2. In renal failure, levels of erythropoietin are decreased, leading to anemia. An increase in hemoglobin and hematocrit indicates the client is in the recovery period. 3. Nausea, vomiting, and diarrhea are common in the client with ARF; therefore, an absence of these indicates the client is in the recovery period.

The client is diagnosed with ARF. Which signs/symptoms indicate to the nurse the client is in the recovery period? Select all that apply. 1. Increased alertness and no seizure activity. 2. Increase in hemoglobin and hematocrit. 3. Denial of nausea and vomiting. 4. Decreased urine-specific gravity. 5. Increased serum creatinine level.

1. The head of the client's bed should be elevated to help the lungs expand and prevent stasis of secretions that could lead to pneumonia, a complication of immobility.

The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as "high risk for immobility complications." Which intervention would be included in the plan of care? 1. Position the client with the head of the bed elevated at intervals. 2. Perform active range-of-motion exercises every four (4) hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them.

4. MRI scans are often done in a very confined space; many people who have claustrophobia must be medicated or even rescheduled for the procedure in an open MRI machine, which may be available if needed.

The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test? 1. "Do you have trouble hearing?" 2. "Are you allergic to any type of dairy products?" 3. "Have you eaten anything in the last eight (8) hours?" 4. "Are you uncomfortable in closed spaces?"

2. The nurse must always assess the client to determine if the chest pain that is occurring is expected postoperatively or if it is a complication of the surgery

The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with intravenous morphine. 2. Assess the client's chest dressing and vital signs. 3. Encourage the client to turn from side to side. 4. Check the client's telemetry monitor.

4. Safety is always an issue with a client with diminished mental capacity

The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority? 1. Altered nutrition, less than body requirements. 2. Anticipatory grieving. 3. Knowledge deficit, procedures and prognosis. 4. Risk for injury

3. Regular insulin peaks in 2 to 4 hours. Therefore, the nurse should think about the possibility the client is having a hypoglycemic reaction and should assess the client. The nurse should not delegate nursing tasks to a UAP if the client is unstable.

The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the unlicensed assistive personnel (UAP) tells the nurse the client has a headache and is really acting "funny." Which intervention should the nurse implement first? 1. Instruct the UAP to obtain the blood glucose level. 2. Have the client drink eight (8) ounces of orange juice. 3. Go to the client's room and assess the client for hypoglycemia. 4. Prepare to administer one (1) ampule 50% dextrose intravenously.

1. The nurse should place the client's chair with the head lower than the body, which will shunt blood to the brain; this is the Trendelenburg position.

The client receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first? 1. Place the client in the Trendelenburg position. 2. Turn off the dialysis machine immediately. 3. Bolus the client with 500 mL of normal saline. 4. Notify the health-care provider as soon as possible.

2. Cool water gives immediate and striking relief from pain and limits local tissue edema and damage.

The client sustained a hot grease burn to the right hand and calls the emergency room for advice. Which information should the nurse provide to the client? 1. Apply an ice pack to the right hand. 2. Place the hand in cool water. 3. Be sure to rupture any blister formation. 4. Go immediately to the doctor's office.

3. The primary phase of infection ranges from being asymptomatic to severe flu-like symptoms, but during this time, the test may be negative although the individual is infected with HIV

The client who has engaged in needle-sharing activities has developed a flu-like infection. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding? 1. The client is fortunate not to have contracted HIV from an infected needle. 2. The client must be repeatedly exposed to HIV before becoming infected. 3. The client may be in the primary infection phase of an HIV infection. 4. The antibody test is negative because the client has a different flu virus.

3. This is a basic layperson's terms explanation of ARDS and explains why the client is having trouble breathing.

The client who smokes two (2) packs of cigarettes a day develops ARDS after a near-drowning. The client asks the nurse, "What is happening to me? Why did I get this?" Which statement by the nurse is most appropriate? 1. "Most people who almost drown end up developing ARDS." 2. "Platelets and fluid enter the alveoli due to permeability instability." 3. "Your lungs are filling up with fluid, causing breathing problems." 4. "Smoking has caused your lungs to become weakened, so you got ARDS."

4. The ET tube should be secure to ensure it does not enter the right main bronchus. The ET tube should be one (1) inch above the bifurcation of the bronchi. TEST-TAKING HINT: Th

The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube care? 1. Do not move or touch the ET tube. 2. Obtain a chest x-ray daily. 3. Determine if the ET cuff is deflated. 4. Ensure that the ET tube is secure.

3. This is an acute emergency caused by exaggerated autonomic responses to stimuli and only occurs after spinal shock has resolved in the client with a spinal cord injury above T6. The most common cause is a full bladder.

The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement? 1. Keep the client flat in bed. 2. Dim the lights in the room. 3. Assess for bladder distention. 4. Administer a narcotic analgesic.

2. Reddened areas, especially under the brace, must be reported to the HCP because pressure ulcers can occur when wearing this appliance for an extended period.

The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client? 1. Discuss how to correctly remove the insertion pins. 2. Instruct the client to report reddened or irritated skin areas. 3. Inform the client that the vest liner cannot be changed. 4. Encourage the client to remain in the recliner as much as possible.

3. The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid, and the HCP should be notified immediately once this is determined.

The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? 1. Notify the health-care provider immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for presence of glucose. 4. Place 2 × 2 gauze under the nose to collect drainage

4. The client's legs should have pedal pulses and be warm to the touch, and the client must be able to move the toes.

The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Adequate peripheral circulation to both feet ensured.

2. Biguanide medication must be held for a test with contrast medium because it increases the risk of lactic acidosis, which leads to renal problems.

The client with type 2 diabetes controlled with biguanide oral diabetic medication is scheduled for a computed tomography (CT) scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? 1. Provide a high-fat diet 24 hours prior to test. 2. Hold the biguanide medication for 48 hours prior to test. 3. Obtain an informed consent form for the test. 4. Administer pancreatic enzymes prior to the test.

1. The most important issue to teach clients is to take insulin even if they are unable to eat. Glucose levels are increased with illness and stress. 2. The client should drink liquids such as regular cola or orange juice, or eat regular gelatin, which provide enough glucose to prevent hypoglycemia when receiving insulin. 5. The HCP should be notified if the blood glucose level is this high. Regular insulin may need to be prescribed to keep the blood glucose level within acceptable range.

The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? Select all that apply. 1. Take diabetic medication even if unable to eat the client's normal diabetic diet. 2. If unable to eat, drink liquids equal to the client's normal caloric intake. 3. It is not necessary to notify the health-care provider if ketones are in the urine. 4. Test blood glucose levels and test urine ketones once a day and keep a record. 5. Call the health-care provider if glucose levels are higher than 180 mg/dL.

1. The initial fluid replacement is 0.9% normal saline (an isotonic solution) intravenously, followed by 0.45% saline. The rate depends on the client's fluid volume status and physical health, especially of the heart.

The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care? 1. Infuse 0.9% normal saline intravenously. 2. Administer intermediate-acting insulin. 3. Perform blood glucometer checks daily. 4. Monitor arterial blood gas results.

3. The most common precipitating factor is infection. The manifestations may be slow to appear, with onset ranging from 24 hours to 2 weeks.

The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication? 1. "When is the last time you took your insulin?" 2. "When did you have your last meal?" 3. "Have you had some type of infection lately?" 4. "How long have you had diabetes?"

2. Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore, the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored.

The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? 1. Instruct the client to take a cough suppressant if a cough develops. 2. Teach the client how to prevent orthostatic hypotension. 3. Encourage the client to eat bananas to increase potassium level. 4. Explain the importance of taking the medication with food.

1. These arterial blood gases are within normal limits, and therefore the nurse should not take any action except to continue to monitor the client.

The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, PaO2 92, PaCO2 38, HCO3 24. Which action should the nurse implement? 1. Continue to monitor the client without taking any action. 2. Encourage the client to take deep breaths and cough. 3. Administer one (1) ampule of sodium bicarbonate IVP. 4. Notify the respiratory therapist of the ABG results.

1. Therapeutic communication addresses the client's feelings and attempts to allow the client to verbalize feelings; the nurse should be a therapeutic listener.

The home health nurse is caring for a 28-year-old client with a T10 SCI who says, "I can't do anything. Why am I so worthless?" Which statement by the nurse would be the most therapeutic? 1. "This must be very hard for you. You're feeling worthless?" 2. "You shouldn't feel worthless—you are still alive." 3. "Why do you feel worthless? You still have the use of your arms." 4. "If you attended a work rehab program you wouldn't feel worthless."

1. Age-related visual changes and diabetic retinopathy could cause the client to have difficulty in reading and drawing up insulin dosage accurately.

The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care? 1. Assess the client's ability to read small print. 2. Monitor the client's serum PT level. 3. Teach the client how to perform a hemoglobin A1c test daily. 4. Instruct the client to check the feet weekly.

1. An S3 indicates left ventricular failure and should be reported to the healthcare provider. It is a potential lifethreatening complication of a myocardial infarction.

The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement? 1. Notify the health-care provider immediately. 2. Elevate the head of the client's bed. 3. Document this as a normal and expected finding. 4. Administer morphine intravenously.

4. For the first two (2) weeks after an SCI above T7, the blood pressure tends to be unstable and low; slight elevations of the head of the bed can cause profound hypotension; therefore, the nurse should lower the head of the bed immediately

The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of lightheadedness and dizziness. The client's vital signs are T 99.2˚F, P 98, R 24, and BP 84/40. Which action should the nurse implement? 1. Notify the health-care provider ASAP. 2. Calm the client down by talking therapeutically. 3. Increase the IV rate by 50 mL/hour. 4. Lower the head of the bed immediately

1. Although this is a potential problem, it is priority because the body's protective barrier, the skin, has been compromised and there is an impaired immune response

The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority? 1. High risk for infection. 2. Ineffective coping. 3. Impaired physical mobility. 4. Knowledge deficit.

3. After the initial administration of erythropoietin, a client's antihypertensive medications may need to be adjusted. Therefore, this complaint requires notification of the HCP. Erythropoietin therapy is contraindicated in clients with uncontrolled hypertension.

The male client diagnosed with CKD has received the initial dose of erythropoietin, a biologic response modifier, 1 week ago. Which complaint by the client indicates the need to notify the health-care provider? 1. The client complains of flu-like symptoms. 2. The client complains of being tired all the time. 3. The client reports an elevation in his blood pressure. 4. The client reports discomfort in his legs and back.

2. Reflecting the client's feelings and restating them are therapeutic responses the nurse should use when addressing the client's issues.

The male client diagnosed with CKD secondary to diabetes has been receiving dialysis for 12 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for any more dialysis treatments. Which response by the nurse is most therapeutic? 1. "You cannot just quit your dialysis. This is not an option." 2. "Your angry at not being on the list, and you want to quit dialysis?" 3. "I will call your nephrologist right now so you can talk to the HCP." 4. "Make your funeral arrangements because you are going to die."

4. Fluid and electrolyte balance is the priority for a client with a severe burn. Fluid resuscitation must be maintained to keep a urine output of 30 mL/hr. Therefore, a 25-mL/hr output would warrant immediate intervention.

The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider? 1. The client is complaining of severe pain. 2. The client's pulse oximeter reading is 95%. 3. The client has T 100.4˚F, P 100, R 24, and BP 102/60. 4. The client's urinary output is 50 mL in two (2) hours.

1. Humulin N peaks in 6 to 8 hours, making the client at risk for hypoglycemia around midnight, which is why the client should receive a bedtime snack. This snack will prevent nighttime hypoglycemia

The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with type 1 diabetes at 1600. Which intervention should the nurse implement? 1. Ensure the client eats the bedtime snack. 2. Determine how much food the client ate at lunch. 3. Perform a glucometer reading at 0700. 4. Offer the client protein after administering insulin.

3. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.

The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places a hand under the client's right axilla to move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently

1. The UAP can collect specimens. Collecting a midstream urine specimen requires the client to clean the perineal area, to urinate a little, and then collect the rest of the urine output in a sterile container.

The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task is most appropriate for the nurse to delegate? 1. Collect a clean voided midstream urine specimen. 2. Evaluate the client's 8-hour intake and output. 3. Assist in checking a unit of blood prior to hanging. 4. Administer a cation-exchange resin enema.

4. The UAP can assist the x-ray technician in positioning the client for the portable x-ray. This does not require judgment.

The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? 1. Assist the client to go down to the smoking area for a cigarette. 2. Transport the client to the intensive care unit via a stretcher. 3. Provide the client going home discharge-teaching instructions. 4. Help position the client who is having a portable x-ray done.

1. The nurse should not delegate feeding a client who is at risk for complications during feeding. This requires judgment that the UAP is not expected to possess.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? 1. Feed the 69-year-old client diagnosed with Parkinson's disease who is having difficulty swallowing. 2. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson's disease. 3. Assist the 54-year-old client diagnosed with Parkinson's disease with toilet-training activities. 4. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson's disease.

2. Client advocacy focuses support on the client's autonomy. Even if the nurse disagrees with his living on the street, it is the client's right. Arranging for someone to give him his insulin provides for his needs and allows his choices

The nurse at a freestanding health care clinic is caring for a 56-year-old male client who is homeless and is a type 2 diabetic controlled with insulin. Which action is an example of client advocacy? 1. Ask the client if he has somewhere he can go and live. 2. Arrange for someone to give him insulin at a local homeless shelter. 3. Notify Adult Protective Services about the client's situation. 4. Ask the HCP to take the client off insulin because he is homeless.

4. Noncompliance is a choice the client has a right to make, but the nurse should determine the reason for the noncompliance and then take appropriate actions based on the client's rationale. For example, if the client has financial difficulties, the nurse may suggest how the client can afford the proper foods along with medications, or the nurse may be able to refer the client to a social worker.

The nurse caring for a client diagnosed with CKD writes a client problem of "noncompliance with dietary restrictions." Which intervention should be included in the plan of care? 1. Teach the client the proper diet to eat while undergoing dialysis. 2. Refer the client and significant other to the dietitian. 3. Explain the importance of eating the proper foods. 4. Determine the reason for the client not adhering to the diet.

4. The client's energy levels will not sustain eating for long periods. Offering frequent and easy-to-chew (soft) meals of small proportions is the preferred dietary plan.

The nurse caring for a client diagnosed with Parkinson's disease writes a problem of "impaired nutrition." Which nursing intervention would be included in the plan of care? 1. Consult the occupational therapist for adaptive appliances for eating. 2. Request a low-fat, low-sodium diet from the dietary department. 3. Provide three (3) meals per day that include nuts and whole-grain breads. 4. Offer six (6) meals per day with a soft consistency

1. The nurse should attempt to flush the skin and get the area to bleed. It is hoped this will remove contaminated blood from the body prior to infecting the nurse.

The nurse caring for a client who is HIV positive is stuck with the stylet used to start an IV. Which intervention should the nurse implement first? 1. Flush the skin with water and try to get the area to bleed. 2. Notify the charge nurse and complete an incident report. 3. Report to the employee health nurse for prophylactic medication. 4. Follow up with the infection control nurse to have lab work done.

4. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client's forehead.

The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the client's forehead. 2. Obtain a pulse oximetry reading. 3. Take the client's vital signs. 4. Assist the client to a sitting position.

4. Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome.

The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)-g sodium diet. 3. Weigh client daily. 4. Plan for frequent rest periods.

2. Excess fluid volume could be secondary to portal hypertension. Therefore, no increase in abdominal girth would be an appropriate short-term goal, indicating no excess of fluid volume.

The nurse identifies the client problem "excess fluid volume" for the client in liver failure. Which short-term goal would be most appropriate for this problem? 1. The client will not gain more than two (2) kg a day. 2. The client will have no increase in abdominal girth. 3. The client's vital signs will remain within normal limits. 4. The client will receive a low-sodium diet.

1. Oxygen is administered initially to prevent hypoxemia, which can worsen the spinal cord injury; therefore, the nurse should determine how much oxygen is reaching the periphery. 3. Breathing exercises are supervised by the nurse to increase the strength and endurance of inspiratory muscles, especially those of the diaphragm. 5. Corticosteroids are administered to decrease inflammation, which will decrease edema, and help prevent edema from ascending up the spinal cord, causing breathing difficulties.

The nurse in the neurointensive care unit is caring for a client with a new C6 SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply. 1. Monitor the pulse oximetry reading. 2. Provide pureed foods six (6) times a day. 3. Encourage coughing and deep breathing. 4. Assess for autonomic dysreflexia. 5. Administer intravenous corticosteroids.

4. The client's blood pressure is low, and a calcium channel blocker could cause the blood pressure to bottom out.

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication? 1. The client's apical pulse is 64. 2. The client's calcium level is elevated. 3. The client's telemetry shows occasional PVCs. 4. The client's blood pressure is 90/62.

4. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and some herbal remedies are nephrotoxic; therefore, asking about medications is appropriate.

The nurse is admitting a client diagnosed with acute renal failure (ARF). Which question is most important for the nurse to ask during the admission interview? 1. "Have you recently traveled outside the United States?" 2. "Did you recently begin a vigorous exercise program?" 3. "Is there a chance you have been exposed to a virus?" 4. "What over-the-counter medications do you take regularly?"

4. Masklike facies and a shuffling gait are two clinical manifestations of PD.

The nurse is admitting a client with the diagnosis of Parkinson's disease. Which assessment data support this diagnosis? 1. Crackles in the upper lung fields and jugular vein distention. 2. Muscle weakness in the upper extremities and ptosis. 3. Exaggerated arm swinging and scanning speech. 4. Masklike facies and a shuffling gait.

3. Sulfamylon is a strong carbonic anhydrase inhibitor that may reduce renal buffering and can cause metabolic acidosis. These ABGs indicate metabolic acidosis and therefore require immediate intervention.

The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse? 1. The client complains of pain when the medication is administered. 2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L. 3. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20. 4. The client is able to perform active range-of-motion exercises.

2. The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.

The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family

1. BNP is a specific diagnostic test. Levels higher than normal indicate congestive heart failure, with the higher the number, the more severe the CHF.

The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? 1. An elevated B-type natriuretic peptide (BNP). 2. An elevated creatine kinase (CK-MB). 3. A positive D-dimer. 4. A positive ventilation/perfusion (V/Q) scan.

3. Being able to perform activities of daily living (ADLs) without shortness of breath (dyspnea) would indicate the client's condition is improving. The client's heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs.

The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective? 1. The client's peripheral pitting edema has gone from 3+ to 4+. 2. The client is able to take the radial pulse accurately. 3. The client is able to perform ADLs without dyspnea. 4. The client has minimal jugular vein distention.

3. A necrotic big toe indicates "dead" tissue. The client does not feel pain, does not realize the injury, and does not seek treatment. Increased blood glucose levels decrease the oxygen supply needed to heal the wound and increase the risk for developing an infection.

The nurse is assessing the feet of a client with long-term type 2 diabetes. Which assessment data warrant immediate intervention by the nurse? 1. The client has crumbling toenails. 2. The client has athlete's foot. 3. The client has a necrotic big toe. 4. The client has thickened toenails.

2. Aspirin is an antiplatelet medication and should be administered orally. 3. Oxygen will help decrease myocardial ischemia, thereby decreasing pain.

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. 4. Place the client in a supine position. 5. Administer nitroglycerin subcutaneously

2. Stool softeners are initiated to prevent the Valsalva maneuver, which increases intracranial pressure. 3. Oxygen saturation higher than 93% ensures oxygenation of the brain tissues; decreasing oxygen levels increase cerebral edema 5. Mild sedatives will reduce the client's agitation; strong narcotics would not be administered because they decrease the client's level of consciousness

The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees of elevation. 2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93%. 4. Perform deep nasal suction every two (2) hours. 5. Administer mild sedatives

2. Hypotension, which causes a decreased blood supply to the kidney, is one of the most common causes of prerenal failure (before the kidney).

The nurse is caring for a client diagnosed with rule-out ARF. Which condition predisposes the client to developing prerenal failure? 1. Diabetes mellitus. 2. Hypotension. 3. Aminoglycosides. 4. Benign prostatic hypertrophy.

3. Ventricular fibrillation is the most common dysrhythmia associated with sudden cardiac death; ventricular fibrillation is responsible for 65% to 85% of sudden cardiac deaths

The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death? 1. The 84-year-old client exhibiting uncontrolled atrial fibrillation. 2. The 60-year-old client exhibiting asymptomatic sinus bradycardia. 3. The 53-year-old client exhibiting ventricular fibrillation. 4. The 65-year-old client exhibiting supraventricular tachycardia.

3. Body image is a concern for clients diagnosed with PD. This client is the one client who is not experiencing expected sequelae of the disease.

The nurse is caring for clients on a medical-surgical floor. Which client should be assessed first? 1. The 65-year-old client diagnosed with seizures who is complaining of a headache that is a "2" on a 1-to-10 scale. 2. The 24-year-old client diagnosed with a T10 spinal cord injury who cannot move his toes. 3. The 58-year-old client diagnosed with Parkinson's disease who is crying and worried about her facial appearance. 4. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis.

1. Altered level of consciousness is the earliest sign of hypoxemia.3. The 3.client is at risk for complications of immobility; therefore, the nurse should turn the client at least every two (2) hours to prevent pressure ulcers. 4. The client is at risk for fluid volume overload, so the nurse should monitor and maintain the fluid intake. 5. Fowler's position facilitates lung expansion and reduces the workload of breathing.

The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply. 1. Assess the client's level of consciousness. 2. Monitor urine output every shift. 3. Turn the client every two (2) hours. 4. Maintain intravenous fluids as ordered. 5. Place the client in the Fowler's position.

3. This is the correct scientific rationale for metabolic acidosis occurring in the client with CKD.

The nurse is caring for the client diagnosed with chronic kidney disease (CKD) who is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this client? 1. There is an increased excretion of phosphates and organic acids, which leads to an increase in arterial blood pH. 2. A shortened life span of red blood cells because of damage secondary to dialysis treatments in turn leads to metabolic acidosis. 3. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate. 4. An increase in nausea and vomiting causes a loss of hydrochloric acid and the respiratory system cannot compensate adequately.

3. The Glasgow Coma Scale is used to determine a client's response to stimuli (eye-opening response, best verbal response, and best motor response) secondary to a neurological problem; scores range from 3 (deep coma) to 15 (intact neurological function). A client with a score of 6 should be assessed first by the nurse.

The nurse is caring for the following clients. Which client would the nurse assess first after receiving the shift report? 1. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. 2. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. 3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. 4. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.

2. These are psychosocial manifestations of PD. These should be discussed in the support meeting.

The nurse is conducting a support group for clients diagnosed with Parkinson's disease and their significant others. Which information regarding psychosocial needs should be included in the discussion? 1. The client should discuss feelings about being placed on a ventilator. 2. The client may have rapid mood swings and become easily upset. 3. Pill-rolling tremors will become worse when the medication is wearing off. 4. The client may automatically start to repeat what another person says.

1. The short-term goal must address the response part of the nursing diagnosis, which is "high risk for hyperglycemia," and this blood glucose level is within acceptable ranges for a client who is noncompliant.

The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem "high risk for hyperglycemia related to noncompliance with the medication regimen." Which statement is an appropriate short-term goal for the client? 1. The client will have a blood glucose level between 90 and 140 mg/dL. 2. The client will demonstrate appropriate insulin injection technique. 3. The nurse will monitor the client's blood glucose levels four (4) times a day. 4. The client will maintain normal kidney function with 30-mL/hr urine output.

2. The client should not take digoxin if the radial pulse is less than 60. 3. The client should be on a low-sodium diet to prevent water retention.

The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply. 1. Notify health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table. 4. Encourage client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime.

2. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure which could be life threatening.

The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? The client will: 1. Be able to ambulate in the hall by date of discharge. 2. Have an audible S1 and S2 with no S3 heard by end of shift. 3. Turn, cough, and deep breathe every two (2) hours. 4. Have a pulse oximeter reading of 98% by day two (2) of care.

3. Renal failure causes an imbalance of electrolytes (potassium, sodium, calcium, phosphorus). Therefore, the desired client outcome is electrolytes within normal limits.

The nurse is developing a plan of care for a client diagnosed with ARF. Which statement is an appropriate outcome for the client? 1. Monitor intake and output every shift. 2. Decrease of pain by 3 levels on a 1-10 scale. 3. Electrolytes are within normal limits. 4. Administer enemas to decrease hyperkalemia.

2. Many in the African American culture believe the body must be kept intact after death, and organ donation is rare among African Americans. This is also why a client of African American descent will be on a transplant waiting list longer than people of other races. This is because of tissue-typing compatibility. Remember, this does not apply to all African-Americans; every client is an individual.

The nurse is discussing kidney transplants with clients at a dialysis center. Which population is less likely to participate in organ donation? 1. Caucasian. 2. African American. 3. Asian. 4. Hispanic.

4. All clients who exercise should perform warmup and cool-down exercises to help prevent muscle strain and injury.

The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes? 1. Eat a simple carbohydrate snack before exercising. 2. Carry peanut butter crackers when exercising. 3. Encourage the client to walk 20 minutes three (3) times a week. 4. Perform warmup and cool-down exercises.

3. Illness increases blood glucose levels; therefore, the client must take insulin and consume high-carbohydrate foods such as regular Jell-O, regular popsicles, and orange juice.

The nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client? 1. Refer the client to the American Diabetes Association. 2. Do not take any over-the-counter medications. 3. Take the prescribed insulin even when unable to eat because of illness. 4. Explain the need to get the annual flu and pneumonia vaccines.

4. The nurse should always assume that a client with traumatic head injury may have sustained spinal cord injury. Moving the client could further injure the spinal cord and cause paralysis; therefore, the nurse should stabilize the cervical spinal cord as best as possible prior to removing the client from the water.

The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first? 1. Assess the client's level of consciousness. 2. Organize onlookers to remove the client from the lake. 3. Perform a head-to-toe assessment to determine injuries. 4. Stabilize the client's cervical spine.

3. Unexpected death occurring within one (1) hour of the onset of cardiovascular symptoms is the definition of sudden cardiac death.

The nurse is teaching CPR to a class. Which statement best explains the definition of sudden cardiac death? 1. Cardiac death occurs after being removed from a mechanical ventilator. 2. Cardiac death is the time the HCP officially declares the client dead. 3. Cardiac death occurs within one (1) hour of the onset of cardiovascular symptoms. 4. The death is caused by myocardial ischemia resulting from coronary artery disease.

1. Flushed warm skin with tented turgor indicates dehydration. The HCP should be notified immediately for fluid orders or other orders to correct the reason for the dehydration.

The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first? 1. The client who has flushed, warm skin with tented turgor. 2. The client who states the staff ignores the call light. 3. The client whose vital signs are T 99.9˚F, P 101, R 26, and BP 110/68. 4. The client who is unable to provide a sputum specimen.

1. This client has signs/symptoms of a respiratory complication and should be assessed first.

The nurse on the rehabilitation unit is caring for the following clients. Which client should the nurse assess first after receiving the change-of-shift report? 1. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs. 2. The client with an L4 SCI who is crying and very upset about being discharged home. 3. The client with an L2 SCI who is complaining of a headache and feeling very hot. 4. The client with a T4 SCI who is unable to move the lower extremities.

1. An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. 2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine level.

3. Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of mechanical ventilation

Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator? 1. The client's urine output is 100 mL in four (4) hours. 2. The pulse oximeter reading is greater than 95%. 3. The client has asymmetrical chest expansion. 4. The telemetry reading shows sinus tachycardia.

1. The classic sign of ARDS is decreased arterial oxygen level (PaO2) while administering high levels of oxygen; the oxygen is unable to cross the alveolar membrane.

The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? 1. Low arterial oxygen when administering high concentration of oxygen. 2. The client has dyspnea and tachycardia and is feeling anxious. 3. Bilateral breath sounds clear and pulse oximeter reading is 95%. 4. The client has jugular vein distention and frothy sputum.

2. Daily cleaning reduces bacterial colonization.

The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds." Which intervention would be appropriate for this nursing diagnosis? 1. Provide analgesia before pain becomes severe. 2. Clean the client's wounds, body, and hair daily. 3. Screen visitors for respiratory infections. 4. Encourage visitors to bring plants and flowers

4. The chart is a legal document, and the code must be documented in the chart and provide information needed in the intensive care unit

The nursing administrator responds to a code situation. When assessing the situation, which role must the administrator ensure is performed for legal purposes and continuity of care of the client? 1. A person is ventilating with an Ambu bag. 2. A person is performing chest compressions correctly. 3. A person is administering medications as ordered. 4. A person is keeping an accurate record of the code.

2. Deep vein thrombosis (DVT) is a potential complication of immobility, which can occur because the client cannot move the lower extremities as a result of the L1 SCI. Low-dose anticoagulation therapy (Lovenox) helps prevent blood from coagulating, thereby preventing DVTs.

The rehabilitation nurse caring for the client with an L1 SCI is developing the nursing care plan. Which intervention should the nurse implement? 1. Keep oxygen via nasal cannula on at all times. 2. Administer low-dose subcutaneous anticoagulants. 3. Perform active lower extremity ROM exercises. 4. Refer to a speech therapist for ventilator-assisted speech.

2. These signs/symptoms—weak pulse, shallow respirations, cool pale skin— indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention.

The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with Steri-Strips. Which signs/ symptoms would warrant transferring the resident to the emergency department? 1. A 4-cm area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. Pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that resolves with medication.

4. Abstinence is the only guarantee the client will not contract a sexually transmitted disease, including AIDS. An individual who is HIV negative in a monogamous relationship with another individual who is HIV negative and committed to a monogamous relationship is the safest sexual relationship.

The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included? 1. Females taking birth control pills are protected from becoming infected with HIV. 2. Protected sex is no longer an issue because there is a vaccine for the HIV virus. 3. Adolescents with a normal immune system are not at risk for developing AIDS. 4. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.

1. The opposite side rail should be elevated so the client will not fall out of the bed. Safety is priority, the nurse should demonstrate the proper way to bathe a client in the bed.

The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement? 1. Demonstrate the correct technique for giving a bed bath. 2. Encourage the UAP to put the bed in the lowest position. 3. Instruct the UAP to get another person to help with the bath. 4. Provide praise for performing the bath safely for the client and the UAP.

3. The sternum should be depressed one and one-half (1.5) to two (2) inches during compressions to ensure adequate circulation of blood to the body; therefore, the nurse needs to correct the UAP.

The unlicensed assistive personnel (UAP) is performing cardiac compressions on an adult client during a code. Which behavior warrants immediate intervention by the nurse? 1. The UAP has hand placement on the lower half of the sternum. 2. The UAP performs cardiac compressions and allows for rescue breathing. 3. The UAP depresses the sternum 0.5 to one (1) inch during compressions. 4. The UAP asks to be relieved from performing compressions because of exhaustion.

3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma.

4. This ABG indicates metabolic acidosis, which is expected in a client diagnosed with diabetic ketoacidosis.

Which arterial blood gas results should the nurse expect in the client diagnosed with diabetic ketoacidosis? 1. pH 7.34, PaO2 99, PaCO2 48, HCO3 24. 2. pH 7.38, PaO2 95, PaCO2 40, HCO3 22. 3. pH 7.46, PaO2 85, PaCO2 30, HCO3 26. 4. pH 7.30, PaO2 90, PaCO2 30, HCO3 18.

2. The client's level of consciousness can be altered because of dehydration and acidosis. If the client's sensorium is intact, the client is getting better and responding to the medical treatment

Which assessment data indicate the client diagnosed with diabetic ketoacidosis is responding to the medical treatment? 1. The client has tented skin turgor and dry mucous membranes. 2. The client is alert and oriented to date, time, and place. 3. The client's ABG results are pH 7.29, PaCO2 44, HCO3 15. 4. The client's serum potassium level is 3.3 mEq/L.

3. The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol.

Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis? 1. "How many years have you been drinking alcohol?" 2. "Have you completed an advance directive?" 3. "When did you have your last alcoholic drink?" 4. "What foods did you eat at your last meal?"

3. Troponin is the enzyme that elevates within 1 to 2 hours.

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction? 1. Creatine kinase (CK-MB). 2. Lactate dehydrogenase (LDH). 3. Troponin. 4. White blood cells (WBCs).

1. African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cultural groups.

Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.

2. The client in DKA loses potassium from increased urinary output, acidosis, catabolic state, and vomiting. Replacement is essential for preventing cardiac dysrhythmias secondary to hypokalemia

Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with DKA who has just been admitted to the ICU? 1. Glucose. 2. Potassium. 3. Calcium. 4. Sodium.

2. The crash cart is the mobile unit with the defibrillator and all the medications and supplies needed to conduct a code.

Which equipment must be immediately brought to the client's bedside when a code is called for a client who has experienced a cardiac arrest? 1. A ventilator. 2. A crash cart. 3. A gurney. 4. Portable oxygen.

3. Clay-colored stools and hemorrhoids are gastrointestinal effects of liver failure

Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure? 1. Hypoalbuminemia and muscle wasting. 2. Oligomenorrhea and decreased body hair. 3. Clay-colored stools and hemorrhoids. 4. Dyspnea and caput medusae.

1. The chaplain should be called to help address the client's family or significant others. A small community hospital does not have a 24-hour on-duty pastoral service. A chaplain is part of the code team in large medical center hospitals.

Which health-care team member referral should be made by the nurse when a code is being conducted on a client in a community hospital? 1. The hospital chaplain. 2. The social worker. 3. The respiratory therapist. 4. The director of nurses.

1. Not smoking is vital to prevent further lung damage

Which instruction is priority for the nurse to discuss with the client diagnosed with ARDS who is being discharged from the hospital? 1. Avoid smoking and exposure to smoke. 2. Do not receive flu or pneumonia vaccines. 3. Avoid any type of alcohol intake. 4. It will take about one (1) month to recuperate.

3. This is the most important intervention. The nurse should always treat the client based on the nurse's assessment and data from the monitors; an intervention should not be based on data from the monitors without the nurse's assessment.

Which intervention is most important for the nurse to implement when participating in a code? 1. Elevate the arm after administering medication. 2. Maintain sterile technique throughout the code. 3. Treat the client's signs/symptoms; do not treat the monitor. 4. Provide accurate documentation of what happened during the code.

4. Nurses should protect themselves against possible communicable disease, such as HIV and hepatitis, and should be protected if the client vomits during CPR.

Which intervention is the most important for the nurse to implement when performing mouth-to-mouth resuscitation on a client who has pulseless ventricular fibrillation? 1. Perform the jaw thrust maneuver to open the airway. 2. Use the mouth to cover the client's mouth and nose. 3. Insert an oral airway prior to performing mouth-to-mouth. 4. Use a pocket mouth shield to cover client's mouth.

2. Surfactant therapy may be prescribed to reduce the surface tension in the alveoli. The surfactant helps maintain open alveoli, decreases the work of breathing, improves compliance, and helps prevent atelectasis.

Which medication should the nurse anticipate the health-care provider ordering for the client diagnosed with ARDS? 1. An aminoglycoside antibiotic. 2. A synthetic surfactant. 3. A potassium cation. 4. A nonsteroidal anti-inflammatory drug.

1. Hand washing is the number-one intervention used to prevent infection, which is priority for the client with a burn. 2. Aseptic techniques minimize risk of crosscontamination and spread of bacteria. 3. Aseptic techniques minimize risk of crosscontamination and spread of bacteria. 5. Antibiotics reduce bacteria.

Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply. 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 4. Change invasive lines once a week. 5. Administer antibiotics as prescribed.

1. Gastric distention occurs from overventilating clients. When compressions are performed, the pressure will cause vomiting which may cause aspiration into the lungs.

Which statement explains the scientific rationale for having emergency suction equipment available during resuscitation efforts? 1. Gastric distention can occur as a result of ventilation. 2. It is needed to assist when intubating the client. 3. This equipment will ensure a patent airway. 4. It keeps the vomitus away from the health-care provider