Final SATA

ANS: A, C, D, E Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.

2. The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking

660 mL A low tidal volume of 6 mL/kg is used to prevent lung injury. 242 pounds = 110 kg. 110 kg × 6 mL/kg = 660 mL.

A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) ___ mL

ANS: 60 mg The dose of t-PA is 0.9 mg/kg with a maximum dose of 90 mg. The client weighs 66.4 kg. 0.9 mg ´ 66.4 = 59.76 mg, which rounds to 60 mg.

1. A client in the emergency department is having a stroke and the provider has prescribed the tissue plasminogen activator (t-PA) alteplase (Activase). The client weighs 146 pounds. How much medication will this client receive? (Record your answer using a whole number.) _____ mg

ANS: A, C, D An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM.

1. A nursing student studying the neurologic system learns which information? (Select all that apply.) a. An aneurysm is a ballooning in a weakened part of an arterial wall. b. An arteriovenous malformation is the usual cause of strokes. c. Intracerebral hemorrhage is bleeding directly into the brain. d. Reduced perfusion from vasospasm often makes stroke worse. e. Subarachnoid hemorrhage is caused by high blood pressure.

ANS: A, B, D There are many nonpharmacologic means for controlling the symptoms of fibromyalgia, including acupuncture, stretching, tai chi, low-impact aerobics, swimming, biking, strengthening, massage, stress management, and hypnosis. Dietary supplements and vigorous aerobics are not recommended.

A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? (Select all that apply.) a. Acupuncture b. Stretching c. Supplements d. Tai chi e. Vigorous aerobics

A. Maintain IV fluids, and monitor for fluid imbalance. B. Assess for signs and symptoms of deep vein thrombosis. E. Check finger-stick blood glucose levels regularly. Rationale It is important to maintain available access for TPN and fluids. Care should be taken to prevent any line sepsis. Clients are at risk for DVT after any surgical procedure in which extended immobility is a problem. The nurse should monitor for hypoglycemia or hyperglycemia due to surgical manipulation of the pancreas. An NG tube will be attached to low suction to prevent distention and pressure on the remaining stomach. PERT will be started when the client is able to take solid meals. The client should be placed in a semi-Fowler's position to reduce stress on the anastomosis and suture line. This position will also aid in lung expansion.

A client has had an open Whipple procedure for pancreatic cancer. Which nursing interventions are appropriate for this client in the postoperative period? Select all that apply. A. Maintain IV fluids, and monitor for fluid imbalance. B. Assess for signs and symptoms of deep vein thrombosis. C. Connect the nasogastric tube to high intermittent suction. D. Start pancreatic enzyme replacements as soon as possible. E. Check finger-stick blood glucose levels regularly.

ANS: A, B, D Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence.

A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort

ANS: 66 mm Hg MAP= 98+(2x50)/3=66

A client in the intensive care unit with acute kidney injury (AKI) must maintain a mean arterial pressure (MAP) of 65 mm Hg to promote kidney perfusion. What is the client's MAP if the blood pressure is 98/50 mm Hg? (Record your answer using a whole number.) _____ mm Hg

ANS: A, C, E Many clients with AKI are too ill to meet caloric goals and require tube feedings with kidney-specific formulas that are lower in sodium, potassium, and phosphorus, and higher in calories than are standard formulas.

A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client's spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.) a. Lower sodium b. Higher calcium c. Lower potassium d. Higher phosphorus e. Higher calories

ANS: A, D, E The student can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. The client should be NPO at this point, so hot tea is prohibited. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the client's painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance

ANS: A, B, D Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Modest decreases in blood pressure, as is the case with this client, can be maintained with rate adjustment, Trendelenburg positioning, and a fluid bolus. If the blood pressure drops considerably after two boluses and cooling dialysate, the hemodialysis can be stopped and the health care provider contacted.

A client is undergoing hemodialysis. The client's blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.) a. Adjust the rate of extracorporeal blood flow. b. Place the client in the Trendelenburg position. c. Stop the hemodialysis treatment. d. Administer a 250-mL bolus of normal saline. e. Contact the health care provider for orders.

ANS: A, B, D PD is based on exchanges of waste, fluid, and electrolytes in the peritoneal cavity. There is no need for vascular access. Protein is lost in the exchange, which allows for more protein and fluid in the diet. There is flexibility in the time for exchanges, but the treatment takes a longer period of time compared to hemodialysis. There still is risk for infection with PD, especially peritonitis.

A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? (Select all that apply.) a. "You will not need vascular access to perform PD." b. "There is less restriction of protein and fluids." c. "You will have no risk for infection with PD." d. "You have flexible scheduling for the exchanges." e. "It takes less time than hemodialysis treatments."

a, b, c, e Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the client's anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

Correct Responses 167 drops/min 20 gtt × 500 mL = 10,000/60 min = 167 drops/min

A client with acute kidney injury is receiving a fluid challenge of 500 mL of normal saline over 1 hour. With a drop factor of 20 drops/mL, how many drops per minute does the nurse infuse? _________

ANS: A, B, C, D Clients with fibromyalgia often have sleep disturbances, which can be exacerbated by the stress, noise, and unfamiliar environment of the hospital. Allowing uninterrupted rest time, adhering to the client's usual bedtime routine as much as possible, limiting noise and light, and offering massages or warm showers can help. The client does not need a strong sleeping pill unless all other options fail and the client requests something for sleep. At that point a mild sleeping agent can be tried.

A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.) a. Allow the client uninterrupted rest time. b. Assess the client's usual bedtime routine. c. Limit environmental noise as much as possible. d. Offer a massage or warm shower at night. e. Request an order for a strong sleeping pill.

ANS: A, B, D, E Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees.

A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.

ANS: A, C, D Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

ANS: B, C Tracheal deviation and sudden onset of shortness of breath are manifestations of a tension pneumothorax. The nurse must intervene immediately for this emergency situation. Pink sputum is associated with pulmonary edema and is not a complication of a chest tube. Pain at the insertion site and drainage of 75 mL/hr are normal findings with a chest tube.

A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) a.Production of pink sputum b.Tracheal deviation c.Sudden onset of shortness of breath d.Pain at insertion site e.Drainage of 75 mL/hr

ANS: B, E, F Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the client's confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.

A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially causing complications of this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)

ANS: B, C, E b. Night sweats c. Cardiac murmur e. Osler's nodes

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.) a. Weight gain b. Night sweats c. Cardiac murmur d. Abdominal bloating e. Osler's nodes

B, D, E

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor

ANS: B, C, D, E Myocardial infarction (chest pain), pulmonary embolism (shortness of breath), adynamic ileus (lack of bowel sounds or flatus), and renal failure (urine output of 20 mL/6 hr) are just some of the complications for which the nurse must assess the client after the Whipple procedure. Clay-colored stools are associated with cholecystitis and are not a complication of a Whipple procedure.

A nurse assesses a client who is recovering from a Whipple procedure. Which clinical manifestations alert the nurse to a complication from this procedure? (Select all that apply.) a. Clay-colored stools b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr

ANS: A, C, D, F Information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

ANS: A, B, E The nurse should urgently communicate changes in a client's neurologic status, including a decrease in the Glasgow Coma Scale score, abnormal flexion or extension, changes in cognition or speech, and pinpointed, dilated, and nonreactive pupils.

A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Glasgow Coma Scale score of 8 b. Decerebrate posturing c. Reactive pupils d. Uninhibited speech e. Diminished cognition

ANS: B, D, E Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not associated with damage to the medulla.

A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Loss of smell b. Impaired swallowing c. Visual changes d. Inability to shrug shoulders e. Loss of gag reflex

ANS: B, E Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception of pain, and altered balance and/or decreased coordination.

A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.) a. Long-term memory loss b. Slower processing time c. Increased sensory perception d. Decreased risk for infection e. Change in sleep patterns

ANS: A, D, E, F Risk factors for type 2 diabetes include certain ethnic/racial groups (African Americans, American Indians, Hispanics), obesity and physical inactivity, and giving birth to large babies. Pancreatic trauma and a 30-pound gestational weight gain are not risk factors.

A nurse assesses clients at a health fair. Which clients should the nurse counsel to be tested for diabetes? (Select all that apply.) a. 56-year-old African-American male b. Female with a 30-pound weight gain during pregnancy c. Male with a history of pancreatic trauma d. 48-year-old woman with a sedentary lifestyle e. Male with a body mass index greater than 25 kg/m2 f. 28-year-old female who gave birth to a baby weighing 9.2 pounds

ANS: A, B, D a. A 36-year-old woman with systemic lupus erythematosus (SLE) b. A 42-year-old man recovering from coronary artery bypass graft surgery d. An 80-year-old man with a bacterial infection of the respiratory tract

A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.) a. A 36-year-old woman with systemic lupus erythematosus (SLE) b. A 42-year-old man recovering from coronary artery bypass graft surgery c. A 59-year-old woman recovering from a hysterectomy d. An 80-year-old man with a bacterial infection of the respiratory tract e. An 88-year-old woman with a stage III sacral ulcer

ANS: A, B Clients who are experiencing biliary colic may present with tachycardia, pallor, diaphoresis, prostration, or other signs of shock. The nurse should stay with the client, lower the client's head, and contact the provider or Rapid Response Team for immediate assistance. Treatment for shock usually includes intravenous fluids; therefore, decreasing fluids would be an incorrect intervention. The client's tachycardia is a result of shock, not pain. Performing the vagal maneuver or administering opioids could knock out the client's compensation mechanism.

A nurse cares for a client who presents with tachycardia and prostration related to biliary colic. Which actions should the nurse take? (Select all that apply.) a. Contact the provider immediately. b. Lower the head of the bed. c. Decrease intravenous fluids. d. Ask the client to bear down. e. Administer prescribed opioids.

ANS: B, D, F For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client that includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. If the client becomes impacted, the nurse would need to perform manual disimpaction. Pouring warm water over the perineum, administering daily enemas, and massaging the abdomen would not assist this client.

A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's constipation? (Select all that apply.) a. Pour warm water over the perineum. b. Provide a diet high in fluids and fiber. c. Administer daily tap water enemas. d. Implement a consistent daily time for elimination. e. Massage the abdomen from left to right. f. Perform manual disimpaction.

ANS: A, B, C Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a.Administer analgesics. b.Prevent wound infections. c.Provide fluid replacement. d.Decrease core temperature. e.Initiate physical therapy.

ANS: A, B, E Nonpharmacologic comfort measures for clients with burn injuries include music therapy, tactile stimulation, massaging unburned areas, warm compresses, and increasing client control.

A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a.Music as a distraction b.Tactile stimulation c.Massage to injury sites d.Cold compresses e Increasing client control

ANS: B, C, D The client should be placed in a private room and dirty linens kept in the client's room until the radiation source is removed. The nurse should wear a lead apron while providing care, ensuring that the apron always faces the client. The nurse should also bundle care to minimize exposure to the client. Transmission-Based Precautions will not protect the nurse from the implanted radioactive iodine seeds.

A nurse cares for a client with pancreatic cancer who is prescribed implanted radioactive iodine seeds. Which actions should the nurse take when caring for this client? (Select all that apply.) a. Dispose of dirty linen in a red "biohazard" bag. b. Place the client in a private room. c. Wear a lead apron when providing client care. d. Bundle care to minimize exposure to the client. e. Initiate Transmission-Based Precautions.

ANS: A, C, D Slower healing time will place the older adult client at risk for loss of function from contracture formation due to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response, including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure.

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a.Slower healing time - Increased risk for loss of function from contracture formation b.Reduced inflammatory response - Deep partial-thickness wound with minimal exposure c.Reduced thoracic compliance - Increased risk for atelectasis d.High incidence of cardiac impairments - Increased risk for acute kidney injury e.Thinner skin - May not exhibit a fever when infection is present

ANS: B, C, D During the healing phase of pancreatitis, the client should be provided small, frequent, moderate- to high-carbohydrate, high-protein, low-fat meals. Protein shakes can be provided to supplement the diet. Foods and beverages should not contain caffeine and should be bland.

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.) a. "Do not allow the client to eat between meals." b. "Make sure the client receives a protein shake." c. "Do not allow caffeine-containing beverages." d. "Make sure the foods are bland with little spice." e. "Do not allow high-carbohydrate food tems."

ANS: A, C, D Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush should be used to prevent gum bleeding, and the client's nails should be trimmed short to prevent the client from scratching himself or herself. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap.

A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.) a. "Apply lotion to the client's dry skin areas." b. "Use a basin with warm water to bathe the client." c. "For the client's oral care, use a soft toothbrush." d. "Provide clippers so the client can trim the fingernails." e. "Bathe with antibacterial and water-based soaps."

ANS: A, B, E, F a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L e. Proteinuria f. Microalbuminuria

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply.) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L c. Serum potassium: 4.0 mEq/L d. Serum creatinine: 1.0 mg/dL e. Proteinuria f. Microalbuminuria

b, d, e Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur

ANS: B, C, D, E In discharge teaching, the nurse must emphasize that the client needs to have an antibiotic prophylactically before dental procedures to prevent infection. There may be a need for dose reduction in medications if the kidney is not excreting them properly (antacids with magnesium, antibiotics, antidiabetic drugs, insulin, opioids, and anticoagulants).

A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "I can continue to take antacids to relieve heartburn." b. "I need to ask for an antibiotic when scheduling a dental appointment." c. "I'll need to check my blood sugar often to prevent hypoglycemia." d. "The dose of my pain medication may have to be adjusted." e. "I should watch for bleeding when taking my anticoagulants."

ANS: A, B, D A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

ANS: A, B, E A special halo wrench should be taped to the client's vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the client's chest and back for skin breakdown from the halo vest.

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Tape a halo wrench to the client's vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the client's oral fluid intake. e. Assess the chest and back for skin breakdown.

ANS: A, C, D, E A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes.

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this client's plan of care to ensure adequate nutrition? (Select all that apply.) a.Provide at least 5000 kcal/day. b.Start an oral diet on the first day. c.Administer a diet high in protein. d.Collaborate with a registered dietitian. e.Offer frequent high-calorie snacks.

ANS: B, D, F The client should be advised to stay sober, and AA is a great resource. The client requires a low-fat diet, and cooking spray is low in fat compared with butter or margarine. If the client smokes, he or she must stop because nicotine can precipitate an exacerbation. A nicotine patch may help the client quit smoking. The client must rest until his or her strength returns. The client requires high carbohydrates and calories for healing; complex carbohydrates are not preferred over simple ones. Dairy products do not cause a problem.

A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Take a 20-minute walk at least 5 days each week." b. "Attend local Alcoholics Anonymous (AA) meetings weekly." c. "Choose whole grains rather than foods with simple sugars." d. "Use cooking spray when you cook rather than margarine or butter." e. "Stay away from milk and dairy products that contain lactose." f. "We can talk to your doctor about a prescription for nicotine patches."

ANS: A, B, E The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

ANS: B, C, D, E Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Stress

ANS: A, B, D, E The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion.

A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause

ANS: A, B, E Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor, some motor and sensory deficits may remain. Spinal tumors usually cause disability but are not usually fatal. Radiation therapy is often used to shrink spinal tumors but can cause progressive spinal cord degeneration and neurologic deficits. The client should be turned every 2 hours to prevent skin breakdown and arrangements should be made at home so that the client can complete activities of daily living without needing to go up and down stairs.

After teaching a client with a spinal cord tumor, the nurse assesses the client's understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "Even though turning hurts, I will remind you to turn me every 2 hours." b. "Radiation therapy can shrink the tumor but also can cause more problems." c. "Surgery will be scheduled to remove the tumor and reverse my symptoms." d. "I put my affairs in order because this type of cancer is almost always fatal." e. "My family is moving my bedroom downstairs for when I am discharged home."

ANS: B, D Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, diaphoresis, cool and clammy skin, and confusion.

An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.) a. Hypertension b. Tachycardia c. Flushed skin d. Confusion e. Shallow respirations

B, C, E

An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath

333 drops/min 1000 mL divided by 90 minutes, then multiplied by 30 drops, equals 333 drops/min.

An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) ____ drops/min

A C D Breakdown of protein leads to azotemia and increased blood urea nitrogen. Fluid is restricted during the oliguric stage. Potassium intoxication may occur, so dietary potassium is also restricted. Sodium is restricted during AKI because oliguria causes fluid retention. Fats may be used for needed calories when proteins are restricted.

The nurse assists a client with acute kidney injury (AKI) to modify the diet in which ways? (Select all that apply.) A) Restricted protein B) Liberal sodium C) Restricted fluids D) Low potassium E) Low fat

ANS: A, C, D, E Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

a, b, d Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of chest wall, decreased muscle strength, and less elasticity of lung tissue.

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing

a, b, c, d The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule

ANS: A, B, C, D Immobility, decreased thirst response, diminished immune response, and malnutrition can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor for shock.

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration

ANS: A, B, E Within the first 3 hours of suspecting severe sepsis, the nurse should draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the cultures have been obtained). Infusing vasopressors and measuring central venous pressure are actions that should occur within the first 6 hours.

The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures.

ANS: C, D, E The client with SSc should avoid cold temperatures, which may lead to vasospasms and Raynaud's phenomenon. The UAP can adjust the room temperature for the client's comfort. Keeping the sheets off the feet will help prevent injury; the UAP can apply a foot cradle to the bed to hold the sheets up. Because of esophageal problems, the client should remain in an upright position for 1 to 2 hours after meals. The UAP can remind the client of this once he or she has been taught. The other actions are performed by the registered nurse.

The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Collaborate with a registered dietitian for appropriate foods. b. Inspect the skin and note any areas of ulceration. c. Keep the room at a comfortably warm temperature. d. Place a foot cradle at the end of the bed to lift sheets. e. Remind the client to elevate the head of the bed after eating.

ANS: A, B, C Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes post-renal AKI. Severe burns would be a pre-renal cause. Lupus would be an intrarenal cause for AKI.

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.) a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis d. Firefighter with severe burns e. Young woman with lupus

ANS: B, D, E Weight should be maintained at a body mass index (BMI) of 22 to 25. A BMI of 30 indicates obesity. The use of nonsteroidal anti-inflammatory drugs such as aspirin should be limited to the lowest time at the lowest dose due to interference with kidney blood flow. The client should drink at least 2 liters of water daily. Diet adjustments should be made by restricting sodium, cholesterol, and protein. Smoking causes constriction of blood vessels and decreases kidney perfusion, so the client should stop smoking.

The nurse is teaching a client with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.) a. "I need to decrease sodium, cholesterol, and protein in my diet." b. "My weight should be maintained at a body mass index of 30." c. "Smoking should be stopped as soon as I possibly can." d. "I can continue to take an aspirin every 4 to 8 hours for my pain." e. "I really only need to drink a couple of glasses of water each day."

ANS: A, B, E A dry, scaly skin rash is the most frequent dermatologic manifestation of SLE. Systemic sclerosis can lead to esophageal motility problems. Vasculitis leads to organ damage in rheumatoid arthritis. Gout is caused by hyperuricemia; the production of uric acid exceeds the excretion capability of the kidneys. Footdrop and paresthesias occur in rheumatoid arthritis.

The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired with their manifestations? (Select all that apply.) a. Dry, scaly skin rash - Systemic lupus erythematosus (SLE) b. Esophageal dysmotility - Systemic sclerosis c. Excess uric acid excretion - Gout d. Footdrop and paresthesias - Osteoarthritis e. Vasculitis causing organ damage - Rheumatoid arthritis

ANS: B, C, E Late manifestations of RA include Felty's syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.

The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.) a. Anorexia b. Felty's syndrome c. Joint deformity d. Low-grade fever e. Weight loss

B C E A bruit or swishing sound, and a thrill or buzzing sensation upon palpation should be present in this client, indicating patency of the fistula. No blood pressure, venipuncture, or compression, such as lying on the fistula, should occur. Distal pulses and capillary refill should be checked, and for a forearm fistula, the radial pulse is checked—the brachial pulse is proximal. Elevating the arm increases venous return, possibly collapsing the fistula.

When caring for a client with a left forearm arteriovenous fistula created for hemodialysis, which actions must the nurse take? (Select all that apply.) A) Check brachial pulses daily. B) Auscultate for a bruit every 8 hours. C) Teach the client to palpate for a thrill over the site. D) Elevate the arm above heart level. E) Ensure that no blood pressures are taken in that arm.

B D E Signs and symptoms of fluid retention (e.g., crackles in the lung fields and 3+ edema of the lower extremities) indicate transplant rejection. Increased blood pressure is also a symptom of transplant rejection. Increasing BUN and creatinine are symptoms of rejection; a BUN of 21 mg/dL and a creatinine of 0.9 mg/dL reflect normal values. Fever, not normothermia, is symptomatic of transplant rejection.

Which signs and symptoms indicate rejection of a transplanted kidney? (Select all that apply.) A) Blood urea nitrogen (BUN) 21 mg/dL, creatinine 0.9 mg/dL B) Crackles in the lung fields C) Temperature of 98.8° F (37.1° C) D) Blood pressure of 164/98 mm Hg E) 3+ edema of the lower extremities

ANS: A, B, C, D All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated.

9. A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the client's care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement.

ANS: A, B, E a. Pulmonary crackles b. Confusion, restlessness e. Cough that worsens at night

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night

ANS: A, C, D, F Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags.

1. Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

ANS: A, B After a coil procedure, up to 20% of clients experience re-bleeding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding.

10. A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.) a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence c. Client who had a coil procedure who says that there will be no problem following up for 1 year d. Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipation e. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise

ANS: B, D, E Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.

11. A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home

ANS: 1.4 mL/hr The client weighs 102 kg. The dose of t-PA is 0.9 mg/kg with a maximum of 90 mg, so the client's dose is 90 mg. 10% of the dose is given as a bolus IV over the first minute (9 mg). That leaves 81 mg to run in over 59 minutes. , which rounds to 1.4 mL/hr.

2. A client in the emergency department is having a stroke. The client weighs 225 pounds. After the initial bolus of t-Pa, at what rate should the nurse set the IV pump? (Record your answer using a decimal rounded to the nearest tenth.) ____ mL/hr

ANS: A, D Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that should be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full-thickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag

2. A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag

ANS: B, E The client with the femur fracture could be transferred to a rehabilitation facility, and the client on the medical unit for wound care should be transferred home with home health or to a long-term care facility for ongoing wound care. The client in the medical decision unit should be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. The infant does not have a definitive diagnosis.

3. A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care

ANS: B, E The UAP can take and document vital signs, including oxygen saturation, and keep the client's head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.

3. A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.

ANS: B, D The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients.

4. A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.) a. Paramedic - Decides the number, acuity, and resource needs of clients b. Hospital incident commander - Assumes overall leadership for implementing the emergency plan c. Public information officer - Provides advanced life support during transportation to the hospital d. Triage officer - Rapidly evaluates each client to determine priorities for treatment e. Medical command physician - Serves as a liaison between the health care facility and the media

ANS: A, D, E Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism. The client must be assessed for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures.

4. A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.) a. Discharging the client on a statin medication b. Providing the client with comprehensive therapies c. Meeting goals for nutrition within 1 week d. Providing and charting stroke education e. Preventing venous thromboembolism

ANS: A, D, E "Mild TBI" is a term used synonymously with the term "concussion." A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8.

5. A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms "mild TBI" and "concussion" have similar meanings.

ANS: A, C, D Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups.

6. A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age group.

ANS: 142 mL/hr The client weighs 250 pounds = 113.63636 kg. The fluid requirement for this client is 30 mL/kg = 3409 mL. To infuse this amount over 24 hours, set the pump at 142 mL/hr (3409/24 = 142).

A client with severe sepsis has a serum lactate level of 6.2 mmol/L. The client weighs 250 pounds. To infuse the amount of fluid this client requires in 24 hours, at what rate does the nurse set the IV pump? (Record your answer using a whole number.) ____ mL/hr

ANS: A, B, C, D The client with meningitis often has high fever, pain, and some degree of confusion. Cool washcloths to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manage pain. Keeping voices low and lights dimmed also helps convey caring in a nonthreatening manner. The nurse provides antipyretics for fever.

7. A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying a cool washcloth to the head b. Assisting the client to a position of comfort c. Keeping voices soft and soothing d. Maintaining low lighting in the room e. Providing antipyretics for fever

ANS: A, B, D, E Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and a slight limp would be a low priority for this referral.

8. A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.) a. Client who exhibits extreme emotional lability b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Client with mild forgetfulness and a slight limp d. Client who has a past hospitalization for a suicide attempt e. Client who is unable to walk or eat 3 weeks post-stroke

B, D, E Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax; sudden shortness of breath because this could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax; or drainage greater than 70 mL/hr because this could indicate hemorrhage. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention.

A client has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Oxygen saturation greater than 95% d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Pain at insertion site

ANS: D, E The HLA-B27 is diagnostic for Reiter's syndrome or ankylosing spondylitis. A positive rheumatoid factor can be seen in autoimmune CTDs, kidney and liver disease, or leukemia. An elevated ANA is indicative of inflammatory CTDs, although a small minority of healthy adults also have this finding. An elevated sedimentation rate indicates inflammation, whether from an infection, an injury, or an autoimmune CTD. Lowered albumin is seen in nutritional deficiencies but also in chronic infection or inflammation.

A client has a possible connective tissue disease and the nurse is reviewing the client's laboratory values. Which laboratory values and their related connective tissue diseases (CTDs) are correctly matched? (Select all that apply.) a. Elevated antinuclear antibody (ANA) - Normal value; no connective tissue disease b. Elevated sedimentation rate - Rheumatoid arthritis c. Lowered albumin - Indicative only of nutritional deficit d. Positive human leukocyte antigen B27 (HLA-B27) - Reiter's syndrome or ankylosing spondylitis e. Positive rheumatoid factor - Possible kidney disease

ANS: B, D, E Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures.

A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.

ANS: A, B, C a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension

ANS: C, D, E Bulging at the incision site or clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. Loss of cerebral spinal fluid may cause a sudden and severe headache, which is also an emergency situation. Pain, redness, and itching at the site are normal.

A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache

ANS: A, D, F Obesity, pregnancy, and diabetes are all risk factors for the development of cholelithiasis. A diet low in saturated fats and moderate alcohol intake may decrease the risk. Although metabolic syndrome is a precursor to diabetes, it is not a risk factor for cholelithiasis. The client should be informed of the connection

A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this client's condition? (Select all that apply.) a. Body mass index of 46 b. Vegetarian diet c. Drinking 4 ounces of red wine nightly d. Pregnant with twins e. History of metabolic syndrome f. Glycosylated hemoglobin level of 15%

ANS: C, E Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the client's risk of respiratory complications but will not decrease pressure on the client's hips and sacrum.

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.

ANS: A, B, E When assessing a client with suspected cirrhosis, the nurse should ask about alcohol consumption, including amount and frequency; sexual history and orientation (specifically men having sex with men); illicit drug use; history of tattoos; and history of military service, incarceration, or work as a firefighter, police officer, or health care provider. A family history of cancer and work as a plumber do not put the client at risk for cirrhosis.

A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this laboratory result? (Select all that apply.) a. "How frequently do you drink alcohol?" b. "Have you ever had sex with a man?" c. "Do you have a family history of cancer?" d. "Have you ever worked as a plumber?" e. "Were you previously incarcerated?"

A, C, E

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade

ANS: A, D, E Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output

ANS: A, C, D a. "Reposition the client every 2 hours." c. "Accurately record intake and output." d. "Use the same scale to weigh the client each morning."

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.) a. "Reposition the client every 2 hours." b. "Teach the client to perform deep-breathing exercises." c. "Accurately record intake and output." d. "Use the same scale to weigh the client each morning." e. "Place the client on oxygen if the client becomes short of breath."

ANS: A, B, D The nurse should tell the UAP to schedule activities when the client is normally awake, encourage the client to use a cane when ambulating, and remind the client to look where feet are placed when walking. The nurse should assess the client for symptoms of pain and should provide sufficient time for older adults to process information, including new teaching. These are not items the nurse can delegate.

A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP). Which statements should the nurse include when delegating this client's care? (Select all that apply.) a. "Plan to bathe the client in the evening when the client is most alert." b. "Encourage the client to use a cane when ambulating." c. "Assess the client for symptoms related to pain and discomfort." d. "Remind the client to look at foot placement when walking." e. "Schedule additional time for teaching about prescribed therapies."

ANS: A, C, E The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done.

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.

a, b, d, e There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the client's skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client's bedside. b. Ensure the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.

ANS: A, B, C A client who is scheduled to receive iodine-based contrast should be asked about allergies, especially allergies to iodine or shellfish. The client's kidney function should also be evaluated to determine if it is safe to administer contrast during the procedure. Finally, the nurse should ensure that an informed consent is present because all clients receiving iodine-based contrast must give consent. The CT will have no impact on the client's breath sounds or hematocrit and hemoglobin levels. Findings from these assessments will not influence the client's safety during the procedure.

A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.) a. Ensure that an informed consent is present. b. Ask the client about any allergies. c. Evaluate the client's renal function. d. Auscultate bilateral breath sounds. e. Assess hematocrit and hemoglobin levels.

A, B, C

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.

ANS: A, C, E The low urine output, sediment, and blood pressure should be reported to the provider. Postoperatively, the nurse should measure intake and output, check the characteristics of the urine, and report sediment, hematuria, and urine output of less than 0.5 mL/kg/hour for 3 to 4 hours. A urine output of 100 mL is low, but a urine output of 500 mL in 12 hours should be within normal limits. Perfusion to the kidneys is compromised with low blood pressure. The amber odorless urine is normal

A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.) a. Urine output of 100 mL in 4 hours b. Urine output of 500 mL in 12 hours c. Large amount of sediment in the urine d. Amber, odorless urine e. Blood pressure of 90/60 mm Hg

ANS: A, B, D, E MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6 weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.

A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.) a. "Avoid acetaminophen in over-the-counter medications." b. "It may take several weeks to become effective on pain." c. "Pregnancy and breast-feeding are not affected by MTX." d. "Stay away from large crowds and people who are ill." e. "You may find that folic acid, a B vitamin, reduces side effects."

ANS: A, C, E Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse should collaborate with the registered dietitian, clinical pharmacist, and health care provider to plan and implement the more appropriate nutritional interventions. The nursing assistant and certified herbalist would not assist with this clinical decision.

A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Health care provider

ANS: A, C, D Care for a client who has hepatopulmonary syndrome should include oxygen therapy, the head of bed elevated at least 30 degrees or as high as the client wants to improve breathing, elevated feet to decrease dependent edema, and daily weights. There is no need to place the client in a prone position, on the client's stomach. Although physical therapy may be helpful to a client who has been hospitalized for several days, physical therapy is not an intervention specifically for hepatopulmonary syndrome.

A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therapy

ANS: A, B, E To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The client should have disposable equipment that is not shared with another client, and plants should not be allowed in the client's room.

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a.Ask all family members and visitors to perform hand hygiene before touching the client. b.Carefully monitor burn wounds when providing each dressing change. c.Clean equipment with alcohol between uses with each client on the unit. d.Allow family members to only bring the client plants from the hospital's gift shop. e.Use aseptic technique and wear gloves when performing wound care.

B, D, E

A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the client's prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.

ANS: A, B, D a. Teach the client about dietary restrictions. b. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. d. Confirm that an echocardiogram has been completed.

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.) a. Teach the client about dietary restrictions. b. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. c. Encourage the client to take a baby aspirin each day. d. Confirm that an echocardiogram has been completed. e. Consult a social worker for additional resources.

ANS: A, B, D a. "Are your bedroom and bathroom on the first floor?" b. "What social support do you have at home?" d. "What spiritual beliefs may impact your recovery?"

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply.) a. "Are your bedroom and bathroom on the first floor?" b. "What social support do you have at home?" c. "Will you be able to afford your oxygen therapy?" d. "What spiritual beliefs may impact your recovery?" e. "Are you able to accurately weigh yourself at home?"

ANS: A, B, C Complications of diabetes mellitus are caused by macrovascular and microvascular changes. Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Microvascular complications include nephropathy, retinopathy, and neuropathy. Respiratory failure and cirrhosis are not complications of diabetes mellitus.

A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? (Select all that apply.) a. Stroke b. Kidney failure c. Blindness d. Respiratory failure e. Cirrhosis

A, C, E

A nurse reviews a client's laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL b. High-density lipoprotein cholesterol: 50 mg/dL c. Triglycerides: 200 mg/dL d. Serum albumin: 4 g/dL e. Low-density lipoprotein cholesterol: 160 mg/dL

ANS: A, C Clients who have diabetes mellitus are at high risk for wounds on the feet secondary to peripheral neuropathy and poor arterial circulation. The client should be instructed to not walk around barefoot or wear sandals with open toes. These actions place the client at higher risk for skin breakdown of the feet. The client should be instructed to trim toenails straight across with a nail clipper. Feet should be washed daily with lukewarm water and soap, but feet should not be soaked in the tub. The client should contact the provider immediately if blisters or sores appear and should not use home remedies to treat these wounds

A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Do not walk around barefoot." b. "Soak your feet in a tub each evening." c. "Trim toenails straight across with a nail clipper." d. "Treat any blisters or sores with Epsom salts." e. "Wash your feet every other day."

ANS: B, C, D, E Acute gout can be treated with colchicine and indomethacin. Chronic gout can be treated with febuxostat and probenecid. Allopurinol is used for chronic gout.

A nurse works with several clients who have gout. Which types of gout and their drug treatments are correctly matched? (Select all that apply.) a. Allopurinol (Zyloprim) - Acute gout b. Colchicine (Colcrys) - Acute gout c. Febuxostat (Uloric) - Chronic gout d. Indomethacin (Indocin) - Acute gout e. Probenecid (Benemid) - Chronic gout

ANS: A, B, C, E Age, diabetes, ethnic background, and smoking are all risk factors for developing CAD; medication use is not.

A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.) a. Advanced age b. Diabetes c. Ethnic background d. Medication use e. Smoking

ANS: B, D Stimulation of the sympathetic nervous system initiates the fight-or-flight response, increasing both the heart rate and the force of contraction. A medication that stimulates the sympathetic nervous system would also increase the client's respiratory rate, blood pressure, and level of consciousness.

After administering a medication that stimulates the sympathetic division of the autonomic nervous system, the nurse assesses the client. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Decreased respiratory rate b. Increased heart rate c. Decreased level of consciousness d. Increased force of contraction e. Decreased blood pressure

ANS: A, D, E a. "I'll read the nutritional labels on food items for salt content." d. "I will eat oatmeal for breakfast instead of ham and eggs." e. "Substituting fresh vegetables for canned ones will lower my salt intake."

After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) a. "I'll read the nutritional labels on food items for salt content." b. "I will drink at least 3 liters of water each day." c. "Using salt in moderation will reduce the workload of my heart." d. "I will eat oatmeal for breakfast instead of ham and eggs." e. "Substituting fresh vegetables for canned ones will lower my salt intake."

ANS: C, D, E Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection.

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation."

ANS: A, C, D Wernicke's area (language area) is located in the temporal lobe and enables the processing of words into coherent thought as well as the understanding of written or spoken words. The temporal lobe also is responsible for the auditory center's interpretation of sound and complicated memory patterns. Personality changes are related to frontal lobe injury. Impaired taste is associated with injury to the parietal lobe.

An emergency department nurse assesses a client who was struck in the temporal lobe with a baseball. For which clinical manifestations that are related to a temporal lobe injury should the nurse assess? (Select all that apply.) a. Memory loss b. Personality changes c. Difficulty with sound interpretation d. Speech difficulties e. Impaired taste

1500 mL/hr The Parkland formula is 4 mL/kg/% total body surface area burn. This client needs 18,000 mL of fluid during the first 24 hours postburn. Half of the calculated fluid replacement needs to be administered during the first 8 hours after injury, and half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 postburn hours.

An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) _____ mL/hr

ANS: A, C, D, E Nurses should always use Standard Precautions for client care, and policies should reflect this. Needleless systems and reduction of sharps can help prevent hepatitis. Postexposure prophylaxis should be provided immediately. All health care workers should receive the hepatitis vaccinations that are available.

An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.) a. Policies related to consistent use of Standard Precautions b. Hepatitis vaccination mandate for workers in high-risk areas c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner

ANS: A, C, E The UAP can apply an abduction pillow, elevate the heels on a pillow, and take/record vital signs. Assessing skin is the nurse's responsibility, although if the UAP notices abnormalities, he or she should report them. Determining when the client is able to get out of bed is also a nursing responsibility.

An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply an abduction pillow to the client's legs. b. Assess the skin under the abduction pillow straps. c. Place pillows under the heels to keep them off the bed. d. Monitor cognition to determine when the client can get up. e. Take and record vital signs per unit/facility policy.

ANS: B, C RA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment.

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.) a. It affects single joints only. b. Antibodies lead to inflammation. c. It consists of an autoimmune process. d. Morning stiffness is rare. e. Permanent damage is inevitable.

ANS: A, C The common manifestations of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not manifestations of shock.

The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased perfusion

c, d, e Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.

When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.

A B C E F To prevent AKI, all people should be urged to avoid dehydration by drinking at least 2 to 3 liters of fluids daily, especially during strenuous exercise or work associated with diaphoresis, or when recovering from an illness that reduces kidney blood flow, such as influenza. Contrast media may cause acute renal failure, especially in older clients with reduced kidney function. Recent surgery or trauma, transfusions, or other factors that might lead to reduced kidney blood flow may cause AKI. Certain antibiotics may cause nephrotoxicity. Diabetes may cause acute kidney failure superimposed on chronic kidney failure.

Which clients are at risk for acute kidney injury (AKI)? (Select all that apply.) A) Football player in preseason practice B) Client who underwent contrast dye radiology C) Accident victim recovering from a severe hemorrhage D) Accountant with diabetes E) Client in the intensive care unit on high doses of antibiotics F) Client recovering from gastrointestinal influenza

A C Obtaining the client's weight and documenting oral fluid intake are routine tasks that can be performed by UAP. Assessment skills (checking the AV fistula and auscultating lung sounds) and client education (explaining special diet) require more education and are in the legal scope of practice of the RN.

While managing care for a client with chronic kidney disease, which actions does the registered nurse (RN) plan to delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) A) Obtain the client's pre-hemodialysis weight. B) Check the arteriovenous (AV) fistula for a thrill and bruit. C) Document the amount the client drinks throughout the shift. D) Auscultate the client's lung sounds every 4 hours. E) Explain the components of a low-sodium diet.