fluid and electrolyte quiz

A visitor to the hospital has a cardiac arrest. When determining to use an automated external defibrillator (AED), the nurse should consider that AEDs are used in cardiac arrest in which circumstances?

AEDs are used for early defibrillation in cases of ventricular fibrillation. The American Heart Association and Canadian Heart and Stroke Foundation place major emphasis on early defibrillation for ventricular fibrillation and use of the AED as a tool to increase sudden cardiac arrest survival rates.

A client with gestational hypertension receives magnesium sulfate 50% 4 g in 250 mL D5W over 20 minutes. What priority assessment should the nurse perform when administering this drug?

DEEP TENDON REFLEX Magnesium sulfate is given to prevent and control seizures in clients with gestational hypertension. It is administered by IV; 4 g of a 50% solution in 250 mL D5W can be given as a bolus before the dose is titrated for continuous infusion. Magnesium sulfate is a general inhibitor of neurotransmission. As such, the two largest complications are the loss of deep tendon reflexes and the suppression of breathing. These are the priority assessments. If deep tendon reflexes decrease or the respiratory rate is 12 breaths/min or less, the medication should be discontinued and calcium gluconate administered. Magnesium sulfate is excreted entirely through the kidneys so intake and output should be evaluated hourly. The mother becomes very hot and flushed. This is a normal response. The fetal heart rate should not decrease from the drug.

The nurse is preparing to administer a continuous enteral feeding. Which action is most important for the nurse to include in the plan of care?

Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. When such elevation is contraindicated, the client should be positioned on the right side. The nurse should give enteral feedings at room temperature to minimize GI distress. Injecting air into a feeding tube to verify placement is highly unreliable and should only be used to help confirm a test of the pH of the gastric aspirate.

The nurse finds a small fire in the linen closet. Which action(s) should the nurse take to minimize the consequences of the fire? Select all that apply.

RACE is an acronym used to remember these actions in the case of a fire. Rescue: assist anyone in immediate danger and help get them to a safe area as fast as possible. Alarm: alert others by activating any available alarm system. Contact 911 to report the location of the fire and alert on-site personnel. Contain: confine the fire as soon as possible by closing windows and doors behind you during evacuation. Extinguish: only attempt to put out the fire if it is small, if you have the proper equipment, and if it is safe to do so yourself. Retrieve the nearest fire extinguisher and follow the "P.A.S.S." procedure:P = Pull the pin breaking the plastic sealA = Aim at the base of the fireS = Squeeze the handles togetherS = Sweep from side to side.

Which action is a priority when a nurse is preparing to administer a transfusion of platelets?

Special transfusion sets should be used when administering platelets. A written consent should be obtained and this is the priority before obtaining equipment. Vital signs should be taken before administration and may be delegated. Platelets are stored at room temperature and a blood-warming device should not be used.

A client in a long-term care facility has signed a form stating that the client does not want to be resuscitated. The client develops an upper respiratory infection that progresses to pneumonia. The client's health rapidly deteriorates and is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case?

The client should be treated with antibiotics for pneumonia.

The nurse is irrigating a client's ear due to impacted cerumen. Which nursing action is correct for this procedure?

The nurse should instill mineral oil 30 minutes before irrigation to soften the cerumen. The nurse can use mineral oil to soften the cerumen before irrigation of the ear. Using warm water, not cool water, is best for irrigation for client comfort and loosening of the cerumen. The client would need gentle, not forceful, irrigation in order to prevent perforation of the tympanic membrane. Irrigation would be completed before attempting to mechanically remove the cerumen.

A nurse and newly hired nursing assistant are caring for a group of clients. The nurse is administering medications and needs to know the fingerstick glucose results before administering a medication. The nurse asks if the nursing assistant has been validated on obtaining fingerstick glucose readings. The nursing assistant does not have the skill validated, but has observed it many times and reports confidence in the ability to perform the skill. What should the nurse do?

The nurse should validate the nursing assistant's ability to perform the fingerstick glucose procedure. The nursing assistant may not perform the procedure without having her skills validated by actually performing the procedure. Providing reading material about the procedure is not enough. If the nurse performs the procedure, she forfeits the opportunity to validate the nursing assistant's skills, and therefore underutilizes the nursing assistant.

A nurse is assessing a client who has a rash on the chest and upper arms. Which questions would the nurse ask in order to gain further information about the client's rash? Select all that apply.

The nurse would first find out when the rash began; this can assist with the correct diagnosis. The nurse would also ask about allergies; rashes can occur when a person changes medications, eats new foods, or contacts pollen. It is also important to find out how the client has been treating the rash; some topical ointments or oral medications may worsen it. The nurse would ask about recent travel; exposure to foreign foods and environments that can cause a rash. The client's ethnic background and smoking and drinking habits would not provide further insight into the rash or its cause.

The nurse is evaluating a client who received tissue plasminogen activator (t-PA) following a myocardial infarction (MI). What is the expected outcome of this drug?

The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and re-establish a blood supply to the area.

A client returns to the medical-surgical floor from the postanesthesia recovery room after a colon resection for adenocarcinoma. The client has comorbidities of stage 2 hypertension and a previous myocardial infarction. The first set of postoperative vital signs recorded are pulse rate of 110 bpm, respiration rate of 20/min, blood pressure of 130/86 mm Hg, and temperature of 98° F (36.7° C). The surgeon calls to ask if the client needs a unit of packed red blood cells. The nurse's response should be based on which data? Select all that apply. 1. cyanotic mucous membrane 2. warm, dry skin 3 vital sign changes 4 oxygen saturation

cyanotic mucous membranes vital signs changes oxygen saturation When assessing a postoperative client for perfusion and the manifestation of shock, nursing assessment should include an inspection for cyanotic mucous membranes; cold, moist, pale skin; and the level of oxygen saturation in relation to hemoglobin. The nurse should also compare the client's postoperative vital signs with the preoperative vital signs to determine how much physiologic stress has occurred during the intraoperative period.

The nurse teaches a client taking desmopressin nasal spray about how to manage treatment. The nurse determines that the client needs additional instruction when the client makes which comment?

"I should use the same nostril each time I take the medicine." The client who is taking desmopressin nasal spray should not use the same nares for administration each time. The client should alternate nares every dose. The client should observe for and report promptly signs and symptoms of nasal ulceration, congestion, or respiratory infection.

Which statement indicates that a client with esophageal reflux disorder understands the dietary teaching?

"I won't drink any carbonated drinks." Carbonated drinks should be avoided when a client has esophageal reflux disorder, because the carbonation causes increased esophageal pressure, which leads to increased reflux. Caffeine will cause increased acid production, as will lemonade. All of these drinks should be avoided.

Which instruction would a nurse include in the discharge teaching for a client who has an ileal conduit?

"Mucous in the pouch is expected." An ileal conduit is a type of urinary diversion in which a segment of the ileum or colon is diverted to the skin and a stoma is formed. Urine will leak continuously into the pouch and a drainage bag must be worn for collection at all times except when cleaning the bag. Mucous in the pouch is a normal finding since the intestines are used to create the diversion. Increased fluid intake is encouraged to prevent dehydration. Feces should not be in the pouch.

The nurse is conducting an admission interview with a client and is assessing for risk factors related to the client's safety. The nurse should include which targeted assessments? Select all that apply.

*suicide or self-harm ideation *recent use of substances of abuse *allergic reactions or adverse drug reactions

A nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate? Select all that apply.

1. Instill isotonic eyedrops as necessary. 2. Provide several small, well-balanced meals. 3. Provide regular rest periods. 4.Weigh the client daily. hyperthyroidism is a condition in which the thyroid is overactive and produces excessive amounts of thyroid hormone, which controls body metabolism. If the client has exophthalmos (a sign of hyperthyroidism), the conjunctivae would be moistened often with isotonic eyedrops. Hyperthyroidism results in increased appetite, which can be satisfied by frequent, small, well-balanced meals. The nurse would provide the client with rest periods to reduce metabolic demands. The client would be weighed daily to check for weight loss, a possible consequence of hyperthyroidism. Because metabolism is increased in hyperthyroidism, heat intolerance and excitability result. Therefore, the nurse would provide a cool and quiet environment, not a warm and busy one, to promote client comfort.

A nurse has just received report on four clients. Which client should the nurse see first?

A client who underwent a thyroidectomy and has new onset hoarseness. New onset of hoarseness following a thyroidectomy may be a sign of tracheal edema and impending airway obstruction, and the nurse should evaluate this client first. The client with Cushing's syndrome may have increased blood sugars associated with stress and hospitalization and will need further information to determine whether the blood sugar was obtained when the client was fasting. A client in renal failure would be expected to have an increase in creatinine, and the nurse can later follow up to compare this result with previous results. The client with ulcerative colitis will experience loose, bloody stools and needs to be continuously evaluated for amounts, but this is not the nurse's first priority.

A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration?

A nonrebreather mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A simple mask delivers 2 to 10 L/minute of oxygen in uncontrollable concentrations.

When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a circle around the moist spot and note the date and time. The nurse should notify the physician if any catheter-related complications are observed. Only a nurse with the appropriate qualifications may remove a central venous catheter, and a moist or loose dressing isn't a reason to remove the catheter.

Which I.M. injection site is appropriate for a 6-month-old infant?

A nurse should administer an I.M. injection to a 6-month-old infant in the vastus lateralis muscle. The nurse should give the injection in the ventrogluteal area only in a child who has been walking for about 1 year. The deltoid and gluteus maximus muscles aren't appropriate injection sites in children.

The client has heart failure and is taking a diuretic to promote fluid loss. Which is the most accurate method of determining the extent of a client's fluid loss?

Accurate daily weight measurement provides the best measure of a client's fluid status: 1 kg (2.2 lb) is equal to 1,000 mL of fluid. To be accurate, weight should be obtained at the same time every day, with the same scale, and with minimal clothing on.

A client is brought to the emergency department with abdominal trauma following an automobile accident. The vital signs are heart rate, 132 bpm; respirations, 28 breaths/min; blood pressure, 84/58 mm Hg; temperature, 97.0° F (36.1° C); oxygen saturation 89% on room air. Which prescription should the nurse implement first?

Administer 1 liter 0.9% saline IV. The client is demonstrating vital signs consistent with fluid volume deficit, likely due to bleeding and/or hypovolemic shock as a result of the automobile accident. The client will need intravenous fluid volume replacement using an isotonic fluid (e.g., 0.9% normal saline) to expand or replace blood volume and normalize vital signs. The other prescriptions can be implemented once the intravenous fluids have been initiated.

The client is admitted to the medical/surgical unit for treatment of acute thrombophlebitis of the right calf. The client is administered 5000 units of heparin IV, followed by 1000 units of IV heparin per hour. Which action by the nurse is most appropriate if the client receives too much heparin?

Administer protamine sulfate Protamine sulfate is the antidote for heparin. Vitamin K is the antidote for warfarin sodium and calcium gluconate is the antidote for magnesium sulfate toxicity. The client is already receiving warfarin sodium.

A nurse is caring for a client with frequent episodes of ventricular tachycardia. The lab calls with a critically high magnesium level of 11 mg/dL on this client. What is the nurse's priority action?

All the actions listed will reduce the serum magnesium concentration. The calcium gluconate will react the quickest to reduce the critical level.

The nurse notes bulging and separation of an abdominal incision while assessing a client. What is the purpose of applying a binder?

Applying an abdominal binder will reduce further stress on the incision and prevent another dehiscence, thus allowing the skin and tissue to heal. The other choices are not accurate reasons to use a binder.

The nurse is preparing to administer furosemide to a 3-year-old with a heart defect. After verifying the arm band, which is the most appropriate second identifier for the nurse to use?

Ask the parent the child's name. Safety standards require the use of two identifiers prior to medication administration. A parent can be used as the second identifier. Many young children will only answer to a nickname that does not coincide with the medical identification band, may not answer, or may answer to any name. It is common for children on a pediatric floor to go into each other's rooms. A small child may not know his or her birth date.

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?

Assess the client's level of pain, and administer prescribed analgesics. The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control.

When developing a teaching plan for a client taking hormonal contraceptives, a nurse should ensure that the client knows she must have which vital sign monitored regularly?

Blood Pressure The incidence of hypertension is three to six times greater in clients using hormonal contraceptives than in women who don't use these drugs. Age and duration of the drug's use increase this incidence. Hormonal contraceptives don't directly affect pulse, respirations, or temperature.

A client is admitted with a diagnosis of chronic hydronephrosis. Which assessment finding requires immediate action or will assist the nurse in planning care?

Client's blood urea nitrogen (BUN) is 32 mg/dL. Clients with chronic hydronephrosis suffer kidney damage. The BUN is elevated. Calcium and potassium levels are within normal range. Urinary output is low but consistent with the diagnosis.

A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse?

Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. This client has been ingesting an unknown amount of drugs and alcohol and is now exhibiting a change in neurologic status. It is a priority to carefully assess and closely monitor for any deterioration. The other choices are incorrect because a family member is not qualified to monitor the client. The client would eventually be referred to an addiction team but is not medically stable. Sedation is not appropriate at this time.

A new nurse will be monitoring a client during a moderate sedation procedure for the first time, and is discussing this with the charge nurse. Which statement made by the newly graduated nurse will the charge nurse verify as accurate?

Complete vital signs should be charted at least every 5 minutes during the procedure. Moderate sedation is a high-risk procedure, and requires frequent monitoring. Client status and vital signs can change rapidly, and must be accurately charted, alongside interventions performed to paint an accurate picture of client care.

A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps have been placed in the client's hospital room. What should the nurse tell the client about how these will be used? The forceps and container will be used for:

Dislodged radioactive materials should not be touched with bare or gloved hands. Forceps are used to place the material in the lead-lined container, which shields the radiation. Exposure to radiation can occur only by direct exposure to the encased radioactive substance; it cannot result from contact with emesis or urine or from touching the clien

Which nursing intervention is most important in preventing postoperative complications?

Early ambulation is the most significant general nursing measure to prevent postoperative complications and has been advocated for more than 40 years. Walking the client increases vital capacity and maintains normal respiratory functioning, stimulates circulation, prevents venous stasis, improves gastrointestinal and genitourinary function, increases muscle tone, and increases wound healing. The client should maintain a healthy diet, manage pain, and have regular bowel movements. However, early ambulation is the most important intervention.

A nurse is working in a clinic where a family member's spouse is treated for a sexually transmitted disease. The nurse is concerned about the risk to family members. What is the most appropriate action for the nurse to take?

Encouraging the client to talk with their spouse is the nurse's only option. According to the Privacy Acts, a client's diagnosis is confidential information that shouldn't be shared with anyone, including a spouse, without the client's permission. Telling a family member about the diagnosis is a violation of the client's confidentiality. The nurse isn't legally obligated to report the diagnosis to family members. It isn't appropriate for the nurse to provide information that would allow other agencies to contact the client's spouse.

The nurse has completed instilling fluid with a bladder irrigation and does not have a return of the fluid into the catheter bag. What is the next action the nurse should do?

Ensure there are no kinks in the catheter tubing. The simplest method to ensure drainage of the catheter is to check the tubing for kinks in the tubing that would affect drainage. After this, palpating the bladder for distention, notifying the healthcare provider, and changing the urinary catheter would be the next steps in troubleshooting this situation.

The nurse is reviewing the serum electrolyte levels of a client with heart failure who has been taking digoxin for 6 months. The nurse should report which finding from the lab report to the health care provider?

Hypokalemia is one of the most common causes of digoxin toxicity. It is essential that the nurse carefully monitor the potassium levels of clients taking digoxin to avoid toxicity. Low serum potassium levels can cause cardiac dysrhythmias.

Which nursing intervention is most important in preventing septic shock?

Maintaining asepsis of indwelling urinary catheters is essential to prevent infection. Preventing septic shock is a major focus of nursing care because the mortality rate for septic shock is as high as 90% in some populations. Very young and elderly clients (those younger than age 2 or older than age 65) are at increased risk for septic shock. Administering IV fluid replacement therapy, obtaining vital signs every 4 hours on all clients, and monitoring red blood cell counts for elevation do not pertain to septic shock prevention.

The nurse has administered mannitol IV. Which is a priority assessment for the nurse to make after administering this drug?

Mannitol is an osmotic diuretic used in acute clinical situations. It increases osmotic pressure and draws fluid into the vascular space. Monitoring hourly urine output is a priority nursing assessment when administering mannitol. Electrolyte levels should also be monitored, most specifically sodium, chloride, and potassium.Calcium levels are not affected by mannitol.

A primary unit nurse tells the nurse-manager that a registered nurse hired 6 weeks ago needs an additional week of orientation to function effectively on the staff. Which action is mostappropriate for the nurse-manager to take?

Meet with the new nurse and the primary nurse and help set up an additional week of orientation . he nurse-manager is responsible for adequate orientation of new staff. A need for additional orientation does not mean that a nurse is not competent or that there are deficits in performance. Although a 6-week orientation may be standard, orientation periods should be individualized to meet the needs of the staff as well as provide the best client outcomes. Periodically reviewing and revising the orientation process is a good idea. However, in this case, the most appropriate course of action is to help the new nurse complete the orientation as efficiently as possible.

While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply?

Moist sterile saline dressings support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent but because it can irritate epithelial cells, it shouldn't be left on an open wound.

The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial actions?

Notify the surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs. The purpose of a registered nurse's signing off the chart is to ensure that the safety of the client has been assessed. Abnormal vital signs identify that priority systems indicate that a stressor or infection is present.

Which client is at increased risk for developing a wound infection?

Nutrition plays an important role in wound healing. Because vitamins and protein are essential for wound healing, a client with an albumin level less than 3.0 g/dl is considered malnourished and is at increased risk for developing a wound infection.

Heparin therapy testing

PTT

A client has been diagnosed with hypothyroidism and started on synthetic levothyroxine for thyroid replacement therapy. Which effect is the most important to report to the physician?

Palpations and chest pain on exertion assessment of the effects of severe hypothyroidism on the circulatory system is important. Serum cholesterol levels are also elevated in clients with hypothyroidism. As the metabolic rate increases with the thyroid replacement therapy, there is more demand on the heart, and angina and palpitations may occur. All of the choices are expected effects once the replacement hormone is started. There is an increase in temperature, a loss in weight, and increased energy levels.

What would be an appropriate action for the nurse prior to performing deep tracheal suctioning due to increased secretions?

Preoxygenation and deep breathing assist in reducing suction-induced hypoxemia because it decreases the risk of atelectasis caused by negative pressure of suctioning.

A nurse is examining the abdomen of a client with suspected peritonitis. How does the nurse elicit rebound tenderness?

Press the affected area firmly with one hand, release pressure quickly, and note any increased tenderness on release.

The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do next?

Promptly assess the client for potential perforation. A sudden spike in temperature following an endoscopic procedure may indicate perforation of the GI tract. The nurse should promptly conduct a further assessment of the client, looking for further indicators of perforation, such as a sudden onset of acute upper abdominal pain; a rigid, boardlike abdomen; and developing signs of shock.

The nurse is preparing to clean around a client's G-tube that was placed 1 week ago and change the gauze dressing. Based on the type of procedure, what type of precautions are needed?

Site care for a recently placed G-tube is a clean procedure, not a sterile procedure. Care should be taken not to introduce bacteria into the fresh site, but sterile gloves and sterile procedure is not necessary or recommended. Universal precautions are required, as the nurse will come into contact with blood and/or bodily fluids while cleaning around the G-tube. Droplet, contact, and airborne precautions are not indicated, because these are for a variety of infectious diseases such as methicillin-resistant Staphylococcus aureus, influenza, measles, meningitis and tuberculosis, not for wound care.

A nursing student and a preceptor nurse are discussing nursing liability. Which statement made by the student would indicate to the nurse that the student understands the concept of liability?

Statute of limitations is the time period during which the injured party must file a case. Discovery rule refers to the time when the client discovers the injury. The statute of limitations typically allows clients to file a lawsuit within 2 years of discovery; however, the time may vary from state to state. Grace period refers to the contractually specified time during which payment is permitted, without penalty, beyond the due date of the debt. Alternative dispute resolution refers to any means of settling disputes outside the courtroom setting.

Which principle should a nurse consider when administering pain medication to a client?

Sustained-release oral formulations should be given around the clock, if possible, for control of chronic pain. Administering sustained-release oral formulations around the clock provides better relief of chronic pain by keeping blood levels within therapeutic range. Opioid combination drugs and nonopioid medications are most effective in the treatment of mild to moderate pain. I.V. medications usually act within 1 hour of administration. Morphine and hydromorphone are drugs of choice for severe pain.

The nurse is administering an IV potassium chloride supplement to a client who has heart failure. What should the nurse consider when developing a plan of care for this client?

The administration of the IV potassium chloride should not exceed 10 mEq/h or a concentration of 40 mEq/L.

The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next?

The amount of residual is within normal limits, and the client should have the feeding started. The residual should be returned to help prevent electrolyte imbalances. The other options do not ensure adequate nutritional management for the client.

A client with a nasogastric (NG) tube who is 2 days postoperative bowel resection is reporting increased abdominal pain and nausea. Which action by the nurse would be most appropriate?

The client is experiencing abdominal pain and nausea. This subjective assessment data indicate that the NG tube may not be functioning, so assessment of its patency and the amount of drainage would be the first step. Then appropriate action can be taken if the tube is not patent. Giving an analgesic and antiemetic would alleviate the symptoms of pain and nausea, but would not correct the problem if the NG tube is not draining properly. Irrigations are done after assessment of patency. The gag reflex is triggered during insertion, but once in position does not cause nausea.

A client from Mexico has bacterial pneumonia and has a temperature of 102°F (39°C). The client has been treating the infection by drinking milk. How should the nurse interpret the client's method of self-treatment?

The client is using hot disease concept The nurse interprets the client's statement as use of the hot disease concept in the Mexican culture, where the belief of a hot and cold balance of the body exists. A hot disease such as an infection is treated with the opposite, a cold food such as milk. The nurse should focus on the cultural differences and be sensitive to the cultural diversity.

The nurse is monitoring a client with a pacemaker. Which finding shows that the client's pacemaker is functioning correctly?

The client should have a spike on the EKG when pacing is initiated; this would come before the P wave if the pacemaker is initiating atrial contraction and before the QRS if the pacemaker initiates ventricular contraction instead. Finding the generator would be an indication of having a pacemaker, but not that it was working. The client should report any pacemaker problems, but it would not be an indication of the pacemaker's function at present. Having bilateral radial pulses does indicate heart function but does not specifically address pacemaker function.

A nurse inadvertently transcribes a client's medication order that was written as "Ampicillin 250 mg four times a day" as "Ampicillin 2500 mg four times a day." The nurse gives two doses as transcribed to the client. Another nurse gives one dose before the pharmacist questions the reorder of the medication. What should the two nurses do in this situation?

The correct answer is that both nurses are responsible for this error. The first nurse transcribed the order incorrectly and did not recognize that the dose was too high when administering the medication. The second nurse should have known the dose was too high. Both nurses must admit to the error. The other options do not reflect a nurse's responsibility in admitting to an error and preventing injury to clients.

A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease?

The lump is round and movable. When assessing a breast with fibrocystic disease, the lumps typically are different from cancerous lumps. The characteristic breast mass of fibrocystic disease is soft to firm, circular, movable, and unlikely to cause nipple retraction. A cancerous mass is typically irregular in shape, firm, and non-movable. Lumps typically do not make one breast larger than the other. Nipple retractions are suggestive of cancerous masses.

The nurse is caring for a client following a cystocele and rectocele repair. The nurse has just received the client from the post anesthesia care unit (PACU). Which healthcare provider orders would the nurse question? Select all that apply.

The nurse is caring for a client following a cystocele and rectocele repair. The nurse has just received the client from the post anesthesia care unit (PACU). Which healthcare provider orders would the nurse question? Select all that apply. Clients following a cystocele and rectocele repair may have a Foley catheter in place for days until the edema decreases. Having the client maintain a sitting position would not be comfortable due to the perineal trauma. The client is immediately postoperative and will need the fluid after surgery. Advancing the diet as tolerated is a routine order following surgery and is based on the nursing judgment. Because of the manipulation of the bladder and the involvement of the rectum, antibiotics will be prescribed as a preventive measure.

The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which action is a correct component in the nursing plan of care?

The nurse must carefully and adequately document the assessment of the abused victim in the chart (not an incident or occurrence report). The documentation must include statements from the victim, physical and psychological assessment findings, and observations relative to the abuse situation. The nurse should give the victim information about community resources, social agencies, and legal services to prevent recurrence of physical abuse. A professional nurse is not qualified to counsel the abuser or the victim. The nurse should refer the abuser and the victim to a professional counselor trained in dealing with domestic violence.

A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse?

The nurse should ask the client to tell the nurse what they are feeling. Asking open-ended questions would encourage the client to verbalize pain. Some clients may not demonstrate their feelings or readily discuss their symptoms due to factors related to cultural norms. Closed-ended questions like "Are you having pain?", "Do you need pain medication?", and "Are you feeling all right?" may block communication.

The nurse is preparing to administer a preoperative medication that includes a sedative to a client who is having abdominal surgery. What should the nurse do first?

The nurse should have the client empty the bladder before the premedication is administered. This will be more comfortable and safe for the client. The purpose of the premedication is to decrease anxiety and promote a relaxed state. The client must have an empty bladder before being transferred to the operating room, where the client will be immobilized and receive IV fluids. The family does not have to be present, but it is usually desired. Shaving the operative area is not generally recommended because it can cause small nicks that harbor bacteria. If the client must be shaved, it is usually done in the operating room holding area. The client should be comfortable at all times and offered a warm blanket before or after the premedication.

The nurse is observing a student nurse perform an irrigation of a client's nasogastric (NG) tube. Which action by the student nurse would cause the nurse to stop the procedure?

The student nurse would not want to instill fluid through the blue air vent port - this is reserved for air only and is a way to decrease pressure that can build up into the stomach when suction is used. The student nurse should wear clean not sterile gloves because it is not a sterile procedure. The student nurse would disconnect the suction tubing in order to attach the syringe and can use gravity versus pushing the fluid in to instill it.

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement to the client would the nurse use to describe a healthy stoma?

The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown.

The client was found not breathing and was transported to the hospital. A family member states the client may have taken too much pain medication because the client frequently forgets if the medication was taken. Which observation(s) by the nurse indicates therapeutic effect of naloxone hydrochloride in the client? Select all that apply.

Therapeutic effect includes reversal of respiratory depression, sedation, and hypotension.

During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure?

To change a tracheostomy dressing effectively, the client should rinse around the clean incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline - not full-strength hydrogen peroxide. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of non-raveling material instead of cotton-filled gauze squares.

A nurse and an unlicensed assistive personnel (UAP) are caring for four clients together on the telemetry unit. Which nursing action can be delegated safely to the UAP?

Unlicensed assistive personnel (UAP) can be educated in correct lead placement for ECG monitoring. Assessment of clients and monitoring of unstable clients is not within the scope of practice for a UAP and should be done by the registered nurse. Client teaching must be completed by an RN, not a UAP.

The nurse manager has noticed a sharp increase in medication errors associated with IV antibiotic administration over the past 2 months. The nurse manager should discuss the situation with each nurse involved and then:

ask them to attend in-service training for administration of IV medications. Identification of causes of medication errors requires in-service education to inform the staff of strategies to decrease these errors. Errors are frequently the result of systemic problems that can be identified and rectified through problem-solving techniques and changes in procedures.

The charge nurse on a pediatric unit is making client assignments for the evening shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)?

a 4-year-old with chronic graft-versus-host disease who is incontinent The LPN/VN's scope of practice includes care of clients with chronic and stable health problems, such as the client with chronic graft-versus host disease. Chemotherapy medications should be administered by an RN who has received additional education in chemotherapy administration. Platelets and other blood products should be administered by the RN. The 5-year-old client is exhibiting clinical manifestations of neutropenia and sepsis and should be assessed by the RN.

A client comes to the emergency department after taking an overdose of amitriptyline hydrochloride. Immediate care for this client should include

administering activated charcoal every 4 hours for 24 hours. After administering appropriate stomach lavage, the nurse should give the client activated charcoal every 4 hours for 24 hours. The charcoal binds with amitriptyline and inactivates it. The nurse shouldn't induce vomiting because the client's mental status may rapidly deteriorate and pose the risk of aspiration. Large boluses of enteral saline can force the drug into the small intestine, where it will be absorbed. The nurse should use a large tube for gastric lavage so she can remove intact pills.

The nurse is conducting a health history of a child. The parent states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which condition?

allergies In children, many symptoms of allergies are often vague and general. They revolve around frequent cold-like symptoms, allergic rhinitis, and pruritus. These symptoms are distracting to children and can affect their ability to concentrate in school. The "itching all the time" descriptor lends itself to allergies and histamine release rather than sinusitis, ringworm, and fifth disease.

A nurse medicates a client with another client's morning medicines. What is the best action by the nurse upon realizing the error?

assess patient

When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing?

at the base of the wound. When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage.

The nurse is observing a nursing student palpating a client's maxillary sinuses. The nurse observes that the student has correctly palpated the client's maxillary sinuses when the student palpates which area?

below the client's cheekbones To palpate the maxillary sinuses, the nurse would place hands on either side of the client's nose, below the cheekbone (zygomatic bone). To palpate the frontal sinuses, the nurse places their thumb just above the client's eye, under the bony ridge of the orbit. No sinuses are located on the bridge of the nose or in the temporal area.

A client reports abdominal pain and vomiting for 24 hours. The client's blood pressure is 98/48 mm Hg. The client is diagnosed with large-bowel obstruction. What is the priority nursing diagnosis for the client?

deficient fluid volume

When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include

delayed gastric emptying. Aging-related physiologic changes include delayed gastric emptying, decreased coronary artery blood flow, an increased posterior thoracic curve, and increased peripheral resistance.

A nurse-manager appropriately behaves as an autocrat in which situation?

directing staff activities if a client experiences a cardiac arrest in a crisis situation, the nurse-manager should take command for the benefit of the client. Planning vacation time and evaluating procedures and client resources require staff input and are actions characteristic of a democratic or participative manager.

To evaluate a client's cerebellar function, a nurse should ask

do you have any problems with your balance To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination. The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves IX, X, and XII. Questions about muscle strength help the nurse evaluate the client's motor system.

The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which action is a correct component in the nursing plan of care?

documenting the situation and providing support for the victim The nurse must carefully and adequately document the assessment of the abused victim in the chart (not an incident or occurrence report). The documentation must include statements from the victim, physical and psychological assessment findings, and observations relative to the abuse situation. The nurse should give the victim information about community resources, social agencies, and legal services to prevent recurrence of physical abuse. A professional nurse is not qualified to counsel the abuser or the victim. The nurse should refer the abuser and the victim to a professional counselor trained in dealing with domestic violence.

A nurse is caring for a client with diarrhea caused by Clostridium difficile. Which personal protective equipment should the nurse use? Select all that apply.

gown and gloves he client should be on contact isolation. Due to expected contact with the client and bedding when doing an assessment, gloves and gowns are needed.

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include

ground beef patties Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.

A day-shift nurse gives a client an injection of pain medication. The nurse forgets to document the injection on the medication administration record (MAR). The day-shift nurse tells the evening-shift nurse that she gave the client 4 mg of morphine at 2 p.m. for postoperative pain but didn't document the injection. The evening-shift nurse puts the day-shift nurse's initials and the date and time the dose was administered in the appropriate area of the MAR. The evening-shift nurse's action is considered to be which type of documentation error?

his action is an unauthorized entry. A nurse shouldn't document for another nurse, except for an authorized entry in an emergency.

A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake which foods should the nurse emphasize?

lean meats and low- fat milk Although the client should eat a balanced diet, including foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing. Legumes provide incomplete protein. Cheese contains complete protein, but it also includes fat, which should be limited to 30% or less of caloric intake. Whole grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates.

The nurse is assessing the client's umbilicus (see the accompanying image). The nurse should document the umbilicus as being:

midline

A nurse is caring for a child with celiac disease. How would the nurse evaluate the effectiveness of nutritional therapy?

monitor the appearance, size and number of stool. gluten-free diet should eliminate fat, bulky, foul-smelling stools in a child with celiac disease. This finding indicates that the disease is controlled and the child is using nutrients effectively. Taking vital signs, reviewing blood urea nitrogen and serum creatinine levels, and recording intake and output don't indicate the effectiveness of nutritional therapy.

The client has second- and third-degree burns. The family asks if there is anything that can be given to the client for pain. Which analgesic would the nurse anticipate to manage the client's pain?

morphine IV The best and most effective medication for second- and third-degree burns would be IV morphine. IM medications may not be absorbed, and codeine may not provide sufficient analgesia.

A nurse who works in a community-based clinic is implementing primary prevention with the clients who use the clinic. What should the nurse include in primary prevention activities?

obtaining a rubella titer on a woman who is planning to start a family Obtaining a rubella titer is a primary prevention activity. Rubella may cause birth defects when contracted during the first 3 months of pregnancy. Identifying those who do not have an immunity and then providing the vaccine is a primary prevention activity.

The nurse should ensure that which item is placed when the client is to receive intravascular therapy for more than 6 days?

peripherally inserted central catheter (PICC) When the duration of intravascular therapy is likely to be more than 6 days, a midline catheter or peripherally inserted central catheter (PICC) is preferred to a short peripheral catheter. In adult clients, use of the femoral vein for central venous access should be avoided. Steel needles should be avoided when administering fluids and medications that might cause tissue necrosis if extravasation occurs.

A nurse is teaching a group of women health promotion strategies. Which activities are primary prevention strategies? Select all that apply.

primary prevention strategies are used to prevent/reduce risk of disease before it occurs such as by using sunscreen to reduce risk of skin cancer; doing weight-bearing exercises to prevent osteoporosis; increasing intake of vegetables and whole grains to reduce cancer risk. Breast self-examinations and Pap smears are secondary prevention because they focus on screening.

Which laboratory test should the nurse monitor when the client is receiving warfarin sodium therapy?

prothrombin time (PT) Warfarin sodium interferes with clotting. The nurse should monitor the PT and evaluate for the therapeutic effects of coumadin. A therapeutic PT is between 1.5 and 2.5 times the control value; the PT should be established by the health care provider (HCP). It may also be reported as an International Normalized Ratio, a standardized system that provides a common basis for communicating and interpreting PT results. The PTT is monitored in clients who are receiving heparin therapy. Serum potassium levels and ABG values are not affected by coumadin.

Upon repositioning an immobile client, the nurse notes redness with blanching over a bony prominence. What is the most probable cause?

reactive hyperemia is likely transient. If the area blanches white and the erythema returns when the finger is removed, the reactive hyperemia is likely transient. The other choices are indicative of further infections or deep tissue damage.

The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position?

semi-fowler A hyphema is the presence of blood in the anterior chamber of the eye. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as penetrating injury from a small bullet or pellet, or indirectly, such as from striking the forehead on the pavement during an accident. The client is treated by bed rest in a semi-Fowler position to assist gravity in keeping the hyphema away from the optical center of the cornea.

During gentamicin therapy, the nurse should monitor a client's

serum creatinine level. during gentamicin therapy, the nurse should monitor a client's serum creatinine level because the most notable adverse reactions to aminoglycoside therapy are nephrotoxicity and ototoxicity. The drug doesn't appear to affect serum potassium or glucose levels or PTT.

An elderly client admitted with new-onset confusion, headache, and bounding pulse has been drinking copious amounts of water and voiding frequently. The nurse reviews the laboratory results (see accompanying chart). Which of the abnormal lab values is consistent with the client's symptoms?

serum sodium

Which action by the client indicates that the client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy?

the correct technique for deep breathing postoperatively to avoid atelectasis and pneumonia is to take in a deep breath through the nose, hold it for 5 seconds, then blow it out through pursed lips. The goal is to fully expand and empty the lungs for pulmonary hygiene.

The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client's respirations are rapid and shallow, the pulse is 120 bpm, and the blood pressure is 88/52 mm Hg. The client's level of consciousness is declining. What should the nurse do first?

the nurse should first call the rapid response team (RRT) or medical emergency team that provides a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration. The client's vital signs have changed since the client was in the PACU, and immediate action is required to manage the changes; the staff in PACU are not responsible for managing care once the client is transferred to the surgical unit. The respiratory therapist may be a part of the RRT but should not be called first.

When injecting an intravenous push medication into intravenous tubing with a solution infusing, the nurse should select which injection port?

the port closest to the client The nurse should inject the medication in the port closest to the client. Administering the medication higher in the tubing makes flushing the tubing difficult and has the potential to interfere with the rate of administration, either of which could alter complete delivery of the medication.

A client is on complete bed rest. The nurse should initiate measures to prevent which complication of bed rest?

thrombophlebitis Thrombophlebitis is an inflammation of a vein. The underlying etiology involves stasis of blood, increased blood coagulability, and vessel wall injury. The symptoms of thrombophlebitis are pain, swelling, and deep muscle tenderness. Air embolus is a result of air entering the vascular system. Fat embolus is associated with the presence of intracellular fat globules in the lung parenchyma and peripheral circulation after long-bone fractures. Stress fractures are associated with the musculoskeletal system.

The nurse is caring for an infant who is retaining fluid. How will the nurse assess for urine output?

weighing the diaper before and after micturition