Focus on Adult Health Exam

A nurse is conducting an admission assessment of a client hospitalized with a diagnosis of Meniere's disease. Which question would elicit information specific to the attacks that occur with this disorder?

"Do you have a feeling of fullness in your ear?" Rationale: Meniere's disease results from a disturbance in the fluid of the endolymphatic system. The cause of the disturbance is unknown. Attacks may be preceded by a feeling of fullness in the ear or by tinnitus.

A client is to receive an intravenous (IV) antibiotic in 50 mL of 0.9% sodium chloride to be administered over 20 minutes. At what rate should the nurse set the infusion pump? Record answer using a whole number. __________ mL/hr

20 min 60 min 20x = 50 x 60 x = 3000 ÷ 20 x = 150 mL/hr

Cefuroxime axetil 1 g in 50 mL of normal saline solution, is to be administered over 30 minutes. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate?

25

An antibiotic mixed in 100 mL of normal saline solution is to be administered over half an hour. The drop factor is 10 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round your answer to the nearest whole number.)

33

Hepatitis A vaccine is prescribed for a client who is planning a trip out of the country. The nurse tells the client that:

A booster dose is needed 6 to 12 months after the initial injection Rationale: Hepatitis A vaccine contains inactivated hepatitis A virus. A single dose of this vaccine is given intramuscularly; a booster dose is administered 6 to 12 months after the initial injection. Active immunity to hepatitis B is provided by the hepatitis B vaccine (Engerix-B, Recombivax-HB). Hepatitis A vaccine is not available in an oral form.

A nurse instructs a client with diabetes mellitus and hypertension in illness management and lists carbohydrate-containing beverages that the client may consume when he cannot tolerate food orally. The nurse determines that the client needs additional instruction if he states that he should consume:

A diabetic client who is unable to tolerate food because of illness should take in approximately 15 g of carbohydrate every 1 to 2 hours. Ginger ale, apple juice, and regular cola each provide 13 to 15 g of carbohydrate in a half-cup serving. Items that are canned are generally high in sodium and should not be used by the client with hypertension.

A nurse is monitoring a client who is attached to a cardiac monitor. The monitor alarm sounds, and the nurse, examining the screen, notes no ECG complexes. The nurse would first:

A sudden loss of ECG complexes indicates either ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The nurse would assess the client first. If, after assessing the client, the nurse feels that there is an absence of ventricular activity, a code (rapid response team) should be called and emergency response measures initiated.

A client who sustained an extensive full-thickness burn injury is being admitted to the nursing unit. Which prescription by the health care provider would the nurse question?

Administer morphine sulfate 6 mg intramuscularly every 3 hours as needed. The intravenous route is the preferred route of administration of opioids to a burned client because of the potential for problems with absorption from the muscle and stomach.

A client with a positive skin test for tuberculosis (TB) isn't showing signs of active disease. Still, the client is worried and asks the nurse what can be done to help prevent the development of active TB. Which therapy would be best for this client?

Because of the increasing incidence of resistant strains of TB, the disease must be treated for up to 24 months in some cases, but treatment typically lasts from 9 to 12 months. Isoniazid is the most common medication used for the treatment of TB

A client is found to have hypoparathyroidism. Which nutritional supplement does the nurse, teaching the client about measures to manage the disorder, tell the client to take on a daily basis?

Calcium carbonate with vitamin D Rationale: Hypoparathyroidism is an endocrine disorder in which parathyroid function is decreased. The client with hypoparathyroidism has low calcium and high phosphate levels and should consume a diet high in calcium but low in phosphorus. Additionally, the generally used treatment is calcium supplementation (either as calcium carbonate or calcium citrate) coupled with vitamin D supplementation.

A nurse participating in a free health screening at the local mall obtains a random blood glucose level of 190 mg/dL (10.6 mmol/L) and a total cholesterol level of 210 mg/dL (5.4 mmol/L) in an otherwise healthy client. What should the nurse tell the client to do next?

Call his health care provider to have these values rechecked as soon as possible Rationale: Adult diabetes mellitus may be diagnosed on the basis of symptoms (e.g., polydipsia, polyuria, polyphagia) or laboratory values. An abnormal glucose tolerance test, a random plasma glucose level greater than 200 mg/dL, and a fasting plasma glucose level greater than 140 mg/dL on two separate occasions are all diagnostic of diabetes mellitus. The total cholesterol should be less than 200 mg/dL.

A hospitalized client has just been found to have acute kidney injury (AKI). The laboratory calls the nursing unit and reports that the client has a serum potassium level of 6.4 mEq/L (6.4 mmol/L). On the basis of this laboratory finding, the nurse should first:

Call the health care provider Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5-5.0 mmol/L). The client with hyperkalemia is at risk for cardiac dysrhythmias and resultant cardiac arrest. Because of this, the health care provider must be notified at once so that the client may receive definitive treatment. The nurse would check the client's sodium level and encourage the client to decrease intake of potassium-rich foods, but these are not priority nursing interventions. Fluid intake would not be increased, because this would contribute to fluid overload and wouldn't effectively lower the serum potassium level.

A nurse educator conducts an informational session for emergency department nurses about smallpox. Which statements by the nurse educator are correct? Select all that apply.

Clinical manifestations of smallpox include sudden onset of influenza-like symptoms, including fever, malaise, headache, prostration, severe back pain, and, less often, abdominal pain and vomiting. Two to 3 days later, the temperature falls and the client feels somewhat better, at which time the characteristic rash appears, first on the face, hands, and forearms and then, after a few days, on the trunk. Lesions also develop in the mucous membranes of the nose and mouth and ulcerate very soon after their formation, releasing large amounts of virus into the mouth and throat. Smallpox is transmitted from person to person in infected aerosols and AIR DROPLETS, especially if the symptoms include coughing. A person is considered infectious at the onset of the rash and until the rash scabs over, which is about 3 weeks.

Diabetes Insipidus: Low level of ADH (antidiuretic hormone)

Diabetes insipidus is seen mostly in neurosurgical patients. Permanent DI is seen in patients with extensive damage in the hypothalamic area. Treatment is usually with vasopressin.

A client is using diphenhydramine 1% as a topical agent to treat allergic dermatosis. Which outcome indicates to the nurse that the medication is having the intended effect?

Diphenhydramine is an antihistamine medication that has many uses. When used as a topical agent on the skin, it reduces the symptoms of allergic reaction, such as itching or urticaria. It does not act to relieve pain, headache, or skin redness.

A nurse is admitting a client with a diagnosis of chronic kidney disease(CKD) to the hospital. Which early sign of CKD does the nurse expect to note during assessment?

Hypertension and changes in urine characteristics are the first signs of CKD. Fatigue, lethargy, and pruritus are also early symptoms. It is important to assess the blood pressure because hypertension in the client with CKD can lead to heart failure as a result of increased cardiac workload in conjunction with fluid overload.

A client arrives at the emergency department and reports a buzzing sound in his ear. The client tells the nurse that an insect flew into the ear. Which intervention does the nurse take first to remove the insect?

Instilling lidocaine into the ear Rationale: Insects that make their way into an ear are killed before removal unless they can be coaxed out with the use of a flashlight or a humming noise. Mineral oil, diluted alcohol, or lidocaine (not water) is instilled into the ear canal (or an ether-soaked cotton ball is placed in the ear) to suffocate the insect, which is then removed with the use of ear forceps. When the foreign object is vegetable matter, irrigation should never be used.

A nurse caring for a client with a diagnosis of peptic ulcer is monitoring the client for signs of perforation. Which findings would cause the nurse to suspect perforation? Select all that apply.

Perforation, a surgical emergency, is characterized by sudden sharp intolerable pain, beginning in the midepigastric area and spreading over the abdomen, which then becomes rigid and board-like. Tachycardia occurs as hypovolemic shock develops.

Signs and Symptoms of Diabetes Insipidus

Polyuria, Polydipsia, Dry mucous membranes, dry skin, decrease skin tugor...very dehydrated, Urine diluted....low urinary specific gravity Hypotension (due to the severe dehydration), Extreme fatigue and muscle pain/weakness. Hypernatremic (due to the concentrate sodium in the body from low water levels).

When preparing an in-service on adult respiratory distress syndrome (ARDS), which sign or symptom will the nurse educator identify as its hallmark?

Progressive hypoxemia despite supplemental oxygen therapy is the hallmark of ARDS.

A client has been taking pyrazinamide (PMS Pyrazinamide) for 2 months. Which culture result does the nurse monitor as an indicator that the medication may soon be discontinued?

Pyrazinamide is an antitubercular medication that is given in conjunction with other antitubercular medications. The prescriber may discontinue its use if sputum cultures become negative. Urine, blood, and wound cultures are not associated with the use of this medication.

A nurse educator conducts an informational session for hospital nurses about skin anthrax. Which statements by the nurse educator are correct? Select all that apply.

Skin anthrax is transmitted through direct contact when spores from contaminated products enter the skin through cuts or abrasions. Person-to-person spread does not occur; therefore, contact precautions may not always be necessary. Symptoms may appear as early as 24 hours or as long as up to 7 days after exposure. Antibiotic treatment cures the skin infection, but, left untreated, skin anthrax results in overwhelming septicemia and death. Inhalation anthrax, transmitted through the inhalation of spores, begins with mild, nonspecific upper respiratory and flulike symptoms, including fever, muscle aches, and fatigue.

Sodium Polystyrene Sulfonate Brand Name: Kayexalate, Kionex

Sodium polystyrene sulfonate is used to treat hyperkalemia.

Nursing Management of Diabetes Insipidus

Strict I and O's, daily weights, safety, watch electrolytes (hypokalemia) Restrict foods that promote diuresis: watermelon, grapes, garlic, berries etc and caffeine (tea, energy drinks, coffee).

A pregnant woman who was admitted to the high-risk maternity unit for severe hyperemesis gravidarum is receiving total parenteral nutrition (TPN). Intralipids are not being administered. For what potential complication should the nurse monitor the client?

TPN is a hypertonic solution that pulls fluid from the interstitial compartment into the intravascular compartment, resulting in diuresis and dehydration. Because of its high glucose content, TPN can cause hyperglycemia.

A client has a prescription to have blood drawn from the radial artery for a set of arterial blood gas (ABG) determinations. For which test does the nurse look for a positive result before the blood is drawn?

The Allen test is performed before blood is drawn for assessment of arterial blood gases. The radial and ulnar arteries are occluded in turn, then released, after which the distal circulation is assessed. If the result is positive, the client has adequate circulation and that site may be used.

A nurse is preparing to teach a client with newly diagnosed chronic kidney disease (CKD) about the disease and its management. The client's ability to learn is diminished as a result of uremia and anxiety. The nurse makes it a priority to include which when conducting teaching sessions with this client?

The client with CKD is faced with barriers to learning as anxiety and the effects of uremia, including short attention span and memory deficits. The effects of uremia effects usually improve once hemodialysis has begun. The presence of family is helpful, because the family must understand the disease and treatment and may help reinforce information with the client after the formal teaching session is over. The presentation of information should be simple, direct, and aimed at the educational level of the client.

The wife of a client with type 1 diabetes mellitus calls the nurse in the health care provider's office about her husband. She states that her husband is sleepy, that his skin is warm and flushed, and that his breathing is faster than normal. The nurse instructs the wife to:

The client's signs and symptoms are consistent with hyperglycemia. The wife should first obtain a blood glucose reading, which the nurse would then report to the health care provider.

A client hospitalized with an Abdominal Aortic Aneurysm (AAA) suddenly complains of severe back and flank pain. The nurse notes on the cardiac monitor that the client's heart rate has increased from 80 to 110 beats/min. The nurse should:

The signs and symptoms in the question are indicative of rupture of the AAA. Typical signs and symptoms of rupture include back and flank pain, ecchymosis of the flank and perianal areas, a pulsating abdominal mass, lightheadedness, nausea, and signs of shock. This is an emergency situation, and the client requires simultaneous resuscitation and preparation for immediate surgical repair.

A client who is undergoing hemodialysis is receiving epoetin alfa. With which nutrients does the nurse instruct the client to supplement his diet to enhance the effects of therapy? Select all that apply.

To form healthy red blood cells, which is the purpose of epoetin alfa, the body needs adequate iron, folic acid, and vitamin B12. Although the client would be encouraged to implement intake of all of the nutrients identified in the options, iron and folic acid are specifically needed to enhance the hematocrit and increase the benefit of epoetin alfa.

Myasthenia gravis (my-us-THEE-nee-uh GRAY-vis)

Weakness and rapid fatigue of any of the muscles under voluntary control. Myasthenia gravis is caused by a breakdown in the normal communication between nerves and muscles. There is no cure for myasthenia gravis, but treatment can help relieve signs and symptoms, such as. weakness of arm or leg muscles, double vision, drooping eyelids, and difficulties with speech, chewing, swallowing and breathing. Symptoms usually improve with rest.

A client is admitted to the emergency department with a stab wound of the left thorax. The nurse should position the client:

When the client lies on the affected side, the unaffected lung can expand to its fullest potential; elevation of the head facilitates respirations by reducing the pressure of the abdominal organs on the diaphragm, allowing the diaphragm to descend with gravity on inspiration. Maximum lung expansion is inhibited when the head is not elevated.

A nurse caring for a client with leukemia who is undergoing chemotherapy reviews the client's laboratory results and notes that the client has thrombocytopenia. Which interventions does the nurse implement when caring for the client?

A client who has thrombocytopenia is at risk for bleeding, and interventions are aimed at protecting the client from injury and detecting bleeding so that appropriate interventions may be initiated. The nurse should inspect all stools, urine, drainage, and vomit for blood and test them for occult blood. The abdominal girth is measured daily because increases in abdominal girth may indicate internal hemorrhage. As a means of reducing the risk of bleeding, intramuscular injections, which can cause trauma to the tissues and result in hematoma formation, are avoided. Additionally, an electric razor is used.

Glargine insulin is prescribed for a client with type 1 diabetes mellitus. What does the nurse tell the client about this type of insulin? Select all that apply

It does not have a peak effect and cannot be mixed. It is given once daily, at bedtime. It has a 24-hour duration of action Rationale: Glargine insulin, a long-acting insulin, has an onset action of 1 to 2 hours, with no peak, and a duration of action more than 24 hours. Glargine insulin may not be mixed in a syringe with other insulin.

A nurse performs a fingerstick glucose test on a client who is receiving (Total)parenteral nutrition (TPN) and obtains a reading of 410 mg/dL(22.8 mmol/L). On the basis of this finding, the nurse would most appropriately:

Hyperglycemia is one complication of TPN. Because the glucose reading is increased, the nurse would immediately notify the health care provider and await further instructions. Stopping the TPN feeding, decreasing the flow rate of the TPN feeding, and administering a dose of NPH insulin would not be implemented without a health care provider's prescription. A sliding-scale dose of regular insulin might be prescribed to keep the blood glucose level between 180 and 200 mg/dL.

The result of two enzyme-linked immunosorbent assays (ELISA) performed to detect HIV is positive. Which diagnostic test does the nurse anticipate will be prescribed next?

If the results of two ELISA tests are positive, the Western blot is performed to confirm the findings. If the Western blot result is positive, the client is considered positive for HIV and therefore infected with the HIV virus. The CD4+ T-count, which identifies the T-helper lymphocyte count, is performed to determine progression and treatment.

Cyclophosphamide is prescribed for a client with a diagnosis of breast cancer. The nurse has provided instructions to the client regarding the medication. Which statement by the client indicates an understanding of this chemotherapeutic regimen?

"I need to increase my fluid intake to 2000 to 3000 mL a day." Rationale: Hemorrhagic cystitis is a toxic effect of cyclophosphamide. The client should be instructed to drink copious amounts of fluid while taking this medication and should also monitor the urine blood. The medication should be taken on an empty stomach unless gastrointestinal upset occurs. Hyperkalemia may result from the use of the medication; therefore the client would not be encouraged to increase potassium intake (i.e., bananas, orange juice).

A nurse is caring for a client who has just undergone craniotomy with an infratentorial incision. In which position does the nurse expect that the health care provider will prescribe the client to be placed?

Flat and on the side Rationale: The client who has undergone infratentorial craniotomy should be kept flat and placed on either side for 24 to 48 hours. This will prevent pressure on the incision site, which is located in the neck. It also prevents the exertion of pressure on the internal tumor excision site by higher cerebral structures. The client who has undergone supratentorial craniotomy would be positioned with the head of the bed elevated 30 degrees to promote venous drainage.

Meniere's disease

Meniere's disease is a disorder of the inner ear that causes vertigo and a progressive, ultimately permanent loss of hearing, ringing in the ear (tinnitus), and sometimes a feeling of fullness or pressure in the ear. In most cases, Meniere's disease affects only one ear.

A nurse in the emergency department is assessing a client who sustained an open leg fracture in a fall from a ladder. Which question is most important for the nurse to ask the client?

With an open fracture, the client is at risk for osteomyelitis, gas gangrene, and tetanus. The nurse must ask the client about the date of her last tetanus vaccine to ensure that prophylaxis is active.

A client with chronic arterial occlusive disease has a history of intermittent claudication. Which question does the nurse ask to assess the degree to which the client is affected by this condition?

Intermittent claudication, characterized by the sudden onset of leg pain with exercise that is relieved by rest, is a classic symptom of peripheral arterial insufficiency.

Radiation Therapy

Radiation therapy damages cells by destroying the genetic material that controls how cells grow and divide. Both healthy and cancerous cells are damaged by radiation therapy, the goal of radiation therapy is to destroy as few normal, healthy cells as possible.

A client is undergoing anticonvulsant therapy with phenytoin. Which laboratory parameter does the nurse monitor most closely in this client?

Closely monitors the CBC of a client taking the drug because hematological side effects of this therapy include blood dyscrasias such as agranulocytosis, leukopenia, and thrombocytopenia. Liver function tests, a CBC, and a platelet count should be performed before therapy is begun and periodically during therapy.

A client just had a thoracentesis. For which response is it most important for the nurse to observe the client?

Expectoration of blood is an indication that the lung itself was damaged during the procedure; a pneumothorax or hemothorax may occur. It is too soon after a thoracentesis for an infection to develop. Signs of infection are important for the client to assess for several days after the procedure.

Hyperkalemia

The most common cause of hyperkalemia is related to the kidneys such as: Acute kidney failure and Chronic kidney disease. Other causes of hyperkalemia include: Addison's disease, Dehydration, Destruction of red blood cells due to severe injury or burns, Excessive use of potassium supplements, Type 1 diabetes.

A nurse is caring for a client who has been fitted with a continuous bladder irrigation system. During the nurse's 8-hour shift, total infusion of bladder irrigant is 1075 mL. At the end of the 8-hour shift, the nurse calculates that 2050 mL of output was emptied from the Foley catheter drainage bag. How many milliliters of true urine output does the nurse document?

If the total volume emptied from the Foley catheter was 2050 mL and 1075 mL was bladder irrigant, the amount of true urine was 975 mL. To obtain this answer, you must subtract 1075 mL of bladder irrigant from the total emptied 2050 mL

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?

A nonrebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.

What should the nurse expect when assessing a client with pleural effusion?

Compression of the lung by fluid that accumulates at its base reduces expansion and air exchange. This results in reduced or absent breath sounds at the base of the lung.

A nurse is evaluating goal achievement for a client in skeletal traction. Which finding would indicate to the nurse that the goals require revision?

Expected outcomes for the client in skeletal traction include clear lung sounds, intact skin, a bowel movement every other to every third day, and the absence of thrombophlebitis, a disorder marked by calf or groin tenderness, unilateral swelling of the affected extremity, and pain. The client should also be performing active range of motion of uninvolved joints.

A nurse is caring for a young client with cystic fibrosis who has frequent episodes of dyspnea. Which intervention from the plan of care should the nurse perform?

Routine scheduling of airway clearance using chest physiotherapy is an essential intervention for clients with CF. Suctioning the upper airway will not help dyspnea due to thick secretions in the lungs.

During a client's immediate postoperative period after a laryngectomy, a nursing priority is to:

A patent airway is the priority ; therefore, removal of secretions is necessary.

A nurse is caring for a child with cystic fibrosis. The parents ask the nurse if any foods make it worse. Which diet should the nurse include when reinforcing dietary education?

A well-balanced, high-calorie, high-protein diet is recommended for a child with cystic fibrosis due to impaired intestinal absorption. Low-sodium foods can lead to hyponatremia; therefore, high-salt foods are recommended, especially during hot weather or when the child has a fever.

A nurse is teaching a preoperative client about postoperative breathing exercises. What information should the nurse include?

Abdominal breathing improves lung expansion. Placing the hand on the abdomen provides feedback, ensuring that abdominal rather than intercostal breathing is accomplished. Holding the breath for several seconds at the height of inspiration allows several additional seconds for oxygen and carbon dioxide to exchange in the alveoli. Short breaths do not expand the lungs; deep slow breaths at 16 per minute should be encouraged. Exhalation with pursed lips, not an open mouth, promotes exhalation of air from the lung and minimizes trapping of air in the alveoli. Breathing exercises should be performed at least every two hours.

A nurse prepares to treat frostbite of the toes of a homeless man who was brought to the emergency department by the police. Which action by the nurse is appropriate?

Acute frostbite is treated with rapid and continuous rewarming of the tissue in a warm-water bath (90˚ to 107˚ F for 15 to 20 minutes or until flushing of the skin occurs. Dry heat should never be applied, nor should the frostbitten areas be rubbed or massaged as part of the warming process; these actions may produce further tissue injury.

A nurse is caring for a client who is undergoing lumbar puncture (LP). In which position should the nurse place the client after the procedure?

After LP, the client should remain in a supine or dorsal recumbent position for 4 to 12 hours or as prescribed by the health care provider. This position helps prevent headache. Elevating or lowering the head after LP may increase intracranial pressure, resulting in spinal headache.

A nurse is caring for a client who is experiencing spinal shock after sustaining a spinal cord injury. The nurse monitors the client for gastrointestinal complications, watching for:

After spinal cord injury, paralytic ileus —characterized by the absence of bowel sounds and abdominal distention — may develop.

Radiation therapy is prescribed for a client with a brain tumor. Which side effects would the nurse expect the client to experience? Select all that apply.

Because radiation is a local treatment, most side effects are site specific, depending on the organs and tissues that are within or close to the treatment field. The client undergoing irradiation of the brain will most likely experience such early side effects as earache, headache, dizziness, hair loss, and erythema. Cough, dysphagia, and hoarseness occur with radiation to the lung, mediastinum, or esophagus.

A nurse is caring for a client who has just undergone thyroidectomy. Which technique is the best way for the nurse to assess the surgical site for bleeding?

Checking for moisture on the back of the dressing over the client's neck and shoulders Rationale: Thyroid surgery may be complicated by hemorrhage, respiratory distress, parathyroid gland injury (resulting in hypocalcemia and tetany), damage to the laryngeal nerves, and thyroid storm. Hemorrhage is most likely during the 24 hours after surgery. If the client is bleeding after surgery, gravity will cause the blood to seep down the sides of the dressing and drain onto the underlying bed linens even as the top of the dressing remains clean and dry. Asking the client whether the dressing feels wet and replacing the dry sterile dressing every 2 hours are not the best actions. Replacing the dressing frequently when it is not warranted could also increase the risk of infection.

Levothyroxine sodium is prescribed for a client with hypothyroidism, and the nurse provides information to the client about the medication. Which occurrences does the nurse tell the client to report to the health care provider? Select all that apply.

Chest pain Palpitations Rapid heart rate Rationale: The client taking levothyroxine sodium may have hypothyroidism if the dosage is inadequate or may experience of hyperthyroidism if the dosage is too high. Thyroid preparations increase metabolic rate, oxygen demands, and demands on the heart, which may result in angina and cardiac dysrhythmias. The client should be instructed to report chest pain, palpitations, or a rapid heart rate immediately.

A nurse provides instructions to a client who is taking allopurinol for the treatment of gout. Which statements by the client indicate an understanding of the medication? Select all that apply.

Clients taking allopurinol are encouraged to drink at least 8 glasses of fluid a day. Coffee and tea are avoided because they can increase the level of uric acid in the body. Allopurinol is to be given with milk or immediately after meals to ease gastric distress. If the client experiences a rash, irritation of the eyes, or swelling of the lips or mouth, he or she should contact the health care provider, because these are all signs of hypersensitivity. The client should not take large doses of vitamin C while taking allopurinol, because kidney stones could develop.

A nurse is caring for a client who has just had a plaster leg cast applied. Which measure does the nurse implement to prevent the development of compartment syndrome?

Controlling edema helps prevent compartment syndrome. This is best achieved with the use of elevation and the application of ice.

A nurse is assessing a client admitted to the emergency department with a diagnosis of diabetic ketoacidosis (DKA). The nurse observes the client for respirations that are:

Deep and rapid Rationale: The client in diabetic ketoacidosis exhibits Kussmaul's respirations, which are rapid and deep. They occur as the body tries to eliminate carbon dioxide to compensate for the acidosis. As ketoacidosis improves, this pattern of respiration resolves. The nurse monitors the client's respiratory status as part of the assessment of the client's overall status.

A nurse is reviewing laboratory results for a client who has been taking digoxin for the treatment of heart failure. The nurse notes that the report indicates a serum digoxin level of 0.8 ng/mL (1.02 nmol/L). The nurse would most appropriately:

Document the laboratory result Rationale: The optimal therapeutic serum digoxin range is 0.5 to 0.8 ng/mL (0.64 to 1.02 nmol/L).. A level of 0.8 ng/mL (1.02 nmol/L) is within the therapeutic range. Therefore the nurse would document the laboratory result. Contacting the health care provider, repeating the test, and monitoring the client for signs of toxicity are not necessary at this time, because the result is normal.

A nurse is caring for a client who underwent mastectomy 1 day ago. To help restore arm function on the affected side, the nurse encourages the client to use that arm to:

Immediately after mastectomy the client is encouraged to move the fingers and hands and to flex and extend the elbow. The client may also use the arm for self-care, provided that the client does not raise the arm above shoulder level or abduct the shoulder until the postoperative drains have been removed.

A nurse is preparing to care for a client who just returned from the recovery room after a Billroth II procedure. Which intervention in the plan of care does the nurse question?

In a Billroth II resection, an anastomosis is constructed between the proximal remnant of the stomach and the proximal jejunum. Patency of the NG tube is critical in preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically asked to do so by the health care provider, because the tube is placed directly over the suture line. NPO status, active range-of-motion exercises, and coughing and deep-breathing exercises are all appropriate postoperative interventions.

A nurse is developing a plan of care for an older client with diabetic neuropathy of the lower extremities resulting from type 2 diabetes mellitus. Which problem does the nurse recognize as the highest priority for this client?

Increased risk for injury Rationale: The client with diabetic neuropathy of the lower extremities has a diminished sensation in the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system impairment. Therefore the highest priority nursing problem is increased risk for injury. Increased risk of depression and change in body image are more psychosocial in nature and, as such, are secondary needs. A lower level of physical activity may be a problem but is not the priority.

A nurse provides dietary instructions to a client with viral hepatitis whose laboratory results indicate liver impairment. The nurse teaches the client:

Most calories should come from carbohydrates. A low-fat, high-carbohydrate diet is best tolerated. Protein and sodium intake are limited.

A nurse is monitoring a client with myocardial infarction for signs of left ventricular heart failure. The nurse specifically monitors the client for:

Most heart failure begins with failure of the left ventricle and progresses to failure of both ventricles. Decreased tissue perfusion stemming from poor cardiac output and pulmonary congestion resulting from increased pressure in the pulmonary vessels indicate left ventricular failure. In right ventricular failure, the right ventricle is unable to empty completely. Increased volume and pressure develop in the systemic veins, and systemic congestion and peripheral edema develop.

A client sustains a fractured femur and pelvic fractures in a motor vehicle crash. For which signs and symptoms, indicative of hypovolemic shock, does the nurse monitor the client closely? Select all that apply.

Oliguria Tachycardia Hypotension Rationale: Clients who sustain fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh. This can occur with closed as well as open fractures. Signs of hypovolemic shock include tachycardia, hypotension, and diminished urine output.

A nurse is monitoring a client with a head injury for signs of diabetes insipidus (DI). Which finding would cause the nurse to suspect that this complication is developing?

One complication of head injury is diabetes insipidus (DI), which may occur with insult to the hypothalamus, the antidiuretic hormone storage vesicles, or the posterior pituitary gland. In DI the urine specific gravity ranges from 1.003-1.030 and the serum osmolarity and serum sodium level are high. Large quantities of very dilute urine are excreted, putting the client at risk for severe dehydration. The normal sodium range is 135 to 145 mEq/L

A client is experiencing frequent premature ventricular contractions (PVCs). To which assessment would the nurse give priority?

Peripheral pulses may be diminished or absent with PVCs because the decreased stroke volume of the premature beats may decrease peripheral perfusion. It is essential for the nurse to determine whether the premature complexes are resulting in perfusion. This is done by palpating the carotid, brachial, or femoral arteries while observing the monitor for widened complexes or by auscultating for the apical heart sounds. PVCs may be caused by cardiac disorders or any number of physiological stressors, including infection, illness, surgery, and trauma, as well as the intake of caffeine, nicotine, or alcohol.

A nurse provides discharge instructions to a client who was hospitalized for an acute attack of Meniere's disease. Which statements by the nurse are correct? Select all that apply.

Position changes should be made slowly. If an acute attack occurs, sit down and keep the eyes closed. If an acute attack of vertigo occurs, the client is instructed to immediately lie down on a firm surface if possible, loosen clothing, and close the eyes until the acute vertigo stops. The client may resume normal activities but should avoid underwater swimming, which may cause a loss of orientation. Encourage the client to follow a low-salt diet and to avoid excessive use of caffeine, sugar, monosodium glutamate, and alcohol. The client should be taught to avoid sudden head movements or position changes.

A client with acute kidney injury (AKI) has a prescription for oral sodium polystyrene sulfonate. Which serum electrolyte value does the nurse recognize as the cause for this prescription?

Potassium 5.9 mEq/L (5.9 mmol/L) Rationale: The normal potassium range is 3.5 to 5.0 mEq/L , so this client is experiencing hyperkalemia. If the potassium level rises too high, sodium polystyrene sulfonate may be given to produce excretion of potassium through the gastrointestinal tract.

A client with severe heart failure suddenly becomes tachycardic, shows signs of air hunger, and is extremely anxious. The nurse listens to the client's breath sounds and suspects pulmonary edema. The nurse should first:

Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles in the bases. The nurse would immediately place the client in a high Fowler's position to ease the client's breathing.

Scabies

Scabies is contagious and can spread quickly through close contact in a family, child care group, school class, nursing home or prison. Because scabies is so contagious, treatment is recommended for entire families or contact groups. Scabies can be readily treated. Medications applied to skin kill the mites that cause scabies and their eggs. Teach client to: Use hot, soapy water to wash all clothing, towels and bedding used within three days before beginning treatment. Dry with high heat. Dry-clean items that can't wash at home. Starve the mites. Consider placing items that can't be washed in a sealed plastic bag and leaving it in an out-of-the-way place, such as in a garage, for a couple of weeks. Mites die after a few days without food.

A nurse is providing dietary instructions to the spouse of a client with newly diagnosed AIDS who is being discharged from the hospital. The nurse instructs the spouse to:

Serve foods at room temperature Rationale: The AIDS client may experience problems with nutrition as a result of the side effects of medications, anorexia, nausea and vomiting, altered taste, impaired swallowing and chewing, diarrhea, fatigue, depression, or impaired cognition. Foods are best tolerated either cold or at room temperature. Spicy foods may be irritating and can aggravate nausea. Peanut butter, a sticky food, should be avoided in the client having difficulty swallowing. Milk and milk products can exacerbate diarrhea.

The nurse is teaching a client with newly diagnosed diabetes mellitus who has been prescribed NPH insulin how to recognize the signs of hypoglycemia. The client states that he must look for certain signs and symptoms in the late afternoon, indicating to the nurse that he has understood the instructions. What are these signs and symptoms? Select all that apply.

Shakiness Blurred vision Feelings of hunger Rationale: The client taking NPH insulin experiences peak medication effects 6 to 12 hours after administration. When the medication's action peaks, the client is at risk of hypoglycemia. Signs and symptoms of hypoglycemia: anxiety, confusion, difficulty concentrating, blurred vision, cold sweats, headache, increased pulse, shakiness, and hunger.

A client is receiving digoxin for the treatment of heart failure. For which signs of digoxin toxicity does the nurse monitor the client? Select all that apply.

Signs and symptoms of toxicity include abdominal pain, nausea and vomiting, diarrhea, headaches, blurred, yellow, or green vision; halos, confusion, bradycardia, and dysrhythmias.

A nurse is conducting an assessment of a client with angina pectoris. The client reports that the anginal pain is triggered by exercise and relieved by rest or nitroglycerin. In the client's record, the nurse notes that the client is experiencing:

Stable angina is induced by exercise and relieved by rest or nitroglycerin. Variant angina, or Prinzmetal angina, is prolonged and severe and occurs at the same time each day, most often in the morning. Unstable angina occurs with lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction.

A nurse is administering a dose of oral pyridostigmine bromide to a client with myasthenia gravis. What does the nurse ask the client to do before administering the medication?

Take sips of water Rationale: Myasthenia gravis can affect the ability to swallow, so the nurse must determine the client's ability to swallow before administering oral medication.

A nurse is monitoring a client who is taking spironolactone for the treatment of hypertension. Which findings denote adverse effects of the medication? Select all that apply.

Tall T waves Prolonged PR interval Hyperactive bowel sounds Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing diuretics can cause hyperkalemia. Cardiovascular manifestations of hyperkalemia include tall T waves, widened QRS complexes, prolonged PR intervals, and flat P waves. Other cardiovascular manifestations include an irregular heart rate, decreased blood pressure, and ectopic heartbeats. Muscle twitches occur in hyperkalemia. Hyperactive bowel sounds and diarrhea also occur in hyperkalemia. Constipation, hyporeflexia, and shallow respirations are signs of hypokalemia.

A nurse caring for a client with a spinal cord injury is watching for signs of autonomic dysreflexia. For which manifestation of this complication does the nurse monitor the client?

The client with a spinal cord injury is at risk for autonomic dysreflexia if the injury is located above the level of T7. The condition is characterized by severe throbbing headache, flushing of the face and neck, bradycardia, nasal stuffiness, and sudden severe hypertension. Other signs include blurred vision, nausea, and sweating. This life-threatening syndrome is triggered by a noxious stimulus below the level of the injury.

A nurse is assessing a client's fluid balance on the day after craniotomy. Which laboratory result would the nurse report to the health care provider?

The normal plasma osmolarity is 275 to 295 mOsm/kg. A value greater than 295 mOsm/kg indicates dehydration; a value less than 275 mOsm/kg indicates overhydration. After craniotomy, the goal is to keep the plasma osmolarity on the high side of normal as a means of helping control cerebral edema. Because a plasma osmolarity of 265 mOsm/kg is low, the client is overhydrated and at risk for cerebral edema. The nurse should report this finding.

A client is scheduled to undergo insertion of an inferior vena cava (IVC) filter in 2 days. Which medication should the nurse anticipate to withhold as prescribed during the preoperative period?

The nurse should anticipate that the surgeon will prescribe the warfarin sodium to be withheld in the period just before insertion of an IVC filter. This medication is often withheld before surgery to minimize the risk of intraoperative hemorrhage. The other medications may also be withheld by request of the surgeon, but usually they are discontinued as part of an "NPO [nothing by mouth] after midnight" prescription.

A client with deep vein thrombus (DVT) is undergoing anticoagulant therapy with warfarin sodium (Coumadin). The client's prothrombin time is 18 seconds, with a control of 11 seconds, and the International Normalized Ratio (INR) is 2.0. The nurse recognizes these results as:

The therapeutic range for prothrombin time (PT) is 1.5 to 2 times the control for clients at high risk for thrombus. This client's control value means that the therapeutic range for would be 16.5 to 22 seconds. Therefore the result is within the therapeutic range. The client receiving warfarin sodium for DVT should have an INR between 2.0 and 3.0.

A client who sustained a major burn injury is beginning to take an oral diet again. Which between-meal menu selections meet the client's needs for wound healing and tissue repair? Select all that apply.

Whole-milk shake and granola Baked potato topped with cheese Cheese and whole-wheat crackers Rationale: To facilitate healing and meet continued high metabolic needs, the client with a major burn should eat a diet high in calories, protein, and carbohydrates. This type of diet also keeps the client in positive nitrogen balance. Foods such as milkshakes, granola, cheese, and whole-wheat products are acceptable choices. Though fresh fruits and vegetables and skim milk are high in nutrients, higher-calorie foods, including versions of dairy products prepared with whole milk, are preferable in this situation.

A nurse planning care for a client who has undergone transurethral resection of the prostate (TURP) remembers that the most common cause of postoperative pain is:

Bladder spasms may occur after TURP because of postoperative bladder distention or irritation by the balloon of the indwelling urinary catheter. The nurse administers antispasmodic medications as prescribed to treat this type of pain. Because the prostate is accessed through the urethra, there is no incision in a TURP. Bleeding within the bladder and tension on the Foley catheter are not common causes of pain.

A nurse is developing a plan of care for a client who has had a stroke and is experiencing homonymous hemianopsia. Which interventions does the nurse include in the care plan to help the client to overcome this deficit?

Encouraging the client to turn the head from side to side to scan the complete range of vision Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and conducts client teaching from within the intact field of vision. The nurse encourages the use of the client's own eyeglasses, if they are available.

A client with cancer is admitted to the hospital for a chemotherapy treatment with intravenous bleomycin sulfate. Which nursing assessment would be given the highest priority while the chemotherapy is being administered?

Bleomycin sulfate, an antineoplastic medication, can cause pneumonitis that may progress to pulmonary fibrosis. Pulmonary function studies, along with hematologic, hepatic, and renal function, need to be monitored. Monitor lung sounds for dyspnea and crackles indicating pulmonary toxicity. The medication should be discontinued immediately if pulmonary toxicity occurs.

For which findings, early signs of increased intracranial pressure (ICP), does the nurse caring for a client who sustained a head injury monitor the client? Select all that apply.

Early signs of increased ICP include a decreasing level of consciousness (this is the earliest and most sensitive sign), a headache that intensifies with coughing or straining, pupillary changes or visual disturbances, and contralateral motor or sensory losses. Late signs include changes in vital signs (e.g., widened pulse pressure, slowed pulse); shallow, slowed respirations; irregular periods of apnea; hiccups; fever without a source of infection; vomiting; and posturing.

A nurse assessing the skin of a client who is immobile notes this change in appearance of the sacaral area. It should be documented as?

In stage I pressure ulcer, the skin is reddened but intact. In a stage II pressure ulcer, there is partial-thickness skin loss involving the epidermis or dermis. The ulcer is superficial and may be characterized as an abrasion, blister, or shallow crater. A deep crater is seen in stage III, and, in stage IV, sinus tracts have developed.

A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV infection. Forty-eight hours after administration, the nurse checks the test site (see image).

Positive Rationale: The tuberculin, or TST, test is a reliable determinant of tuberculosis (TB) infection. A reaction measuring 5 mm or more in diameter is considered positive in a client with HIV infection. A reaction measuring 10 mm or more in diameter is considered positive in a non-immunosuppressed client. In this instance, the area of induration measures 9 mm, indicating a positive reaction. A positive reaction does not mean that active disease is present, but it does indicate exposure to TB or the presence of inactive (dormant) disease.

A home care nurse, assessing the skin of a client, notes the following rash beneath the skin: Which precaution will the nurse immediately institute before completing the assessment?

Putting on a gown and gloves Rationale: Scabies presents as vesicle or pustule irritations, burrows, or rash of the skin, especially in the webbing between the fingers. When a client is infested with scabies, a gown and gloves should be worn for close contact. A mask and head covering are not necessary. Transmission by way of clothing and other inanimate objects is uncommon. Scabies is transmitted from person to person by direct skin contact. All of the client's contacts should be treated for the infestation at the same time.

A client with myocardial infarction is being monitored closely for signs of cardiogenic shock. For which signs of this type of shock is the nurse alert?

Signs of cardiogenic shock include tachycardia; hypotension; urine output of less than 30 mL/hr; cold, clammy skin; poor peripheral pulses; agitation; restlessness or confusion; pulmonary congestion; tachypnea; chest pain; and increased CVP.

A client is receiving heparin sodium by way of continuous intravenous (IV) infusion. For which adverse effect of this therapy does the nurse monitor the client?

The client who receives continuous IV heparin is at risk for bleeding. The nurse assesses the client for signs of bleeding, including bleeding from the gums, petechiae, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood.

A nurse is caring for a client with a cervical spine injury to whom Crutchfield tongs have been applied. Which intervention listed in the nursing care plan would the nurse question?

Obtaining help from another nurse to remove the weights when repositioning the client Rationale: Crutchfield tongs are applied after holes have been drilled in the client's skull. Local anesthesia is used for this procedure. Weights, used to exert pulling pressure on the longitudinal axis of the cervical spine, are attached to the tongs. Serial x-rays of the cervical spine are taken and weights gradually added until the x-ray reveals that the vertebral column has been properly realigned. Thereafter, the weight may be gradually reduced as prescribed to a point that maintains alignment. The client with Crutchfield tongs is placed on a Stryker frame, RotoRest bed, or other specialized bed. The nurse ensures that weights hang freely and that the weight in use matches the current prescription. The nurse also inspects the integrity and position of the ropes and pulleys. If the client complains of severe muscle pain, the weights may be too heavy or the client may require realignment. The nurse reports the pain to the health care provider if realignment fails to reduce the discomfort. The nurse does not remove the weights to administer care.

A nurse is teaching a client with newly diagnosed diabetes mellitus how to perform fingerstick blood glucose measurements. The nurse tells the client to:

Before performing a fingerstick for blood glucose measurement, the client should wash the hands, using warm water to stimulate the circulation to the area. The finger is punctured near the side, not the center, because there are fewer nerve endings along the side of the finger. The puncture is only deep enough to obtain an adequate size of a drop of blood; an excessively deep puncture may result in pain and bruising. The arm should be allowed to hang dependently, and the finger may be massaged to promote obtaining a good-sized drop of blood. The site is cleaned with alcohol or an antiseptic swab and allowed to dry completely before puncture, because alcohol can cause hemolysis of blood. To help prevent infection, a lancet or blood-letting device is used once and then discarded.

A client is scheduled to have blood obtained for a serum digoxin determination. The nurse should arrange to have the blood sample drawn:

Blood for measurement of the serum digoxin level is most often drawn immediately before the next dose, although it may also be drawn 6 to 8 hours after a dose. Recall that the purpose of the laboratory test is to measure the serum concentration of the medication to ensure that it is in the therapeutic range. Drawing the blood 8 hours after the last dose was given ensures that the level is not falsely increased. The range for digoxin is is 0.5 to 0.8 ng/mL

A nurse is reviewing the nursing care plan for a client who has seizure precautions in place. Which intervention documented in the plan of care should the nurse question?

Keep a padded tongue blade at the bedside: airway, oxygen, and suctioning equipment should be at the bedside. The side rails of the bed may be padded, and the bed is kept in the lowest position. The client has IV access in place to facilitate rapid administration of anticonvulsant medications must be administered. A padded tongue blade, however, should not be kept at the bedside. Forcing a tongue blade or anything else into the mouth during a seizure is likely to result in harm to the client who bites down during seizure activity. Risks include airway blockage resulting from improper placement and chipping of the client's teeth with a subsequent risk of aspiration of tooth fragments. If the client has an aura before the seizure, the nurse may have enough time to place an oral airway before seizure activity begins.