HESI Exit Practice Questions and Rationale

A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which client statement indicates a need for further instruction? 1."I will obtain adequate rest." 2."I will take acetaminophen if I get a headache." 3."I should monitor my weight on a regular basis." 4."I need to include sufficient amounts of carbohydrates in my diet."

2 Acetaminophen is avoided because it can cause fatal liver damage in the client with cirrhosis. Adequate rest and nutrition are important. The client's weight should be monitored on a regular basis. The diet should supply sufficient carbohydrates with a total daily calorie intake of 2000 to 3000.

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? 1.Waves of loud gurgles auscultated in all 4 quadrants 2.Low-pitched swishing auscultated in 1 or 2 quadrants 3.Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants 4.Very high-pitched, loud rushes auscultated especially in 1 or 2 quadrants

2 Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very high-pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.

The nurse is monitoring a client who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication? 1. The development of complaints of insomnia 2. The development of audible expiratory wheezes 3. A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after 2 doses of the medication 4. A baseline resting heart rate of 88 beats/minute followed by a resting heart rate of 72 beats/minute after 2 doses of the medication

2 Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. Beta blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored.

After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication? 1.Stroke 2.Pernicious anemia 3.Bacterial meningitis 4.Peripheral arterial disease

2 Billroth I surgery involves removing one half to two thirds of the stomach and reanastomosing the remaining segment of the stomach to the duodenum. With the loss of this much of the stomach, development of pernicious anemia is not uncommon. Pernicious anemia is a macrocytic anemia that most commonly is caused by the lack of intrinsic factor. During a Billroth I procedure, a large portion of the parietal cells, which are responsible for producing intrinsic factor (a necessary component for vitamin B12 absorption), are removed. In this anemia, the red blood cell is larger than usual and hence does not last as long in the circulation as normal red blood cells do, causing the client to have anemia with resultant fatigue. Vitamin B12 also is necessary for normal nerve function. Because of the lack of the necessary intrinsic factor, persons with pernicious anemia also experience paresthesias, impaired gait, and impaired balance. Although the symptoms could possibly indicate the other options listed, pernicious anemia is the most logical based on the surgery the client underwent.

A client being treated for heart failure is administered intravenous bumetanide. Which outcome indicates that the medication has achieved the expected effect? 1. Cough becomes productive of frothy pink sputum. 2.Urine output increases from 10 mL/hour to greater than 50 mL hourly. 3.The serum potassium level changes from 3.8 to 3.1 mEq/L (3.8 to 3.1 mmol/L). 4.B-type natriuretic peptide (BNP) factor increases from 200 to 262 pg/mL (200 to 262 ng/L).

2 Bumetanide is a diuretic and expected outcomes include increased urine output, decreased crackles, and decreased weight. Options 1, 3, and 4 are incorrect.

A calcium carbonate antacid has been prescribed for a client, and the nurse provides instructions to the client about the medication. The nurse should tell the client that it is best to take the antacid with which item? 1.Milk 2.Water 3.Yogurt 4.Cheese

2 Calcium carbonate antacids should not be taken with milk, milk products, or foods or supplements high in vitamin D because milk-alkali syndrome (headache, urinary frequency, anorexia, nausea, vomiting, and fatigue) can occur. The best item to consume when taking calcium carbonate is water.

A client with heart failure is scheduled to be discharged to home with digoxin and furosemide as daily prescribed medications. The nurse tells the client to report which finding as an indication that the medications are not having the intended effect? 1.Sudden increase in appetite 2.Weight gain of 2 to 3 lb in a few days 3.Increased urine output during the day 4.Cough accompanied by other signs of respiratory infection

2 Clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia. An increase in urine output during the day is expected with diuretic therapy. A cough resulting from respiratory infection does not necessarily indicate that heart failure is worsening.

The health care provider has prescribed clonidine for a client with hypertension. The nurse should inform the client that which is a side effect of this medication? 1.Restlessness 2.Constipation 3.Hypertension 4.Increased salivation

2 Clonidine is an antihypertensive medication. Side effects of clonidine include dry mouth, drowsiness, constipation, and hypotension. Therefore, symptoms in the remaining options are incorrect.

A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hour. The nurse determines that the client is receiving the therapeutic effect based on which results? 1. Prothrombin time of 12.5 seconds 2. Activated partial thromboplastin time of 60 seconds 3. Activated partial thromboplastin time of 28 seconds 4. Activated partial thromboplastin time longer than 120 seconds

2 Common laboratory ranges for activated partial thromboplastin time (aPTT) are 30 to 40 seconds. Because the aPTT should be 1.5 to 2.5 times the normal value, the client's aPTT would be considered therapeutic if it was 60 seconds. Prothrombin time assesses response to warfarin therapy.

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client and family? 1.Discouraging the family from touching the client 2.Explaining equipment and procedures on an ongoing basis 3.Ensuring adherence to visiting hours to ensure the client's rest 4.Encouraging the family not to "give in" to their feelings of grief

2 Families often need assistance to cope with the illness of a loved one. The nurse should explain all equipment, treatments, and procedures and should supplement or reinforce information given by the health care provider. Family members should be encouraged to touch and speak to the client and to become involved in the client's care to the extent they are comfortable. The nurse should allow the family to stay with the client to the extent possible and should encourage them to eat and sleep adequately to maintain strength. The nurse can help family members of an unconscious client by assisting them to work through their feelings of grief.

The nurse is planning teaching for a female client diagnosed with urethritis caused by chlamydial infection. Which information should the nurse plan to include in the teaching session? 1.Alter the perineal pH by using a spermicide with a condom. 2.Keep follow-up appointments for repeat cultures in 4 to 7 days. 3.Discontinue antibiotics after 3 weeks of uninterrupted administration. 4.Identify sexual partners for the past 12 months so they can be treated.

2 Follow-up cultures are typically done in 4 to 7 days to evaluate the effectiveness of the medication. Using a spermicide does not change the perineal pH. The infection can be prevented by the use of latex condoms. Chlamydial infection is treated with antibiotics, which are not discontinued until the prescribed course is completed. All sexual partners during the 30 days before diagnosis should be notified, examined, and treated as necessary.

The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? 1. Keep the legs aligned with the heart. 2.Elevate the legs higher than the heart. 3.Clean the skin with alcohol every hour. 4.Position the client onto the side during every shift.

2 In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the heart. Alcohol is very irritating and drying to tissues and should not be used in areas of skin breakdown. Option 4 specifies infrequent care intervals, so it is not the priority intervention.

The nurse is performing discharge teaching for a client with chronic pancreatitis. Which information should the nurse include? 1.Alcohol should be consumed in moderation. 2.Avoid caffeine because it may aggravate symptoms. 3.Diet should be high in carbohydrates, fats, and proteins. 4.Frothy, fatty stools indicate that enzyme replacement is working.

2 Knowing that caffeinated beverages, such as coffee, tea, and soda, will worsen symptoms, such as pain, will direct you to select the correct option. Alcohol can precipitate an attack of pancreatitis and needs to be avoided. The recommended diet is moderate carbohydrates, low fat, and moderate protein. Frothy, fatty stools indicate that the replacement enzyme dose needs to be increased.

A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1.Glipizide 2.Metformin 3.Repaglinide 4.Regular insulin

2 Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization.

The nurse reads that metoclopramide is prescribed for a client. Based on this prescription, the nurse expects to note that which diagnosis is documented? 1.Asthma 2.Gastroparesis 3.Allergic rhinitis 4.Chronic kidney disease

2 Metoclopramide stimulates motility of the upper gastrointestinal tract. It is used to stimulate gastric emptying, for the treatment of gastroparesis, and to treat gastroesophageal reflux disease. It may also be prescribed to relieve nausea and vomiting. It is not a respiratory medication or a renal/urinary medication and is not used to treat the conditions noted in the incorrect options.

Nitrofurantoin is prescribed for a client with urinary tract infection. The nurse is instructing the client regarding the administration of the medication. Which information about the best time to take this medication should be included in the client's education? 1.At bedtime 2.With meals 3.One hour before the dinner meal 4.In the morning 2 hours after breakfast

2 Nitrofurantoin is an antibacterial used to treat urinary tract infections. The nurse would instruct the client to take the medication with food to reduce any gastrointestinal upset that the medication can cause. Therefore, the best time to take the medication is with meals.

The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? 1. Blood pressure 2.Status of airway 3.Oxygen flow rate 4.Level of consciousness

2 Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Cardioversion is a medical procedure that restores a normal heart rhythm in people with certain types of abnormal heartbeats (arrhythmias)

A client has been taking omeprazole for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom? 1.Diarrhea 2.Heartburn 3.Flatulence 4.Constipation

2 Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called heartburn by clients. Omeprazole is not used to treat the conditions identified in options 1, 3, and 4.

The client with gastroesophageal reflux disease (GERD) has a new prescription for pantoprazole. Which instruction should the nurse provide to the client? 1.Chew the pill thoroughly. 2.Swallow the tablet whole. 3.Headache is expected to occur. 4.Crush the pill if it is difficult to swallow.

2 Pantoprazole, a proton pump inhibitor, is a delayed-release medication and should be swallowed whole. It should not be chewed or crushed. Headache is a potential side effect of the medication and should be reported to the health care provider if it is troublesome.

The nurse has provided self-care activity instructions to a client after insertion of an implanted cardioverter-defibrillator (ICD). The nurse determines that further instruction is needed if the client makes which statement? 1."I need to avoid doing anything that could involve rough contact with the ICD insertion site." 2."I can perform activities such as swimming, driving, or operating heavy equipment as I need to." 3."I should try to avoid doing strenuous things that would make my heart rate go up to or above the rate cutoff on the ICD." 4."I should keep away from electromagnetic sources such as transformers, large electrical generators, and metal detectors, and I shouldn't lean over running motors."

2 Postdischarge instructions typically include avoiding tight clothing or belts over the ICD insertion sites; rough contact with the ICD insertion site; and electromagnetic fields such as with electrical transformers, radio/TV/radar transmitters, metal detectors, and running motors of cars or boats. Clients also must alert health care providers (HCPs) or dentists to the presence of the device because certain procedures such as diathermy, electrocautery, and magnetic resonance imaging may need to be avoided to prevent device malfunction. Clients should follow the specific advice of a HCP regarding activities that are potentially hazardous to self or others, such as swimming, driving, or operating heavy equipment.

A client with ulcerative colitis has a prescription to begin a salicylate compound medication to reduce inflammation. What instruction should the nurse give the client regarding when to take this medication? 1.On arising 2.After meals 3.On an empty stomach 4.30 minutes before meals

2 Salicylate compounds, such as sulfasalazine, act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and increase fluid intake throughout the day. The medication needs to be taken after meals to reduce gastrointestinal irritation. The other options are incorrect and could cause gastric irritation.

A client rings the call bell and asks for medication to relieve postoperative gas pains. The nurse selects which medication to be given as prescribed on the medication sheet? 1.Droperidol 2.Simethicone 3.Acetaminophen 4.Magnesium hydroxide

2 Simethicone is an antiflatulent used in the relief of pain caused by excessive gas in the gastrointestinal tract. Droperidol relieves postoperative nausea and vomiting. Acetaminophen is a nonopioid analgesic. Magnesium hydroxide is an antacid and laxative.

The nurse is assisting a health care provider (HCP) with the insertion of a Miller-Abbott tube. The nurse understands that the procedure places the client at risk for aspiration and should therefore implement which action to decrease this risk? 1.Insert the tube with the balloon inflated. 2.Place the client in a semi Fowler's to high Fowler's position. 3.Instruct the client to cough when the tube reaches the nasal pharynx. 4.Instruct the client to perform a Valsalva maneuver if the impulse to gag and vomit occurs.

2 The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine, as in correcting a bowel obstruction. Initial insertion of the tube is an HCP responsibility. The tube is inserted with the balloon deflated in a manner similar to the proper procedure for inserting a nasogastric tube. The client is usually given water to drink to facilitate passage of the tube through the nasopharynx and esophagus. A semi Fowler's to high Fowler's position decreases the risk of aspiration if vomiting occurs. A Valsalva maneuver is not helpful and is not used if the impulse to gag occurs.

Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit? 1. Vitamin K 2.Protamine sulfate 3.Potassium chloride 4.Aminocaproic acid

2 The antidote to heparin is protamine sulfate; it should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin sodium. Potassium chloride is administered for a potassium deficit. Aminocaproic acid is the antidote for thrombolytic therapy.

A client with appendicitis is scheduled for an appendectomy. The nurse providing preoperative teaching for the client describes the location of the appendix by stating that it is attached to which part of the gastrointestinal (GI) system? 1.Ileum 2.Cecum 3.Rectum 4.Jejunum

2 The appendix, sometimes referred to as the vermiform appendix, is attached to the apex of the cecum. The other locations listed are incorrect.

The nurse is providing instructions to a client with a colostomy about measures to reduce the odor from the colostomy. Which client statement indicates that the educational session was effective? 1."I should be sure to eat at least 1 cucumber every day." 2."Beet greens, parsley, or yogurt will help to control the colostomy odor." 3."I will need to increase my egg intake and try to eat ½ to 1 egg per day." 4."Green vegetables such as spinach and broccoli will prevent odor, and I should eat these foods every day."

2 The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also may reduce odor, but it is a gas-forming food and should be avoided. Cucumbers, eggs, and broccoli also are gas-forming foods and should be avoided or limited by the client.

The nurse is caring for a client who is receiving dopamine. Which potential problem is a priority concern for this client? 1.Fluid overload 2.Peripheral vasoconstriction 3.Inability to perform self-care 4.Inability to discriminate hot or cold sensations

2 The client who is receiving dopamine therapy should be assessed for peripheral vasoconstriction related to the action of the medication. The remaining options are not related directly to this medication therapy.

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1.Hypovolemia 2.Acute kidney injury 3.Glomerulonephritis 4.Urinary tract infection

2 The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10-20 mg/dL (3.6-7.1 mmol/L), and creatinine, male, 0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1 mg/dL (44-97 mcmol/L). The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or urinary tract infection.

A client who uses nonsteroidal antiinflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that the misoprostol is having the intended therapeutic effect if which finding is noted? 1.Resolved diarrhea 2.Relief of epigastric pain 3.Decreased platelet count 4.Decreased white blood cell count

2 The client who uses NSAIDs is prone to gastric mucosal injury. Misoprostol is a gastric protectant and is given specifically to prevent this occurrence in clients taking NSAIDs frequently. Diarrhea can be a side effect of the medication but is not an intended effect. Options 3 and 4 are unrelated to the purpose of misoprostol.

The nurse is providing dietary instructions to a client with a diagnosis of irritable bowel syndrome. The nurse determines that education was effective if the client states the need to avoid which food? 1.Rice 2.Corn 3.Broiled chicken 4.Cream of wheat

2 The client with irritable bowel should take in a diet that consists of 30 to 40 g of fiber daily because dietary fiber will help produce bulky, soft stools and establish regular bowel habits. The client should also drink 8 to 10 glasses of fluid daily and chew food slowly to promote normal bowel function. Foods that are irritating to the intestines need to be avoided. Corn is high in fiber but can be very irritating to the intestines and should be avoided. The food items in the other options are acceptable to eat.

The nurse is reviewing the procedure for performance of an electrocardiogram (ECG). Which action by the nurse indicates understanding of the correct position for the V1 lead when performing a 12-lead electrocardiogram? 1."The lead should be placed on the fourth intercostal space left sternal border." (V2) 2."The lead should be placed on the fourth intercostal space right sternal border." (V1) 3."The lead should be placed on the fifth intercostal space left midaxillary line." (V6) 4."The lead should be placed on the fifth intercostal space left midclavicular line." (V4)

2 The correct location for the V1 lead is the fourth intercostal space right sternal border. Therefore, the locations in the remaining options are incorrect.

Cholestyramine resin is prescribed for a client with an elevated serum cholesterol level. The nurse should instruct the client to take the medication in which way? 1.After meals 2.Mixed with fruit juice 3.Via a rectal suppository 4.At least 3 hours before meals

2 This medication binds with bile salts in the intestines to form a compound that is excreted in the feces. The client should be instructed to mix the medication with 3 to 6 ounces of water, milk, fruit juice, or soup. It should be administered before meals. It is not administered via rectal suppository.

A client is taking trihexyphenidyl hydrochloride. The nurse should assess for which side or adverse effect of this medication? 1.Diarrhea 2.Urinary retention 3.Urinary incontinence 4.Excessive perspiration

2 Trihexyphenidyl is an anticholinergic medication used for the treatment of Parkinson's disease. Therefore, it can cause urinary hesitancy and retention, constipation, dry mouth, and decreased sweating.

A client with a clot in the right atrium is receiving a heparin sodium infusion at 1000 units/hour and warfarin sodium 7.5 mg at 5:00 p.m. daily. The morning laboratory results are as follows: activated partial thromboplastin time (aPTT), 32 seconds; international normalized ratio (INR), 1.3. The nurse should take which action based on the client's laboratory results? 1. Collaborate with the health care provider (HCP) to discontinue the heparin infusion and administer the warfarin sodium as prescribed. 2.Collaborate with the HCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed. 3.Collaborate with the HCP to withhold the warfarin sodium since the client is receiving a heparin infusion and the aPTT is within the therapeutic range. 4.Collaborate with the HCP to continue the heparin infusion at the same rate and to discuss use of dabigatran etexilate in place of warfarin sodium.

2 When a client is receiving warfarin for clot prevention due to atrial fibrillation, an INR of 2 to 3 is appropriate for most clients. Until the INR has achieved a therapeutic range, the client should be maintained on a continuous heparin infusion with the aPTT ranging between 60 and 80 seconds. Therefore, the nurse should collaborate with the HCP to obtain a prescription to increase the heparin infusion and to administer the warfarin as prescribed.

The nurse is providing discharge instructions to a client receiving trimethoprim-sulfamethoxazole. Which instruction should be included in the list? 1.Advise that sunscreen is not needed. 2.Drink 8 to 10 glasses of water per day. 3.If the urine turns dark brown, call the health care provider (HCP) immediately. 4.Decrease the dosage when symptoms are improving to prevent an allergic response.

2 Each dose of trimethoprim-sulfamethoxazole should be administered with a full glass of water, and the client should maintain a high fluid intake to avoid crystalluria. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Clients should be advised to use sunscreen since the skin becomes sensitive to the sun. Some forms of trimethoprim-sulfamethoxazole cause urine to turn dark brown or red. This does not indicate the need to notify the HCP.

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? 1. Muffled heart sounds 2. A rise in blood pressure 3. Jugular venous distention 4.Client expressions of dyspnea

2 Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs with cardiac tamponade.

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1. Hypovolemia 2.Acute kidney injury 3.Glomerulonephritis 4.Urinary tract infection

2 The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10-20 mg/dL (3.6-7.1 mmol/L), and creatinine, male, 0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1 mg/dL (44-97 mcmol/L). The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or urinary tract infection.

The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply. 1.Use products that contain alcohol. 2.Position the client on his or her side. 3.Brush the teeth with a small, soft toothbrush. 4.Cleanse the mucous membranes with soft sponges. 5.Use lemon glycerin swabs when performing mouth care.

2, 3, 4 The unconscious client is positioned on the side during mouth care to prevent aspiration. The teeth are brushed at least twice daily with a small toothbrush. The gums, tongue, roof of the mouth, and oral mucous membranes are cleansed with soft sponges to avoid encrustation and infection. The lips are coated with water-soluble lubricant to prevent drying, cracking, and encrustation. The use of products with alcohol and lemon glycerin swabs should be avoided because they have a drying effect.

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1.Clustering nursing activities 2.Hyperoxygenating before suctioning 3.Maintaining 20 degree flexion of the knees 4.Maintaining the head and neck in midline position 5.Maintaining the head of the bed (HOB) at 30 degrees elevation

2, 4, 5 Measures aimed at preventing increased ICP in the poststroke client include hyperoxgenating before suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries; maintaining the head in a midline, neutral position to help promote venous drainage from the brain; and keeping the HOB elevated to between 25 and 30 degrees to prevent a decreased blood flow to the brain. Clustering activities can be stressful for the client and increase ICP. Maintaining 20 degree flexion of the knees increases intraabdominal pressure and consequently ICP.

The nurse is monitoring a client who is taking digoxin for adverse effects. Which findings are characteristic of digoxin toxicity? Select all that apply. 1.Tremors 2.Diarrhea 3.Irritability 4.Blurred vision 5.Nausea and vomiting

2, 4, 5 Digoxin is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. Subsequent manifestations include headache; visual disturbances such as diplopia, blurred vision, yellow-green halos, and photophobia; drowsiness; fatigue; and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitors the digoxin level. The optimal therapeutic range for digoxin is 0.5 to 0.8 ng/mL.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/symptom(s) of duodenal ulcer? 1.Weight loss 2.Nausea and vomiting 3.Pain relieved by food intake 4.Pain radiating down the right arm

3 A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the mid-epigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.

A health care provider (HCP) prescribes a Salem sump tube for gastrointestinal intubation. Which item should the nurse obtain from the supply room? 1.A Dobbhoff weighted tube 2.A Sengstaken-Blakemore tube 3.A tube with a large lumen and an air vent 4.A tube with a single lumen that connects to suction

3 A tube with a large lumen and an air vent is a Salem sump tube. A Dobbhoff weighted tube is a type of feeding tube. A Sengstaken-Blakemore tube is used to control bleeding in the esophagus. A tube with a single lumen is called a Levin tube.

A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication? 1.Sodium level, 140 mEq/L (140 mmol/L) 2.Uric acid level, 4.0 mg/dL (0.24 mmol/L) 3.White blood cell count, 3000 mm3 (3.0 × 109/L) 4.Blood urea nitrogen level, 10 mg/dL (3.6 mmol/L)

3 Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia; cardiovascular disturbances, including thrombophlebitis and dysrhythmias; and dermatological effects. The low white blood cell count reflects agranulocytosis. The laboratory values in options 1, 2, and 4 are normal values.

The nurse is preparing to administer an intermittent enteral feeding though a nasogastric (NG) tube. Which priority assessment should the nurse perform? 1.Observe for digestion of formula. 2.Assess fluid and electrolyte status. 3.Evaluate absorption of the last feeding. 4.Evaluate percussion tone of the stomach.

3 All stomach contents are aspirated and measured before a tube feeding is administered. This procedure measures the gastric residual. The gastric residual is assessed to confirm whether undigested formula from a previous feeding remains, thereby evaluating absorption of the last feeding. It is important to assess gastric residual because administration of an enteral feeding to a full stomach could result in overdistention, predisposing the client to regurgitation and possible aspiration. The remaining options do not relate to the purpose of assessing residual.

A client with a gastric ulcer is prescribed both magnesium hydroxide and cimetidine twice daily. How should the nurse schedule the medications for administration? 1.Drink 8 ounces of water between taking each medication. 2.Administer the cimetidine and magnesium hydroxide at the same time twice daily. 3.Administer each dose of cimetidine 1 hour prior to the administration of magnesium hydroxide. 4.Collaborate with the health care provider (HCP), as the client should not be receiving both medications.

3 Antacids, such as magnesium hydroxide, can decrease absorption of cimetidine. At least 1 hour should separate administration of an antacid and cimetidine. The remaining options are incorrect.

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? 1. A stage 1 ulcer 2.A vascular ulcer 3.An arterial ulcer 4.A venous stasis ulcer

3 Arterial ulcers have a pale deep base and are surrounded by tissue that is cool with trophic changes such as dry skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A stage 1 ulcer indicates a reddened area with an intact skin surface. A venous stasis ulcer (vascular) has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion.

The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? 1. Flat neck veins 2.A pulse rate of 60 beats/minute 3.Muffled or distant heart sounds 4.Wheezing on auscultation of the lungs

3 Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). The other options are not signs of cardiac tamponade.

A client seen in the health care clinic for follow-up care is taking atorvastatin. The nurse should assess the client for which adverse effect of the medication? 1.Earache 2.Hearing loss 3.Photosensitivity 4.Lung congestion

3 Atorvastatin is a reductase inhibitor (HMG-CoA reductase inhibitor) that is used to treat hypercholesterolemia and hypertriglyceridemia. Adverse effects include photosensitivity and the potential for developing cataracts. The symptoms in the remaining options are not side and adverse effects of this medication.

Benztropine mesylate is prescribed for a client. What statement by the client indicates that the client needs further teaching about the medication? 1."I will avoid driving if I get drowsy or dizzy." 2."I will watch my urinary output and look for signs of constipation." 3."I will sit in the sun for an hour a day to enhance medication effectiveness." 4."I will call the health care provider if I have difficulty swallowing or if I start vomiting."

3 Benztropine mesylate is an anticholinergic that may be prescribed to treat Parkinson's disease. The client taking benztropine mesylate may have decreased tolerance to heat as a result of diminished ability to sweat and should plan rest periods in cool places during the day. The client is instructed to avoid driving or operating hazardous equipment if drowsy or dizzy. The client is also instructed to monitor urinary output and watch for signs of constipation. The client should be instructed to contact the health care provider if difficulty swallowing or speaking develops, vomiting occurs, or central nervous system effects occur. In addition, the use of anticholinergic medications should be avoided in older adults because they can cause confusion, urinary retention, constipation, dry mouth, and blurred vision.

The clinic nurse is providing instructions to a client with hypertension who will be taking captopril. Which statement by the client indicates a need for further instruction? 1."I need to change positions slowly." 2."I need to avoid taking hot baths or showers." 3."I need to drink at least 4 quarts (4 liters) of water daily." 4."I need to sit down and rest if dizziness or lightheadedness occurs."

3 Captopril is an antihypertensive medication (angiotensin-converting enzyme [ACE] inhibitor). Orthostatic hypotension can occur in clients taking this medication. Adequate fluid is important, but 4 quarts (4 liters) of water daily could actually aggravate the hypertension. Clients are advised to avoid standing in one position for long periods, to change positions slowly, and to avoid extreme warmth such as with baths, showers, or heat from the sun in warm weather. The client should be instructed to monitor for signs of orthostatic hypotension, such as dizziness, lightheadedness, weakness, and syncope.

The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? 1. Heart failure 2.Atrial fibrillation 3.Myocardial infarction 4.Ventricular tachycardia

3 Cardiac troponin T or cardiac troponin I have been found to be a protein marker in the detection of myocardial infarction, and assay for this protein is used in some institutions to aid in the diagnosis of a myocardial infarction. The test is not used to diagnose heart failure, ventricular tachycardia, or atrial fibrillation.

The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate? 1.Document the findings. 2.Reinforce the dressing. 3.Notify the health care provider (HCP). 4.Mark the area of drainage with a pen and monitor for further drainage.

3 Cerebrospinal fluid (CSF) leakage after cranial surgery may be detected by noting drainage that is serosanguineous surrounded by an area of straw-colored or pale drainage. The physical appearance of CSF drainage is that of a halo. If the nurse notes the presence of this type of drainage, the HCP needs to be notified. The remaining options are inappropriate nursing actions.

An older client recently has been taking cimetidine. The nurse monitors the client for which most frequent central nervous system side effect of this medication? 1. Tremors 2.Dizziness 3.Confusion 4.Hallucinations

3 Cimetidine is a histamine (H2)-receptor antagonist. Older clients are especially susceptible to central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations.

A client who is undergoing peritoneal dialysis calls the nurse at the renal unit and reports the presence of severe abdominal pain and diarrhea. The client also informs the nurse that the peritoneal dialysis returns are brown-tinged in color. Which would the nurse suspect? 1.Infection 2.An intact catheter 3.Bowel perforation 4.Bladder perforation

3 Complications of a peritoneal catheter include infection, perforation of the bowel or bladder, and bleeding. Brown-tinged returns suggest bowel perforation, which usually is accompanied by severe abdominal pain and diarrhea. Cloudy or opaque returns suggest possible infection. Urine-colored returns suggest possible bladder perforation. An intact catheter is unrelated to the information provided in the question.

The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? 1.Anxiety related to the need to make lifestyle changes 2.Boredom resulting from having already learned the material 3.An attempt to ignore or deny the need to make lifestyle changes 4.Lack of understanding of the material provided at the teaching session and embarrassment about asking questions

3 Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the client's behavior as boredom or as either understanding or not understanding the material provided at the teaching session.

The nurse is monitoring a client who has returned to the nursing unit after a myelogram. Which client complaint would indicate the need to notify the health care provider (HCP)? 1.Backache 2.Headache 3.Neck stiffness 4.Feelings of fatigue

3 Headache is relatively common after the procedure, but neck stiffness, especially on flexion, and pain should be reported because they signal meningeal irritation. The client also is monitored for evidence of allergic reactions to the dye such as confusion, dizziness, tremors, and hallucinations. Feelings of fatigue may be normal, and back discomfort may occur because of the positions required for the procedure.

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client? 1.Dilated pupils 2.Lumbar trauma 3.A cervical cord injury 4.Altered level of consciousness

3 In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure.

The nurse manager is providing an educational session to nursing staff members about the phases of viral hepatitis. The nurse manager tells the staff that which clinical manifestation(s) are primary characteristics of the preicteric phase? 1.Pruritus 2.Right upper quadrant pain 3.Fatigue, anorexia, and nausea 4.Jaundice, dark-colored urine, and clay-colored stools

3 In the preicteric phase, the client has nonspecific complaints of fatigue, anorexia, nausea, cough, and joint pain. The remaining options are clinical manifestations that occur in the icteric phase. In the posticteric phase, jaundice decreases, the color of urine and stool returns to normal, and the client's appetite improves.

The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, should the nurse question? 1.Digoxin 2.Furosemide 3.Indomethacin 4.Propranolol hydrochloride

3 Indomethacin is a nonsteroidal antiinflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Digoxin is a cardiac medication. Furosemide is a loop diuretic. Propranolol hydrochloride is a beta-adrenergic blocking agent. Digoxin, furosemide, and propranolol are not contraindicated in clients with gastric disorders.

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving after this episode if which breath sounds are noted? 1.Rhonchi 2.Wheezes 3.Crackles in the bases 4.Crackles throughout the lung fields

3 Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. As the client's condition improves, the amount of fluid in the alveoli decreases, which may be detected by crackles in the bases. (Clear lung sounds indicate full resolution of the episode.) Rhonchi and wheezes are not associated with pulmonary edema. Auscultation of the lungs reveals crackles throughout the lung fields.

A client is scheduled for a dose of ramipril. The nurse should check which measurement before administering the medication? 1.Weight 2.Apical pulse 3.Blood pressure 4.Potassium level

3 Ramipril is an angiotensin-converting enzyme (ACE) inhibitor, and a serious adverse effect of this medication is profound hypotension. The client's blood pressure should be checked before administration of this medication. The medication does not cause weight gain or loss, bradycardia, or depletion of potassium.

The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? 1. Use nail polish to protect the nail beds from injury. 2.Wear gloves for all activities involving the use of both hands. 3. Stop smoking because it causes cutaneous blood vessel spasm. 4.Always wear warm clothing, even in warm climates, to prevent vasoconstriction.

3 Raynaud's disease is peripheral vascular disease characterized by abnormal vasoconstriction in the extremities. Smoking cessation is one of the most important lifestyle changes that the client must make. The nurse should emphasize the effects of tobacco on the blood vessels and the principles involved in stopping smoking. The nurse needs to provide information to the client about smoking cessation programs available in the community. It is not necessary to wear gloves for all activities, nor should warm clothing be worn in warm climates.

A client who is taking a stimulant laxative develops abdominal cramps. The nurse interprets that this clinical manifestation most likely indicates the presence of which problem? 1.The client has peptic ulcer disease. 2.The client is experiencing a case of influenza. 3.This is a common side effect of this medication. 4.The client may have a partial bowel obstruction

3 Stimulant laxatives commonly cause abdominal cramps as a side effect. The health problems noted in the other options are not determined based on a single symptom

A client with a history of gastroesophageal reflux disease (GERD) is diagnosed with peptic ulcer disease (PUD). The health care provider prescribes sucralfate in addition to the client's other medications. What teaching should the nurse include in this client's instructions? 1.Take the sucralfate once a day at bedtime with food. 2.Take the sucralfate daily with the proton pump inhibitor. 3.Take the sucralfate before meals and at bedtime on an empty stomach. 4.Take the sucralfate immediately after eating and within 30 minutes of an antacid.

3 Sucralfate is an antiulcer medication that promotes ulcer healing by creating a protective barrier against acid and pepsin. It should be taken on an empty stomach. The usual recommended adult dosage is 1 gram 4 times a day, taken 1 hour before meals and at bedtime. Options 1, 2, and 4 are incorrect, as sucralfate should be taken on an empty stomach, at least twice a day, and at least 30 minutes apart from an antacid.

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? 1."I know I must sign the consent form." 2."I hope the throat spray keeps me from gagging." 3."I'm glad I don't have to lie still for this procedure." 4."I'm glad some intravenous medication will be given to relax me."

3 The client does have to lie still for ERCP, which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.

The nurse is teaching a client with nephrotic syndrome about managing the disorder. What should the nurse instruct the client to adjust according to the amount of edema present? 1.Salt intake 2.Water intake 3.Activity level 4.Use of diuretics

3 The client is taught to adjust the activity level according to the amount of edema. As edema decreases, activity can increase. Correspondingly, as edema increases, the client should increase rest periods and limit activity. Bed rest is recommended during periods of severe edema. The client with nephrotic syndrome usually has a standard limit set on sodium intake. Fluids are not restricted unless the client also is hyponatremic. Diuretics are prescribed on a specific schedule, and doses are not titrated according to the level of edema.

A client who is to have a cystectomy with creation of an ileal conduit asks the nurse why the bowel needs to be cleansed before surgery if the bladder is being removed. Which response by the nurse is the most appropriate? 1."All clients undergo bowel preparation with major surgery." 2."This will decrease the chance of postoperative paralytic ileus." 3."A portion of the bowel will be used to create the conduit for urinary diversion." 4."This will reduce the chance that the surgeon will nick the bowel during surgery."

3 The client scheduled for surgical creation of either an ileal conduit or a reservoir undergoes bowel preparation the night before the procedure. Preparation can include intake of copious clear liquids, laxatives, enemas, and antibiotics, depending on health care provider preference. This is done primarily to prevent infection because a loop of bowel will be used to create the urinary diversion.

The nurse has given instructions to a client with hepatitis about postdischarge management during convalescence. The nurse determines that further teaching is needed if the client makes which statement? 1."I need to avoid alcohol and aspirin." 2."I should eat a high-carbohydrate, low-fat diet." 3."I can resume a full activity level within 1 week." 4."I need to take the prescribed amounts of vitamin K."

3 The client with hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is important for the client to get adequate rest so that the liver can heal. The client should avoid hepatotoxic substances such as aspirin and alcohol. The client should take in a high-carbohydrate and low-fat diet. Vitamin K may be prescribed for prolonged clotting times.

The client who is beginning an exercise program asks the nurse why his heart "feels like it's pounding" when he is exercising vigorously. The nurse provides education to the client about increased cardiac response based on which physiological concept? 1.Pulse rate is not a reflection of cardiac response. 2.Cardiac index is the mechanism that allows blood to flow better. 3.Cardiac output is the body's attempt to meet metabolic demands. 4.Stroke volume is an artificial number used to determine the adequacy of cardiac output.

3 The client's symptoms are the direct result of the body's attempt to meet the metabolic demands generated during exercise. An adequate cardiac output is needed to maintain perfusion to the vital organs of the body. With exercise, these demands increase, and the heart must beat faster (increased heart rate) and harder (increased stroke volume) to meet them. Cardiac index is an artificial number used to determine the adequacy of the cardiac output for a given individual. It is calculated by adjusting the cardiac output for body surface area.

The nurse is caring for a client with gastroesophageal reflux disease (GERD) and provides client education on measures to decrease GERD. Which statement made by the client indicates a need for further teaching? 1."I plan to eat 4 to 6 small meals a day." 2."I should sleep in the right side-lying position." 3."I plan to have a snack 1 hour before going to bed." 4."I will stop having a glass of wine each evening with dinner."

3 The control of GERD involves lifestyle changes to promote health and control reflux. These include eating 4 to 6 small meals a day; avoiding alcohol and smoking; sleeping in the right side-lying position to promote oxygenation and frequent swallowing to clear the esophagus; and avoiding eating at least 3 hours before going to bed because reflux episodes are most damaging at night.

The nurse is auscultating a 56-year-old adult client's apical heart rate before giving digoxin and notes that the heart rate is 48 beats/minute. Which action should the nurse take? 1.Withhold the digoxin, and re-evaluate the heart rate in 4 hours. 2.Administer half of the prescribed dose to avoid a further decrease in heart rate. 3.Withhold the digoxin, and assess for signs of decreased cardiac output and digoxin toxicity. 4.Administer the digoxin; the heart rate would be considered normal because of the client's age.

3 The normal heart rate is 60 to 100 beats/minute in an adult. If the nurse notes a heart rate that is less than 60 beats/minute, the nurse would not administer the digoxin and would further evaluate the client for signs and symptoms of digoxin toxicity. When clients are bradycardic, they may have symptoms of decreased cardiac output, so this would also be assessed.

The registered nurse (RN) is educating a new RN about the use of oxygen for clients with angina pectoris. Which statement by the new nurse indicates that the teaching has been effective? 1."Oxygen has a calming effect." 2."Oxygen will prevent the development of any thrombus." 3."The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells." 4."Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle."

3 The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that places more oxygen demand on heart muscle. Supplemental oxygen will help meet the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly calm the client.

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? 1.Endotracheal intubation 2.100 units of NPH insulin 3.Intravenous infusion of normal saline 4.Intravenous infusion of sodium bicarbonate

3 The primary goal of treatment in hyperosmolar hyperglycemic syndrome (HHS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous (IV) fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS

The nurse is caring for a client whose urine output was 25 mL per hour for 2 consecutive hours. The nurse reviews the health care provider's prescriptions and plans care, knowing that which client-related factor would increase the amount of blood flow to the kidneys? 1.Physiological stress 2.Release of norepinephrine 3.Release of low levels of dopamine 4.Sympathetic nervous system stimulation

3 The release of low levels of dopamine exerts a vasodilating effect on the renal arteries, increasing urinary output. The other options cause renal vasoconstriction.

The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? 1. Bananas 2.Broccoli 3.Antacids 4.Cantaloupe

3 The sodium level can increase with the use of several types of products, including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water and mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium.

The nurse is planning to administer hydrochlorothiazide to a client. The nurse should monitor for which adverse effects related to the administration of this medication? 1. Hypouricemia, hyperkalemia 2.Increased risk of osteoporosis 3.Hypokalemia, hyperglycemia, sulfa allergy 4.Hyperkalemia, hypoglycemia, penicillin allergy

3 Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.

A thrombolytic is administered in the hospital emergency department to a client who has had a myocardial infarction. The client's spouse asks the nurse about the purpose of the medication. The nurse bases the response on which fact regarding this medication? 1.Thrombolytics suppress the production of fibrin. 2.Thrombolytics act to prevent thrombus formation. 3.Thrombolytics act to dissolve thrombi that have already formed. 4.Thrombolytics have been proved to reverse all detrimental effects of heart attacks.

3 Thrombolytics are most effective when started within 4 to 6 hours after symptom onset and act to dissolve or lyse existing thrombi that are causing a blockage. The remaining options are incorrect.

A client is diagnosed with an ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? 1. Monitor for kidney failure 2.Monitor psychosocial status. 3.Monitor for signs of bleeding. 4.Have heparin sodium available.

3 Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin may be administered after thrombolytic therapy, but the question is not asking about follow-up medications.

The nurse is planning to administer furosemide 40 mg by intravenous push (IVP) through an existing intravenous (IV) line. To deliver this medication safely, the nurse should perform which action? 1.Give the medication rapidly over 10 seconds. 2.Give the medication slowly, diluted in 100 mL of 5% dextrose in water. 3.Pinch the IV tubing above the injection port, and inject slowly over 1 to 2 minutes. 4.Pinch the IV tubing below the injection port, and inject slowly over 1 to 2 minutes.

3 To administer medication by IVP, the IV tubing must be pinched above the injection port so that the medication does not go back up the tubing during injection. Most IVP medications should be injected slowly. Considering the need for and action of the medication, it is not diluted unless prescribed.

A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse should assess the client for a history of chronic use of which medication? 1.Ibuprofen 2.Ranitidine 3.Acetaminophen 4.Acetylsalicylic acid

3 Acetaminophen is a potentially hepatotoxic medication. Use of this medication and other hepatotoxic agents should be investigated whenever a client presents with signs and symptoms compatible with liver disease (such as ascites and jaundice). Hepatotoxicity is not an adverse effect of the medications identified in the remaining options.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 1. Call a code. 2.Call the health care provider. 3.Check the client's status and lead placement. 4.Press the recorder button on the electrocardiogram console.

3 Sudden loss of electrocardiographic complexes indicates 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 remaining options are secondary to client assessment.

The health care provider writes prescriptions for a client with chronic kidney disease (CKD). Which prescription should the nurse question? 1.Insert a saline lock. 2.Obtain a daily weight. 3.Provide a high-protein diet. 4.Administer a calcium supplement with each meal.

3 When a client experiences CKD, the blood urea nitrogen (BUN) and serum creatinine levels rise. The client also experiences increased potassium, increased phosphates, and decreased calcium. BUN and creatinine are the byproducts of protein metabolism, so monitoring protein intake is important, with care taken to include proteins of high biological value. Clients with CKD will have protein restricted early in the disease to preserve kidney function. In end-stage disease, protein is restricted according to the client's weight, the type of dialysis, and protein loss. With CKD, the nurse is concerned about fluid volume overload and accumulation of waste products. Because of the kidneys' inability to excrete fluid, it is important for the nurse to prevent as well as assess for early signs of fluid volume excess. Infusing an intravenous (IV) solution into a client with CKD significantly increases the risk for overload. If an IV access is needed, it usually involves only a saline lock. Obtaining the client's daily weight is one of the most important assessment tools for evaluating changes in fluid volume. The kidneys also are responsible for removing waste products. The client also receives phosphate binders, calcium supplements, and vitamin D to prevent bone demineralization (osteodystrophy) from chronically elevated phosphate levels.

The nurse is caring for an older client. The nurse should anticipate that medication dosages will be further adjusted if the client has dysfunction of which organ? 1.Liver 2.Stomach 3.Pancreas 4.Gallbladder

1 An important function of the liver is to break down medications and other toxic substances. The older client with liver disease is at increased risk for toxic medication effects and should be monitored carefully for adverse effects. Diseases of the stomach, pancreas, and gallbladder are a lesser concern for prolonged medication effects.

A client is admitted to the hospital with acute viral hepatitis. Which sign or symptom should the nurse expect to note based on this diagnosis? 1.Fatigue 2.Pale urine 3.Weight gain 4.Spider angiomas

1 Common manifestations of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas—small, dilated blood vessels—are commonly seen in cirrhosis of the liver.

The nurse has provided dietary instructions to a client with a diagnosis of peptic ulcer disease. Which client statement indicates that education was effective? 1."Baked foods such as chicken or fish are all right to eat." 2."Citrus fruits and raw vegetables need to be included in my daily diet." 3."I can drink beer as long as I consume only a moderate amount each day." 4."I can drink coffee or tea as long as I limit the amount to 2 cups daily."

1 Dietary modifications for the client with peptic ulcer disease include eliminating foods that can cause irritation to the gastrointestinal (GI) tract. Items that should be eliminated or avoided include highly spiced foods, alcohol, caffeine, chocolate, and citrus fruits. Other foods may be taken according to the client's level of tolerance for that food.

A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching? 1."I eat at least 3 large meals each day." 2."I eat while lying in a semirecumbent position." 3."I have eliminated taking liquids with my meals." 4."I eat a high-protein, low- to moderate-carbohydrate diet."

1 Dumping syndrome describes a group of symptoms that occur after eating. It is believed to result from rapid dumping of gastric contents into the small intestine, which causes fluid to shift into the intestine. Signs and symptoms of dumping syndrome include diarrhea, abdominal distention, sweating, pallor, palpitations, and syncope. To manage this syndrome, clients are encouraged to decrease the amount of food taken at each sitting, eat in a semirecumbent position, eliminate ingesting fluids with meals, and avoid consumption of high-carbohydrate meals.

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? 1. Sweating and pallor 2.Bradycardia and indigestion 3.Double vision and chest pain 4.Abdominal cramping and pain

1 Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

The nurse is giving dietary instructions to a client who has a new colostomy. The nurse should encourage the client to eat foods representing which diet for the first 4 to 6 weeks postoperatively? 1.Low fiber 2.Low calorie 3.High protein 4.High carbohydrate

1 For the first 4 to 6 weeks after colostomy formation, the client should consume a low-fiber diet. After this period, the client should eat a high-carbohydrate, high-protein diet. The client also is instructed to add new foods, including those with fiber, one at a time to determine tolerance to that food.

Phenytoin 100 mg to be given orally 3 times daily has been prescribed to a client. The home health nurse visits the client and provides instructions regarding the medication. Which statement, if made by the client, would indicate an understanding of the instructions? 1."I will use a soft toothbrush to brush my teeth." 2."It's okay to break the capsules to make it easier for me to swallow them." 3."If I forget to take my medication, I can wait until the next dose and eliminate that dose." 4."If my throat becomes sore, it's a normal effect of the medication, and it's nothing to be concerned about."

1 Phenytoin is an anticonvulsant used to treat seizure disorders. Gingival hyperplasia, bleeding, swelling, and tenderness of the gums can occur with the use of this medication. The client needs to be taught good oral hygiene, gum massage, and the need for regular dentist visits. Capsules should not be chewed or broken. The client should not skip medication doses because inadequate blood levels could precipitate a seizure. The client needs to be instructed to report a sore throat, fever, glandular swelling, or any skin reaction because such findings may indicate hematological toxicity.

The nurse is working with a client newly diagnosed with chronic kidney disease (CKD) to set up a schedule for hemodialysis. The client states, "This is impossible! How can I even think about leading a normal life again if this is what I'm going to have to do?" The nurse determines that the client is exhibiting which problem? 1.Anger 2.Projection 3.Depression 4.Withdrawal

1 Psychosocial reactions to CKD and hemodialysis are varied and may include anger. Other reactions include personality changes, emotional lability, withdrawal, and depression. The individual client's response may vary depending on the client's personality and support systems. The client in this question is exhibiting anger. The client's behavior is not indicative of projection; in addition, the client's statement does not reflect withdrawal or depression.

A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? 1.Sinus tachycardia 2.Sinus bradycardia 3.Sinus dysrhythmia 4.Normal sinus rhythm

1 Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute.

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse would include which intervention in the plan? 1.Maintain activity level as prescribed. 2.Maintain the affected leg in a dependent position. 3.Administer an opioid analgesic every 4 hours around the clock. 4.Apply cool packs to the affected leg for 20 minutes every 4 hours.

1 Standard management for the client with DVT includes maintaining the activity level as prescribed by the PHCP; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Recent research is showing that ambulation, as previously thought, does not cause pulmonary embolism and does not cause the existing DVT to worsen. Therefore, the nurse should maintain the prescribed activity level. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen.

The nurse assesses the sternotomy incision of a client on the third day after cardiac surgery. The incision shows some slight puffiness along the edges and is nonreddened, with no apparent drainage. The client's temperature is 99°F (37.2°C) orally. The white blood cell count is 7500 mm3 (7.5 × 109/L). How should the nurse interpret these findings? 1.Incision is slightly edematous but shows no active signs of infection. 2.Incision shows early signs of infection, although the temperature is nearly normal. 3.Incision shows no sign of infection, although the white blood cell count is elevated. 4.Incision shows early signs of infection, supported by an elevated white blood cell count.

1 Sternotomy incision sites are assessed for signs and symptoms of infection, such as redness, swelling, induration, and drainage. An elevated temperature and white blood cell count 3 to 4 days postoperatively usually indicate infection. Therefore, the option indicating that there is slight edema and no active signs of infection is correct.

Sulfasalazine is prescribed for a client with a diagnosis of ulcerative colitis, and the nurse instructs the client about the medication. Which statement made by the client indicates a need for further teaching? 1."The medication will cause constipation." 2."I need to take the medication with meals." 3."I may have increased sensitivity to sunlight." 4."This medication should be taken as prescribed."

1 Sulfasalazine is an antiinflammatory sulfonamide. Constipation is not associated with this medication. It can cause photosensitivity, and the client should be instructed to avoid sun and ultraviolet light. It should be administered with meals, if possible, to prolong intestinal passage. The client needs to take the medication as prescribed and continue the full course of treatment even if symptoms are relieved.

The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20? 1. "This is a normal finding." 2."This is indicative of atrial flutter." 3."This is indicative of atrial fibrillation." 4."This is indicative of impending reinfarction."

1 The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 second. The remaining options are incorrect and indicate that further education is needed.

A client with viral hepatitis states, "I am so yellow." What is the most appropriate nursing action? 1.Assist the client in expressing feelings. 2.Restrict visitors until the jaundice subsides. 3.Perform most of the activities of daily living for the client. 4.Provide information to the client only when he or she requests it.

1 The client should be supported to explore feelings about the disease process and altered appearance so that appropriate interventions can be planned. Restricting visitors would reinforce the client's negative self-esteem. To assist the client in adapting to changes in appearance, it is important for the nurse to encourage participation in self-care to foster independence and self-esteem. The client should be encouraged to ask questions to clarify misconceptions, to learn ways to prevent the spread of hepatitis, to reduce fear, and to make appropriate decisions.

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? 1.Listening to lung sounds 2.Palpating for organomegaly 3.Assessing for jugular vein distention 4.Assessing for peripheral and sacral edema

1 The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function.

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding? 1.Hypotension 2.Flat neck veins 3.Complaints of nausea 4.Complaints of headache

1 The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

The nurse is preparing to care for a client receiving peritoneal dialysis. Which should be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis? 1.Maintain strict aseptic technique. 2.Add heparin to the dialysate solution. 3.Change the catheter site dressing daily. 4.Monitor the client's level of consciousness.

1 The major complication of peritoneal dialysis is peritonitis. Strict aseptic technique is required in caring for the client receiving this treatment. Although changing the catheter site dressing daily may assist in preventing infection, this option relates to an external site. Adding heparin to the dialysate solution and monitoring the client's level of consciousness are unrelated to the major complication of peritoneal dialysis.

A client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and does not seem to be progressing as quickly as the client or family had hoped. The nurse plans to implement which approach as most helpful to the client and family at this time? 1.Emphasize progress in a realistic manner. 2.Set high goals to give the client something to "aim for." 3.Tell the family to be extremely optimistic with the client. 4.Inform the client and family of standardized goals of care.

1 The most helpful approach by the nurse is to emphasize progress that is being made in a realistic manner. The nurse does not offer false hope but does provide factual information in a clear and positive manner. The nurse encourages the family to be realistic in their expectations and attitudes. The plan of care should be individualized for each client.

The nurse is caring for a client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which food? 1.Pork 2.Milk 3.Chicken 4.Broccoli

1 Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin. Other good sources include peanuts, asparagus, and whole-grain and enriched cereals.

A client tells the nurse about a pattern of a strong urge to void, followed by incontinence before the client can get to the bathroom. Based on the data provided, which condition should the nurse suspect? 1.Urge incontinence 2.Total incontinence 3.Stress incontinence 4.Reflex incontinence

1 Urge incontinence occurs when the client experiences involuntary loss of urine soon after experiencing urgency. Total incontinence occurs when loss of urine is unpredictable and continuous. Stress incontinence occurs when the client voids in increments of less than 50 mL under conditions of increased abdominal pressure. Reflex incontinence occurs at rather predictable times that correspond to when a certain bladder volume is attained.

The nurse is caring for a client who is on bed rest as part of aneurysm precautions. The nurse should avoid doing which action when giving respiratory care to this client? 1.Encouraging hourly coughing 2.Assisting with incentive spirometer 3.Encouraging hourly deep breathing 4.Repositioning gently side to side every 2 hours

1 With aneurysm precautions, any activity that could raise the client's intracranial pressure (ICP) is avoided. For this reason, activities such as straining, coughing, blowing the nose, and even sneezing are avoided whenever possible. The other interventions (repositioning, deep breathing, and incentive spirometry) do not provide added risk of increasing ICP and are beneficial in reducing the respiratory complications of bed rest.

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? 1. The neurovascular status is normal because of increased blood flow through the leg. 2. The neurovascular status is moderately impaired, and the surgeon should be called. 3. The neurovascular status is slightly deteriorating and should be monitored for another hour. 4. The neurovascular status is adequate from an arterial approach, but venous complications are arising.

1 An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations.

A client with end-stage renal disease (ESRD) has the problem of ineffective coping. Which nursing interventions are appropriate in working with this client? Select all that apply. 1.Acknowledge the client's feelings. 2.Assess the client and family's coping patterns. 3.Explore the meaning of the illness with the client. 4.Set limits on mood swings and expressions of hostility. 5.Give the client information when the client is ready to listen.

1, 2, 3, 5 Clients with ESRD are likely to experience mood swings or express hostility, anger, and depression, among other responses. The nurse should acknowledge the client's feelings, allow the client to express those feelings, and be supportive. Options 1, 2, 3, and 5 are helpful and appropriate interventions for the client. Setting limits for this client is not client focused, does not allow the client to express concerns, and is nontherapeutic in this situation.

The nurse is participating in a prostate screening clinic for men. Which complaints by a client are associated with prostatism? Select all that apply. 1.Inability to stop urinating 2.Postvoid dribbling of urine 3.Increased episodes of nocturia 4.Unusual force in urinary stream 5.Hesitancy on initiating the urinary stream

1, 2, 3, 5 Signs and symptoms of prostatism include reduced force and size of urinary stream, intermittent stream, hesitancy in beginning the flow of urine, inability to stop urinating, a sensation of incomplete bladder emptying after voiding, postvoid dribbling of urine, and an increase in episodes of nocturia. These signs and symptoms are the result of pressure of the enlarging prostate on the client's urethra.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific health care provider prescriptions, the nurse should plan to place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral position 3.Flat, with head turned to the side 4.Head of bed elevated 30 to 45 degrees 5.Head of bed elevated with the neck extended

1, 2, 4 The client who is at risk for or who has increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.

A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse should plan which actions as a priority? Select all that apply. 1.Place the client on a cardiac monitor. 2.Notify the health care provider (HCP). 3.Put the client on NPO (nothing by mouth) status except for ice chips. 4.Review the client's medications to determine if any contain or retain potassium. 5.Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.

1, 2, 4 The normal potassium level is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). A potassium level of 7.0 is elevated. The client with hyperkalemia is at risk of developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should be placed on a cardiac monitor. The nurse should notify the HCP and also review medications to determine if any contain potassium or are potassium retaining. The client does not need to be put on NPO status. Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly.

Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. 1. Obtain an intravenous (IV) infusion pump. 2.Monitor urine output during administration. 3.Prepare the medication for bolus administration. 4.Monitor the IV site for signs of infiltration or phlebitis. 5.Ensure that the medication is diluted in the appropriate volume of fluid. 6.Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

1, 2, 4, 5, 6 Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the health care provider if the urinary output is less than 30 mL/hour.

A client diagnosed with chronic kidney disease (CKD) is scheduled to begin hemodialysis. The nurse determines that which neurological and psychosocial manifestations, if exhibited by this client, are related to the CKD? Select all that apply. 1.Agitation 2.Euphoria 3.Depression 4.Withdrawal 5.Labile emotions

1, 3, 4, 5 The client with CKD often experiences a variety of psychosocial changes. These changes are related to uremia and to the stress associated with living with a chronic disease that is life threatening. Euphoria is not part of the clinical picture for the client in renal failure. Clients with CKD may have labile emotions or personality changes and may exhibit withdrawal, depression, or agitation. Delusions and psychosis also can occur.

The nurse is caring for a hospitalized client with pancreatitis. Which findings should the nurse look for and expect to note when reviewing the laboratory results? Select all that apply. 1.Elevated lipase level 2.Elevated lactase level 3.Elevated trypsin level 4.Elevated amylase level 5.Elevated sucrase level

1,3,4 Lipase, trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively. Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Sucrase is produced in the small intestine and converts sucrose into glucose and fructose.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1.Blowing the nose 2.Isometric exercises 3.Coughing vigorously 4.Exhaling during repositioning

4 Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema? 1.Unchanged weight 2.Shift intake 950 mL, output 900 mL 3.Blood urea nitrogen (BUN) 10 mg/dL (3.6 mmol/L) 4.Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)

4 After craniotomy the goal is to keep the serum osmolality on the high side of normal to minimize excess body water and control cerebral edema. The normal serum osmolality is 285 to 295 mOsm/kg H2O (285 to 295 mmol/kg). A higher value indicates dehydration; a lower value indicates overhydration. Stable weight indicates that there is neither fluid excess nor fluid deficit. A difference of 50 mL in intake and output for an 8-hour shift is insignificant. The BUN of 10 mg/dL (3.6 mmol/L) is within normal range and does not indicate overhydration or underhydration.

A client experiencing end-stage kidney disease has an arteriovenous (AV) fistula placed surgically for hemodialysis. Which action is most appropriate for the nurse to document in the plan for care of the AV fistula? 1.Palpate the bruit of the AV fistula weekly to assess for thrombosis. 2.Use the AV fistula site for blood draws to prevent increased pain of multiple blood draws. 3.Take the blood pressure readings in the extremity with the AV fistula to get a more accurate reading. 4.Teach the client to avoid carrying heavy objects that would compress the AV fistula and cause thrombosis.

4 An AV fistula is a vascular access system that is required for hemodialysis. It is a device established for clients who need long-term hemodialysis. It is created by connecting an artery to a vein inside the body to create a vessel that can handle the amount of blood flow necessary for effective dialysis. Bleeding, clotting, and infection are risks with all vascular devices. It also is very important to avoid any activity that would promote the status of blood or increase the risk for infection. Taking the blood pressure in the affected arm, carrying heavy objects in the arm, and lying on the arm at night could increase the risk for clotting in the fistula. To check circulation of the fistula, the nurse should palpate or feel for the thrill or auscultate (listen with a stethoscope) for the bruit. It is important to do this at least daily to ascertain the patency of the fistula. To avoid infection, that extremity is never used for peripheral intravenous access (placement of an intravenous line) or for blood draws. Strict aseptic technique is used in accessing the fistula for dialysis.

Prior to administering a client's daily dose of digoxin, the nurse reviews the client's laboratory data and notes the following results: serum calcium, 9.8 mg/dL (2.45 mmol/L); serum magnesium, 1.0 mEq/L (0.5 mmol/L); serum potassium, 4.1 mEq/L (4.1 mmol/L); serum creatinine, 0.9 mg/dL (79.5 mcmol/L). Which result should alert the nurse that the client is at risk for digoxin toxicity? 1. Serum calcium level 2.Serum potassium level 3.Serum creatinine level 4.Serum magnesium level

4 An increased risk of toxicity exists in clients with hypercalcemia, hypokalemia, hypomagnesemia, hypothyroidism, and impaired renal function. The calcium, creatinine, and potassium levels are all within normal limits. The normal range for magnesium is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L) and the results in the correct option are reflective of hypomagnesemia.

An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? 1.It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals. 2.It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels. 3.It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream. 4.It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal.

4 An insulin pump provides a small continuous dose of short-duration (rapid- or short-acting) insulin subcutaneously throughout the day and night. The client can self-administer an additional bolus dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.

The nurse provides discharge instructions to a client who is taking warfarin sodium. Which statement, by the client, reflects the need for further teaching? 1. "I will avoid alcohol consumption." 2."I will take my pills every day at the same time." 3."I have already called my family to pick up a MedicAlert bracelet." 4."I will take coated aspirin for my headaches because it will coat my stomach."

4 Aspirin-containing products need to be avoided when a client is taking this medication. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking the prescribed medication at the same time each day increases client compliance. The MedicAlert bracelet provides health care personnel with emergency information.

A client with gastrointestinal hypermotility has a prescription to receive atropine sulfate. The nurse should withhold the medication and question the prescription if the client has a history of which disease process? 1.Biliary colic 2.Sinus bradycardia 3.Peptic ulcer disease 4.Narrow-angle glaucoma

4 Atropine sulfate can cause a blockade of muscarinic receptors on the iris sphincter, producing mydriasis (dilation of the pupils). It also produces cycloplegia (relaxation of the ciliary muscles). It is contraindicated in clients with narrow-angle glaucoma. The other options are therapeutic reasons for using the medication.

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What nursing intervention is necessary for this client? 1.Take and record vital signs every 4 to 8 hours. 2.Prophylactically hyperventilate during the first 24 hours. 3.Treat a central fever with the administration of antipyretic medications such as acetaminophen. 4.Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

4 Avoiding extreme flexion and extension of the neck can enhance venous drainage and help prevent increased intracranial pressure. As a general rule, hyperventilation is avoided during the first 24 hours postoperatively because it may produce ischemia caused by cerebral vasoconstriction. Vital signs need to be taken and recorded at least every 1 to 2 hours. Central fevers caused by hypothalamic damage respond better to cooling (hypothermia blankets, sponge baths) than to the administration of antipyretic medications.

A client had a transsphenoidal resection of the pituitary gland. The nurse notes drainage on the nasal dressing. Suspecting cerebrospinal fluid (CSF) leakage, the nurse should look for drainage that is of which characteristic? 1.Serosanguineous only 2.Bloody with very small clots 3.Sanguineous only with no clot formation 4.Serosanguineous, surrounded by clear to straw-colored fluid

4 CSF leakage after cranial surgery may be detected by noting drainage that is serosanguineous (from the surgery) and surrounded by an area of clear or straw-colored drainage. The typical appearance of CSF drainage is that of a "halo." The nurse also would further verify actual CSF drainage by testing the drainage for glucose, which would be positive.

The health care provider (HCP) writes a prescription for carbamazepine for a client who was admitted to the hospital. The nurse contacts the HCP to verify the prescription if which condition is noted in the assessment data? 1.Hypertension 2.Tonic-clonic seizures 3.Trigeminal neuralgia 4.Bone marrow depression

4 Carbamazepine is classified as an iminostilbene derivative and is used as an anticonvulsant, antineuralgic, antimanic, and antipsychotic. It is used to treat seizure disorders, trigeminal neuralgia, and diabetic neuropathy. The medication can cause blood dyscrasias as an adverse effect and is contraindicated if the client has a history of bone marrow depression, hypersensitivity to tricyclic antidepressants, or concurrent use of monoamine oxidase inhibitors.

Carbamazepine has been prescribed for a client. The nurse should tell the client that which blood test will be done periodically while the client is taking this medication? 1.Lipase level 2.Amylase level 3.Ammonia level 4.Complete blood cell (CBC) count

4 Carbamazepine is classified as an iminostilbene derivative and is used as an anticonvulsant, antineuralgic, antimanic, and antipsychotic. The medication can cause blood dyscrasias as an adverse effect, and the client should have a CBC count done before therapy and periodically during therapy. Additional laboratory tests that should be done include a serum iron determination, urinalysis, blood urea nitrogen determination, and carbamazepine level. The tests identified in the remaining options are unnecessary.

The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke? 1."Have you had any headaches in the past few days?" 2."Have you recently been having difficulty with seeing at nighttime?" 3."Have you had any sudden episodes of passing out in the past few days?" 4."Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

4 Cerebral thrombosis (thrombotic stroke) does not occur suddenly. In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on 1 side of the body. Signs and symptoms of this type of stroke vary but may also include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. The client does not complain of difficulty with night vision as part of this clinical problem. In addition, most clients do not have repeated episodes of loss of consciousness.

The nurse is preparing to care for a client with chronic kidney disease and anemia. Which describes the relationship between chronic kidney disease and anemia? 1.Lack of angiotensin I may cause anemia. 2.Increased production of aldosterone leads to anemia. 3.Anemia is caused by insufficient production of renin. 4.Decreased production of erythropoietin is causing anemia.

4 Clients with chronic kidney disease do not manufacture adequate amounts of erythropoietin, which is a glycoprotein needed to synthesize red blood cells. Renin, aldosterone, and angiotensin are substances that assist in maintaining blood pressure.

A client has been prescribed dextroamphetamine. The client complains to the nurse that the client cannot sleep well at night and does not want to take the medication any longer. Before making any specific comment, the nurse plans to investigate whether the client takes the medication at which proper time schedule? 1.2 hours before bedtime 2.After supper each night 3.Just before going to sleep 4.At least 6 hours before bedtime

4 Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent sleep disturbance.

A client has received a dose of dimenhydrinate. The nurse evaluates the effect of the medication by noting whether the client obtained relief from what symptom? 1.Chills 2.Headache 3.Ringing in the ears 4.Nausea and vomiting

4 Dimenhydrinate is an antiemetic and antihistamine used to treat and prevent the signs and symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness. The other options are incorrect; the medication is not used to treat these conditions.

The nurse is caring for a client who has just returned from the operating room after the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is appropriate based on this assessment? 1.Apply ice to the stoma site. 2.Apply pressure to the stoma site. 3.Notify the health care provider (HCP). 4.Document the amount and characteristics of the drainage.

4 During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Applying ice or pressure to the stoma site are inappropriate actions. Notifying the HCP is unnecessary because this is an expected finding.

A client is on enalapril for the treatment of hypertension. The nurse teaches the client to seek emergent care if which is experienced? 1.Nausea 2.Insomnia 3.Dry cough 4.Swelling of the tongue

4 Enalapril is an angiotensin-converting enzyme inhibitor. Angioedema is an adverse effect. Swelling of the tongue and lips can result in airway occlusion. Nausea, insomnia, and a cough can occur as side, not adverse, effects of the medication.

The nurse notes that a client taking ergotamine tartrate is having the intended effects of therapy if the client states relief from which symptom? 1.Cough 2.Diarrhea 3.Backache 4.Headaches

4 Ergotamine tartrate is used to stop an ongoing migraine attack; it also is used to treat cluster headaches. The other options are unrelated to the use of this medication.

A client who had coronary artery bypass surgery states to the home health nurse, "I get so frustrated. I can't even do my gardening." The nurse then assesses the client for activity level since the surgery. Which client statement indicates a need for further teaching? 1."I pace my activities throughout the day." 2."I plan regular rest periods during the day." 3."I avoid outdoor physical activity during the heat of the day." 4."I try to walk immediately after lunch, after I've finished my morning housecleaning."

4 Exercise is an integral part of the rehabilitation program. It is necessary for optimal physiological functioning and psychological well-being. Postoperative physical rehabilitation must be progressive, with planned periods of rest. Exercise tolerance is judged by the client's response, such as heart rate and endurance. Planning regular rest periods, pacing activities, and avoiding outdoor activities during the heat of the day are appropriate client activities. The correct option lacks planned periods of rest, and the client has grouped too many activities in a brief period of time, which will decrease endurance. Also, exercise after meals can decrease the client's tolerance because of shunting of blood to the gastrointestinal tract for digestion.

A client is prescribed nicotinic acid for hyperlipidemia and the nurse provides instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions? 1. It is not necessary to avoid the use of alcohol." 2."The medication should be taken with meals to decrease flushing." 3."Clay-colored stools are a common side effect and should not be of concern." 4."Ibuprofen IB taken 30 minutes before the nicotinic acid should decrease the flushing."

4 Flushing is an adverse effect of this medication. Aspirin or a nonsteroidal antiinflammatory drug can be taken 30 minutes prior to taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this effect. The medication should be taken with meals to decrease gastrointestinal upset; however, taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be reported to the health care provider (HCP) immediately.

A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the health care provider (HCP)? 1.Red, bloody urine 2.Pain rated as 2 on a 0-10 pain scale 3.Urinary output of 200 mL higher than intake 4.Blood pressure, 100/50 mm Hg; pulse, 130 beats/minute

4 Frank bleeding (arterial or venous) may occur during the first day after surgery. Some hematuria is usual for several days after surgery. A urinary output of 200 mL more than intake is adequate. A client pain rating of 2 on a 0-10 scale indicates adequate pain control. A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The HCP should be notified.

The nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is asking the client questions about pain. Which client statement supports the diagnosis of gastric ulcer? 1."The pain doesn't usually come right after I eat." 2."The pain gets so bad that it wakes me up at night." 3."The pain that I get is located on the right side of my chest." 4."My pain comes shortly after I eat, maybe a half-hour or so later."

4 Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by intake of food. The pain occurs 30 to 60 minutes after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night.

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? 1.Meningitis or encephalitis during the last 5 years 2.Seizures or trauma to the brain within the last year 3.Back injury or trauma to the spinal cord during the last 2 years 4.Respiratory or gastrointestinal infection during the previous month

4 Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.

The spouse of a client with acute kidney injury secondary to heart failure asks the nurse how a heart problem can affect the kidneys. The nurse should formulate a response using what fact about the kidneys? 1.The kidneys get fatigued from having to filter too much fluid. 2.The kidneys can react adversely to moderate doses of furosemide. 3.The kidneys will shut down easily if serum levels of digoxin are high. 4.The kidneys generally require and receive about 20% to 25% of the resting cardiac output.

4 Heart failure is referred to as a prerenal cause of acute kidney injury because heart failure results in decreased blood flow to the kidneys. The kidneys normally receive about 20% to 25% of the cardiac output and require adequate perfusion to function properly. With a significant or prolonged decrease in blood supply, the kidneys can fail. Options 1 and 3 are incorrect. As for option 2, large doses of furosemide resulting in severe dehydration may lead to decreased kidney perfusion, but moderate doses of furosemide do not cause prerenal acute kidney injury, and furosemide may be used to treat acute kidney injury.

The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)? 1.Age 2.Hypertension 3.Hyperlipidemia 4.Glucose intolerance

4 Hypertension, cigarette smoking, and hyperlipidemia are modifiable risk factors that are predictors of CAD. Glucose intolerance, obesity, and response to stress are contributing modifiable risk factors for CAD. Age is a nonmodifiable risk factor. The nurse places priority on risk factors that can be modified. In this scenario, the abnormal value is the fasting blood glucose level, indicating glucose intolerance as the priority risk factor.

A client with a complete heart block has had a permanent demand ventricular pacemaker inserted. The nurse assesses for proper pacemaker function by examining the electrocardiogram (ECG) strip for the presence of pacemaker spikes at what point? 1.Before each P wave 2.Just after each P wave 3.Just after each T wave 4.Before each QRS complex

4 If a ventricular pacemaker is functioning properly, there will be a pacer spike followed by a QRS complex. An atrial pacemaker spike precedes a P wave if an atrial pacemaker is implanted.

A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication? 1.Diuretics 2.Antibiotics 3.Antilipemics 4.Decongestants

4 In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. These medications lessen the voluntary ability to contract the bladder. The client should be questioned about the use of these medications if he has urinary retention. Diuretics increase urine output. Antibiotics and antlipemics do not affect ability to urinate.

A client has a prescription for magnesium citrate to prevent constipation after undergoing barium studies of the gastrointestinal tract. How should the nurse administer the magnesium citrate? 1.With fruit juice only 2.At room temperature 3.With a full glass of water 4.After it is chilled in the refrigerator

4 Magnesium citrate is available as an oral solution and should be served chilled to make it more palatable. The other options are incorrect.

A client with nephrolithiasis arrives at the clinic for a follow-up visit. Laboratory analysis of the stone that the client passed 1 week earlier indicates that the stone is composed of calcium oxalate. Based on these data, what food item does the nurse instruct the client to avoid? 1.Pasta 2.Lentils 3.Lettuce 4.Spinach

4 Many kidney stones are composed of calcium oxalate. Foods that raise urinary oxalate excretion include spinach, rhubarb, strawberries, chocolate, wheat bran, nuts, beets, and tea. Pasta, lentils, and lettuce are acceptable to consume.

The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL (10 mmol/L). The client is taking cholestyramine and the nurse teaches the client about the medication. Which statement, by the client, indicates the need for further teaching? 1. "Constipation and bloating might be a problem." 2."I'll continue to watch my diet and reduce my fats." 3."Walking a mile each day will help the whole process." 4."I'll continue my nicotinic acid from the health food store."

4 Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin needs to be avoided. Constipation and bloating are the 2 most common adverse effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels.

A client has an as needed prescription for ondansetron. For which condition(s) should the nurse administer this medication? 1.Paralytic ileus 2.Incisional pain 3.Urinary retention 4.Nausea and vomiting

4 Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. The other options are incorrect reasons for administering this medication

Oral rifaximin has been prescribed for a client with portosystemic encephalopathy. The nurse reviews the health care provider's prescription and determines that this medication has been prescribed for which purpose? 1.Prevent infection. 2.Prevent restlessness in the client. 3.Prevent fluid retention and ascites. 4.Destroy normal bacteria found in the bowel.

4 Rifaximin may be prescribed for the client with portosystemic encephalopathy. It is a broad-spectrum antibiotic that destroys normal bacteria found in the bowel, thereby decreasing protein breakdown and ammonia production. The remaining options are not accurate rationales for administration of this medication to this client.

A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and is receiving education about the procedure from the nurse. Which statement by the client indicates that the teaching has been effective? 1."It involves tying off the veins so that circulation is redirected in another area." 2."It involves surgically removing the varicosity, so anesthesia will be required." 3."It involves tying off the veins to prevent sluggishness of blood from occurring." 4."It involves injecting an agent into the vein to damage the vein wall and close it off."

4 Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, distention will not occur. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries and then removing the vein with the use of a hook and wires applied through multiple small incisions in the leg. Other treatments include the application of radiofrequency (RF) energy, in which the vein is heated from the inside by the RF energy and shrinks; collateral veins nearby take over. Laser treatment is another alternative to surgery; in this treatment a laser fiber is used to heat and close the main vessel that is contributing to the varicosity.

A client is being treated with procainamide for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first? 1. Measure the heart rate on the rhythm strip. 2.Administer prescribed nitroglycerin tablets. 3.Obtain a 12-lead electrocardiogram immediately. 4.Auscultate the client's apical pulse and obtain a blood pressure.

4 Signs of toxicity from procainamide include confusion, dizziness, drowsiness, decreased urination, nausea, vomiting, and tachydysrhythmias. If the client complains of dizziness, the nurse should assess the vital signs first. Although measuring the heart rate on the rhythm strip and obtaining a 12-lead electrocardiogram may be interventions, these would be done after the vital signs are taken. Nitroglycerin is a vasodilator and will lower the blood pressure.

The nurse is caring for a client on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, the nurse should take which action? 1.Document the findings. 2.Reassess the pH in 4 hours. 3.Instill 30 mL of sterile water. 4.Administer a dose of a prescribed antacid.

4 The client on a mechanical ventilator who has a nasogastric tube in place should have the gastric pH monitored at the beginning of each shift or least every 12 hours. Because of the risk of stress ulcer formation, a pH lower than 5 (acidic) should be treated with prescribed antacids. If there is no prescription for the antacid, the health care provider should be notified. Documentation of the findings should be done after the administration of an antacid. Sterile water instillation is not an appropriate treatment.

The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should place the client in which position? 1.Prone 2.Supine 3.Semi Fowler's with the hip and the neck flexed 4.Head of the bed elevated 30 degrees with the head in midline position

4 The health care provider's prescriptions are always followed with regard to positioning the client after stroke. Clients with hemorrhagic stroke usually have the head of the bed elevated to 30 degrees to reduce intracranial pressure that can occur from the hemorrhage. The head should be in a midline, neutral position to facilitate venous drainage from the brain. Extreme hip and neck flexion should be avoided to prevent an increase in intrathoracic pressure and to promote venous drainage from the brain. For clients with ischemic stroke, the head of the bed usually is kept flat to ensure adequate blood flow and thus oxygenation to the brain. Prone, supine, and hip and neck flexion are incorrect positions for clients with hemorrhagic stroke.

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? 1. Anxiety level of the client and family 2.Presence of a MedicAlert card for the client to carry 3. Knowledge of restrictions on postdischarge physical activity 4. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver

4 The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The remaining options are also nursing interventions but are not the priority.

A client who is receiving digoxin daily has a serum potassium level of 3 mEq/L (3 mmol/L) and is complaining of anorexia. The health care provider prescribes a serum digoxin level to be done. The nurse checks the results and should expect to note which level that is outside of the therapeutic range?

4 The optimal therapeutic range for digoxin is 0.5 to 0.8 ng/mL. If the client is experiencing symptoms such as anorexia and is experiencing hypokalemia as evidenced by a low potassium level, digoxin toxicity is a concern. Therefore, option 4 is correct because it is outside of the therapeutic level and an elevated level.

A client who is receiving digoxin daily has a serum potassium level of 3 mEq/L (3 mmol/L) and is complaining of anorexia. The health care provider prescribes a serum digoxin level to be done. The nurse checks the results and should expect to note which level that is outside of the therapeutic range? 1. 0.3 ng/mL 2. 0.5 ng/mL 3. 0.8 ng/mL 4. 1.0 ng/mL

4 The optimal therapeutic range for digoxin is 0.5 to 0.8 ng/mL. If the client is experiencing symptoms such as anorexia and is experiencing hypokalemia as evidenced by a low potassium level, digoxin toxicity is a concern. Therefore, option 4 is correct because it is outside of the therapeutic level and an elevated level.

A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? 1. "I should notify my doctor if my feet or legs start to swell." 2. "My doctor told me to call his office if my pulse rate decreases below 60." 3. "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." 4. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

4 Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. The pain is a result of coronary artery spasm. The treatment of choice is usually a calcium channel blocker, which relaxes and dilates the vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. Adverse effects can include peripheral edema, hypotension, bradycardia, and heart failure. Grapefruit juice interacts with calcium channel blockers and should be avoided. If bradycardia occurs, the client should contact the health care provider. Clients should also be taught to change positions slowly to prevent orthostatic hypotension. Physical exertion does not cause this type of angina; therefore, the client should be able to continue morning walks with his or her spouse.

A client is receiving oxybutynin. The nurse should suspect that this medication is prescribed to relieve which condition? 1.Gastritis 2.Renal calculi 3.Ulcerative colitis 4.Overactive bladder

4 When medication therapy for overactive bladder is indicated, anticholinergic agents are the medications generally prescribed. These medications block muscarinic receptors on the bladder detrusor and thereby inhibit bladder contractions and decrease the urge to void. It is not used to treat gastritis. The medication would not be used to treat renal calculi or ulcerative colitis. In fact, it may make those conditions worse.

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take? 1. Check vital signs. 2.Check laboratory test results. 3.Notify the health care provider. 4.Continue to monitor for any rhythm change.

4 Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or to notify the health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change.

The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? 1. I need to be sure not to go barefoot around the house." 2."If I cut my toenails, I need to be sure that I cut them straight across." 3."It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." 4."I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."

4. Foot care instructions for the client with peripheral arterial disease are the same as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also present. The client statements in the remaining options are correct statements, and indicate that the teaching has been effective.

A client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. The nurse should make which response to the client? 1. "Apply warm packs to the leg." 2."Keep the leg elevated as much as possible." 3."Your health care provider needs to be contacted to report this problem." 4."This normally occurs after surgery and will subside when the edema goes down."

A sensation of pins and needles or feeling as though the surgical limb is falling asleep may indicate temporary or permanent nerve damage after surgery. The saphenous vein and the saphenous nerve run close together, and damage to the nerve will produce paresthesias. The remaining options are inaccurate responses. An alternative to surgery is endovenous ablation of the saphenous vein. Ablation involves the insertion of a catheter that emits energy. This causes collapse and sclerosis of the vein. Potential complications include bruising, tightness along the vein, recanalization (reopening of the vein), and paresthesia. Endovenous ablation also may be done in combination with saphenofemoral ligation or phlebectomy. Transilluminated powdered phlebectomy involves the use of a powdered resector to destroy the varices and then removes the pieces via aspiration.

A client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril. When should the nurse plan to administer this medication? 1.During dialysis 2.Just before dialysis 3.The day after dialysis 4.On return from dialysis

Antihypertensive medications such as enalapril are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and from having the medication removed from the bloodstream by dialysis. No rationale exists for waiting an entire day to resume the medication. This would lead to ineffective control of the blood pressure.

A client who has been advanced to a solid diet after undergoing a subtotal gastrectomy. What is the appropriate nursing intervention in preventing dumping syndrome? 1.Remove fluids from the meal tray. 2.Give the client 2 large meals per day. 3.Ask the client to sit up for 1 hour after eating. 4.Provide concentrated, high-carbohydrate foods.

Factors to minimize dumping syndrome after gastric surgery include having the client lie down for at least 30 minutes after eating; giving small, frequent meals; having the client maintain a low Fowler's position while eating, if possible; avoiding liquids with meals; and avoiding high-carbohydrate food sources. Antispasmodic medications also are prescribed as needed to delay gastric emptying.

The nurse is providing education to a client who is being started on atenolol. Which statement by the client indicates that teaching has been effective? 1."I am taking this medication for hypertension." 2."It is to help manage my rheumatoid arthritis." 3."This medication will help my ulcerative colitis." 4."This medication will reverse my second-degree heart block."

Rationale:Atenolol is a beta-adrenergic blocker that is used as an antihypertensive, antianginal, and antidysrhythmic. It is used to treat conditions such as hypertension and angina pectoris. It is not used to treat the conditions noted in the other options. In addition, its use is contraindicated in the client with heart block greater than first degree

Cardiac troponin T or cardiac troponin I have been found to be a protein marker in the detection of myocardial infarction, and assay for this protein is used in some institutions to aid in the diagnosis of a myocardial infarction. The test is not used to diagnose heart failure, ventricular tachycardia, or atrial fibrillation. 1. Heart failure 2.Atrial fibrillation 3.Myocardial infarction 4.Ventricular tachycardia

The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

The clinic nurse is performing an abdominal assessment on a client and preparing to auscultate bowel sounds. The nurse should place the stethoscope in which quadrant first? Click on the image to indicate your answer.

To auscultate bowel sounds, the nurse should begin in the right lower quadrant, at the ileocecal valve area, because normally bowel sounds are always present there. The diaphragm endpiece is used because bowel sounds are relatively high pitched. The stethoscope is held lightly against the skin because pressing too hard can stimulate more bowel sounds.