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A client with a traumatic closed head injury shows signs that indicate the presence of cerebral edema. Which intravenous solution would increase cellular swelling and cerebral edema? 1.0.9% normal saline 2.0.45% normal saline 3.5% dextrose in water 4.Lactated Ringer's solution

A: 0.45% normal saline R: Hypotonic solutions such as 0.45% normal saline are inappropriate for the client with cerebral edema because hypotonic solutions have the potential to cause cellular swelling and cerebral edema. The remaining choices of solutions would be appropriate because they are examples of isotonic solutions and thus are similar in composition to plasma. These A nursing instructor asks the nursing student to describe the definition of a critical path. Which statement, if made by the student, indicates a need for further teaching regarding critical paths? would remain in the intravascular space without potentiating the client's cerebral edema.

Which intravenous solution would be most appropriate for a client who may be experiencing excess fluid volume secondary to heart failure? 1.0.9% normal saline 2.0.45% normal saline 3.Lactated Ringer's solution 4.5% dextrose in 0.9% normal saline

A: 5% dextrose in 0.9% normal saline R: The fluid of choice for a client with excess fluid volume is a hypertonic solution of 5% dextrose in 0.9% normal saline. This solution would pull fluid into the intravascular space; the kidneys could then excrete the excess fluid. The 0.45% normal saline solution is hypotonic, which pulls fluid into the intracellular space. The lactated Ringer's and 0.9% normal saline solutions are both isotonic solutions that would worsen the excess fluid volume.

A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? 1.Call the surgeon to report the problem. 2.Reposition the NG tube to the proper location. 3.Check the suction device to make sure it is working. 4.Irrigate the NG tube with saline to remove the obstruction.

A: Check the suction device to make sure it is working. R: After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working correctly. The tip of the NG tube may be placed near the suture line. Because of this possibility, the nurse should never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the nurse should call the surgeon, who would do this repositioning under fluoroscopy.

When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply. 1.Limiting the time with the client to 1 hour per shift. 2.Keeping pregnant women out of the client's room. 3.Placing the client in a private room with a private bath. 4.Wearing a lead shield when providing direct client care. 5.Removing the dosimeter film badge when entering the client's room. 6.Allowing individuals younger than 16 years old in the room as long as they are 6 feet away from the client.

A: -Keeping pregnant women out of the client's room. -Placing the client in a private room with a private bath. -Wearing a lead shield when providing direct client care. R: The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The client must be placed in a private room with a private bath. The nurse should wear a lead shield to reduce the transmission of radiation. The dosimeter film badge must be worn when in the client's room. Children younger than 16 years of age and pregnant women are not allowed in the client's room.

The nurse is planning to teach a client with gastroesophageal reflux disease about substances to avoid. Which items should the nurse include on this list? Select all that apply. 1.Coffee 2.Chocolate 3.Peppermint 4.Nonfat milk 5.Fried chicken 6.Scrambled eggs

A: 1.Coffee 2.Chocolate 3.Peppermint 5.Fried chicken R: Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will increase reflux and exacerbate the symptoms of gastroesophageal reflux disease (GERD) and therefore should be avoided. Aggravating substances include chocolate, coffee, fried or fatty foods, peppermint, carbonated beverages, and alcohol. Options 4 and 6 do not promote this effect.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect to note on assessment of this client? Select all that apply. 1.Hypocapnia 2.A hyperinflated chest noted on the chest x-ray 3.Decreased oxygen saturation with mild exercise 4.A widened diaphragm noted on the chest x-ray 5.Pulmonary function tests that demonstrate increased vital capacity

A: -A hyper inflated chest noted on the chest x-ray -Decreased oxygen saturation with mild exercise R: Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. 1.Administer stool softeners as prescribed. 2.Instruct the client to limit fluid intake to avoid urinary retention. 3.Instruct the client to avoid activities that will initiate vasovagal responses. 4.Encourage a high-fiber diet to promote bowel movements without straining. 5.Apply cold packs to the anal-rectal area over the dressing until the packing is removed. 6.Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding.

A: -Administer stool softeners as prescribed. -Encourage a high-fiber diet to promote bowel movements without straining. -Apply cold packs to the anal-rectal area over the dressing until the packing is removed. R: Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the client avoid straining, thereby reducing the chances of rupturing the incision. An ice pack will increase comfort and decrease bleeding. Options 2, 3, and 6 are incorrect interventions.

The nurse is preparing to instill medication into a client's nasogastric tube. Which actions should the nurse take before instilling the medication? Select all that apply. 1.Check the residual volume. 2.Aspirate the stomach contents. 3.Turn off the suction to the nasogastric tube. 4.Remove the tube and place it in the other nostril. 5.Check the stomach contents for a pH of less than 3.5.

A: -Check the residual volume. -Aspirate the stomach contents. -Turn off the suction to the nasogastric tube. -Check the stomach contents for a pH of less than 3.5. R: By aspirating stomach contents the residual volume can be determined and the pH checked. A pH less than 3.5 verifies gastric placement. The suction should be turned off before the tubing is disconnected to check for residual volume; in addition, suction should remain off for 30 to 60 minutes following medication administration to allow for medication absorption. There is no need to remove the tube and place it in the other nostril in order to administer a feeding; in fact, this is an invasive procedure and is unnecessary.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1.Excessive bubbling in the water seal chamber 2.Vigorous bubbling in the suction control chamber 3.Drainage system maintained below the client's chest 4.50 mL of drainage in the drainage collection chamber 5.Occlusive dressing in place over the chest tube insertion site 6.Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

A: -Drainage system maintained below the client's chest -50 mL of drainage in the drainage collection chamber -Occlusive dressing in place over the chest tube insertion site -Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation R: The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires health care provider notification. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral position 3.Head of bed elevated 30 to 45 degrees 4.Head turned to the side when flat in bed 5.Neck and jaw flexed forward when opening the mouth

A: -Headline midline -Neck in neutral position -Head of bed elevated 30 to 45 R: Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating.The head of the client at risk for or with increased intracranial pressure should be positioned so that the head is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the neck or turning the head from side to side.

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client? 1."Take a deep breath when I tell you and hold it while I remove the tube." 2."Take a deep breath when I tell you and bear down while I remove the tube." 3."Take a deep breath when I tell you and slowly exhale while I remove the tube." 4."Take a deep breath when I tell you and breathe normally while I remove the tube."

A: "Take a deep breath when I tell you and hold it while I remove the tube." R: The client should take a deep breath because the client's airway will be temporarily obstructed during tube removal. The client is then told to hold the breath and the tube is withdrawn slowly and evenly over the course of 3 to 6 seconds (coil the tube around the hand while removing it) while the breath is held. Bearing down could inhibit the removal of the tube. Exhaling is not possible during removal because the airway is temporarily obstructed during removal. Breathing normally could result in aspiration of gastric secretions during inhalation.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1.Discourage reminiscing. 2.Make the decisions for the family. 3.Encourage expression of feelings, concerns, and fears. 4.Explain everything that is happening to all family members. 5.Touch and hold the client's or family member's hand if appropriate. 6.Be honest and let the client and family know that they will not be abandoned by the nurse.

A: -Touch and hold the client's or family member's hand if appropriate. -Be honest and let the client and family know that they will not be abandoned by the nurse. -Encourage expression of feelings, concerns, and fears. R: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know that they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply. 1.Sunscreen should be applied every 8 hours. 2.Use sunscreen when participating in outdoor activities. 3.Wear a hat, opaque clothing, and sunglasses when in the sun. 4.Avoid sun exposure in the late afternoon and early evening hours. 5.Examine your body monthly for any lesions that may be suspicious.

A: -Use sunscreen when participating in outdoor activities -Wear a hat, opaque clothing, and sunglasses when in the sun -Examine your body monthly for any lesions that may be suspicious R: The client should be instructed to avoid sun exposure between the hours of 10 am and 4 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or any precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. 1.Contact the surgeon. 2.Instruct the client to remain quiet. 3.Prepare the client for wound closure. 4.Document the findings and actions taken 5.Place a sterile saline dressing and ice packs over the wound. 6.Place the client in a supine position without a pillow under the head.

A: Contact the surgeon. Instruct the client to remain quiet. Prepare the client for wound closure. Document the findings and actions taken R: Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low Fowler's position, and the client is kept quiet, and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken

A sexually active 20-year-old client has developed viral hepatitis. Which client statement indicates the need for further teaching? 1."I should avoid drinking alcohol." 2."I can go back to work right away." 3."My partner should get the vaccine." 4."A condom should be used for sexual intercourse."

A: "I can go back to work right away." R: To prevent transmission of hepatitis, vaccination of the partner is advised. In addition, a condom is advised during sexual intercourse. Alcohol should be avoided because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that liver function has returned to normal. The client's activity is increased gradually, and the client should not return to work right away.

The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction? 1."I should cuddle my child after giving the medication." 2."I can give my child a frozen juice bar after he swallows the medication." 3."I should mix the medication in the baby food and give it when I feed my child." 4."If my child does not like the taste of the medicine, I should encourage him to pinch his nose and drink the medication through a straw."

A: "I should mix the medication in the baby food and give it when I feed my child." R: The nurse would teach the parent to avoid putting medications in foods because it may give an unpleasant taste to the food, and the child may refuse to accept the same food in the future. In addition, the child may not consume the entire serving and would not receive the required medication dosage. The mother should provide comfort measures immediately after medication administration, such as touching, holding, cuddling, and providing a favorite toy. The mother should offer juice, a soft drink, or a frozen juice bar to the child after the child swallows the medication. If the taste of the medication is unpleasant, the child should pinch the nose and drink the medication through a straw.

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests no autopsy be performed. Which response to the family is most appropriate? 1."The decision is made by the medical examiner." 2."An autopsy is mandatory for any client who is DOA." 3."I will contact the medical examiner regarding your request." 4."It is required by federal law. Tell me why you don't want the autopsy done?"

A: "I will contact the medical examiner regarding your request." R: An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. A client may have provided oral or written instructions regarding an autopsy after death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin.

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? 1.1 minute 2.5 seconds 3.10 seconds 4.30 seconds

A: 10 seconds R: Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.

When making assignments to a team consisting of a registered nurse (RN), one licensed practical nurse (LPN), and two unlicensed assistive personnel (UAP), which is the best client for the LPN? 1.A client requiring frequent temperature checks 2.A client requiring assistance with ambulation every 4 hours 3.A client on a mechanical ventilator requiring frequent assessment and suctioning 4.A client with a spinal cord injury requiring urinary catheterization every 6 hours as prescribed

A: A client with a spinal cord injury requiring urinary catheterization every 6 hours as prescribed R: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Frequent temperature checks and ambulation can most appropriately be provided by the UAP, considering the clients identified in each option. The client on the mechanical ventilator requiring frequent assessment and suctioning should most appropriately be cared for by the RN. The LPN is skilled in urinary catheterization, so the client in option 4 would be assigned to this staff member.

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1.A client with an ileostomy 2.A client with heart failure 3.A client on long-term corticosteroid therapy 4.A client receiving frequent wound irrigations

A: A client with an ileostomy R: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy, or a client receiving frequent wound irrigations, are most at risk for fluid volume excess.

he nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? 1.Bradycardia 2.Numbness in the legs 3.Nausea and vomiting 4.A rigid, boardlike abdomen

A: A rigid, boardlike abdomen R: Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the mid-epigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.

The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation?

A: A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed. R: In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid, twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the ankle and great toe with fanning of the other toes; if this occurs in anyone older than 2 years it indicates the presence of central nervous system disease.

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg and asks the admitting nurse to explain what cellulitis means. The nurse bases the response on the understanding that cellulitis has which characteristic? 1.An inflammation of the epidermis only 2.A skin infection of the dermis and underlying hypodermis 3.An acute superficial infection of the dermis and lymphatics 4.An epidermal and lymphatic infection caused by Staphylococcus

A: A skin infection of the dermis and underlying hypodermis R: Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics.

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? 1.A pink, edematous hand 2.A fiery red skin with edema in the nail beds 3.Black fingertips surrounded by an erythematous rash 4.A white color to the skin, which is insensitive to touch

A: A white color to the skin, which is insensitive to touch R: Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present? 1.Weight loss 2.Flat neck and hand veins 3.An increase in blood pressure 4.Decreased central venous pressure (CVP)

A: An increase of BP R: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit.

A client has refused to eat more than a few spoonfuls of breakfast. The health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client had been losing weight for the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation? 1.Assault 2.Battery 3.Slander 4.Invasion of privacy

A: Assault R: Assault occurs when a person puts another person in fear of harmful or offensive contact and the victim fears and believes that harm will result as a result of the threat. In this situation, the nurse could be accused of the tort of assault. Battery is the intentional touching of another's body without the person's consent. Slander is verbal communication that is false and harms the reputation of another. Invasion of privacy is committed when the nurse intrudes into the client's personal affairs or violates confidentiality.

The nurse develops a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1.Out-of-bed activities as desired 2.Bed rest with the affected extremity kept flat 3.Bed rest with elevation of the affected extremity 4.Bed rest with the affected extremity in a dependent position

A: Bed rest with elevation of the affected extremity R: For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking.

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? 1.Serous 2.Bloody 3.Serosanguineous 4.Bloody, with frequent small clots

A: Bloody R: In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

The nurse is caring for a client who is postoperative following a pelvic exenteration and the health care provider changes the client's diet from NPO status to clear liquids. The nurse should check which priority item before administering the diet? 1.Bowel sounds 2.Ability to ambulate 3.Incision appearance 4.Urine specific gravity

A: Bowel Sounds R: The client is kept NPO until peristalsis returns, usually in 4 to 6 days. When signs of bowel function return, clear fluids are given to the client. If no distention occurs, the diet is advanced as tolerated. The most important assessment is to assess bowel sounds before feeding the client. Options 2, 3, and 4 are unrelated to the data in the question.

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. 1.Broth 2.Coffee 3.Gelatin 4.Pudding 5.Vegetable juice 6.Pureed vegetables

A: Broth, Coffee and Gelatin R: A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The client has tolerated the tube being clamped every 2 hours for 1 hour. The health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? 1.Checking for normal serum electrolyte levels 2.Checking for normal pH of the gastric aspirate 3.Checking for proper nasogastric tube placement 4.Checking for the presence of bowel sounds in all four quadrants

A: Checking the presence of bowel sounds in all four quadrants R: Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place, but would not assist in determining the readiness for removing the nasogastric tube.

The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? 1.Position the client supine to assist in medication absorption. 2.Aspirate the nasogastric tube after medication administration to maintain patency. 3.Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. 4.Change the suction setting to low intermittent suction for 30 minutes after medication administration

A: Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. R: If a client has a nasogastric tube connected to suction, the nurse should wait 30 to 60 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. The client should not be placed in the supine position because of the risk for aspiration. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered.

The nurse has administered approximately half of an enema solution to a preoperative client when the client complains of pain and cramping. Which nursing action is most appropriate at this time? 1.Reassure the client and continue the flow. 2.Raise the enema bag so that the solution can be instilled quickly. 3.Discontinue the enema and notify the health care provider (HCP). 4.Clamp the tubing for 30 seconds and restart the flow at a slower rate.

A: Clamp the tubing for 30 seconds and restart the flow at a slower rate. R: The enema fluid should be administered slowly. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. Although client reassurance is important, continuing the flow is inappropriate. Slow enema administration and stopping the flow temporarily, if necessary, decrease the likelihood of intestinal spasm and premature ejection of the solution. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum; this could increase cramping. There is no need to discontinue the enema and notify the HCP at this time.

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An unlicensed assistive personnel (UAP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the UAP? 1. Ignore the resistance. 2.Exert coercion on the UAP. 3.Provide a positive reward system for the UAP. 4.Confront the UAP to encourage verbalization of feelings regarding the change.

A: Confront the UAP to encourage verbalization of feelings regarding the change. R: Confrontation is an important strategy to meet resistance head on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance, but will not address the concern specifically.

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action? 1.Measure abdominal girth. 2.Irrigate the nasogastric tube. 3.Continue to monitor the drainage. 4.Notify the health care provider (HCP).

A: Continue to monitor the drainage. R: Following gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours postoperatively, changes to brown-tinged, and is then yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. The nurse does not need to notify the HCP at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, a nasogastric tube should not be irrigated unless there are specific HCP prescriptions to do so.

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food item on the list? 1.Oranges 2.Broccoli 3.Cream cheese 4.Broiled haddock

A: Cream cheese R: Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Broiled haddock is also naturally lower in fat. Cream cheese is a high-fat food.

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? 1.Cream of wheat, blueberries, coffee 2.Sausage and eggs, banana, orange juice 3.Bacon, cantaloupe melon, tomato juice 4.Cured pork, grits, strawberries, orange juice

A: Cream of wheat, blueberries, coffee R: The diet for a client with chronic kidney disease who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids, which is indicated in the correct option. The food items in the remaining options are high in sodium, phosphorus, or potassium.

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client? 1.Tea 2.Gelatin 3.Custard 4.Ice pop

A: Custard R: Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, refined cooked cereals, and strained vegetable juices. A clear liquid diet consists of foods that are relatively transparent. The food items in the incorrect options are clear liquids.

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider? 1.Dark red drainage 2.Dark brown drainage 3.Green-tinged drainage 4.Light yellowish brown drainage

A: Dark red drainage R: For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish brown color. The presence of bile may cause a green tinge. The health care provider (HCP) should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1.Lung congestion 2.Decreased hematocrit 3.Increased blood pressure 4.Decreased central venous pressure (CVP)

A: Decreased central venous pressure (CVP) R: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased CVP, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration (fluid volume deficit) has a low CVP. The assessment findings in the remaining options are seen in a client with fluid volume excess.

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube? 1.Deflate the cuff on the tube. 2.Place the inner cannula into the tube. 3.Ensure that the client is able to speak. 4.Ensure that the client is able to swallow.

A: Deflate the cuff on the tube. R: Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place. The ability to swallow or speak is unrelated to weaning and plugging the tube.

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? 1.Check for medication interactions. 2.Determine whether there are medication duplications. 3.Call the prescribing health care provider (HCP) and report polypharmacy. 4.Determine whether a family member supervises medication administration.

A: Determine whether there are medication duplications. R: Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined because the nurse needs to know what the client is taking. Asking about medication administration supervision may be part of the assessment but is not a first action. The phone call to the HCP is the intervention after all other information has been collected.

The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to note documented in the client's record? 1.Diarrhea 2.Chronic constipation 3.Constipation alternating with diarrhea 4.Stool constantly oozing from the rectum

A: Diarrhea R: Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options 2, 3, and 4 are not characteristics of Crohn's disease.

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of a pneumothorax in this client? 1.A low respiratory rate 2.Diminished breath sounds 3.The presence of a barrel chest 4.A sucking sound at the site of injury

A: Diminished breath sounds R: This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? 1.Check for an air leak. 2.Document the findings. 3.Notify the health care provider. 4.Change the chest tube drainage system.

A: Document the findings. R: Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. Notifying the health care provider and changing the chest tube drainage system are not indicated at this time.

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse develops a postoperative plan of care for the client and should include which intervention in the plan? 1.Maintain the client in a prone position. 2.Elevate and immobilize the grafted extremity. 3.Maintain the grafted extremity in a flat position. 4.Keep the grafted extremity covered with a blanket.

A: Elevate and immobilize the grafted extremity. R: Autografts placed over joints or on lower extremities are elevated and immobilized following surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site.

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1.Decreased heart rate 2.Increased urinary output 3.Increased blood pressure 4.Elevated hematocrit levels

A: Elevated hematocrit levels R: The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, and renal perfusion and glomerular filtration are decreased, resulting in low urine output. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.

The nurse is caring for a client who is on strict bed rest and develops a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1.Restricting fluids 2.Placing a pillow under the knees 3.Encouraging active range-of-motion exercises 4.Applying a heating pad to the lower extremities

A: Encouraging active range-of-motion exercises R: Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a health care provider's prescription.

A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? 1.Folate deficiency 2.Malabsorption of fat 3.Intestinal obstruction 4.Fluid and electrolyte imbalance

A: Fluid and electrolyte imbalance R: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1.Sodium, 141 mEq/L 2.Hemoglobin, 8.0 g/dL 3.Platelets, 210,000 cells/mm3 4.Serum creatinine, 0.8 mg/dL

A: Hemoglobin, 8.0 g/dL R: Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.

The health care provider has determined that a client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? 1.Hepatitis A 2.Hepatitis B 3.Hepatitis C 4.Hepatitis D

A: Hepatitis A R: Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.

The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? 1.Hold the feeding. 2.Reinstill the amount and continue with administering the feeding. 3.Elevate the client's head at least 45 degrees and administer the feeding. 4.Discard the residual amount and proceed with administering the feeding.

A: Hold the feeding R: Unless specifically indicated, residual amounts more than 100 mL require holding the feeding. In addition, the feeding is not discarded unless its contents are abnormal in color or characteristics.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1.Muscle twitches 2.Decreased urinary output 3.Hyperactive bowel sounds 4.Increased specific gravity of the urine

A: Hyperactive bowel sounds R: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? 1.Out-of-bed activities 2.Bathroom privileges 3.Immobilization of the affected leg 4.Placing the affected leg in a dependent position

A: Immobilization of the affected leg R: Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Options 1, 2, and 4 are incorrect.

A client is admitted to the hospital with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1.Select foods high in fat. 2.Increase intake of fluids, including juices. 3.Eat a good supper when anorexia is not as severe. 4.Eat less often, preferably only three large meals daily.

A: Increase intake of fluids, including juices. R: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription? 1.Transfusing 1 unit of packed red blood cells 2.Administering a diuretic to increase urine output 3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4.Changing the IV lactated Ringer's solution to one that contains dextrose in water

A: Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour R: Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer's solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30 mL/hour. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore the HCP would prescribe an increase in the amount of IV lactated Ringer's solution administered per hour. Blood replacement is not used for fluid therapy for burn injuries. Administering a diuretic would not correct the problem because it would not replace needed fluid. Diuretics promote the removal of the circulating volume, thereby further compromising the inadequate tissue perfusion. Dextrose in water is an isotonic solution, and an isotonic solution maintains fluid balance. This type of solution may be administered after the first 24 hours following the burn injury, depending on the client's physiological needs.

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this client? 1.Low-protein diet 2.High-protein diet 3.Moderate-fat diet 4.High-carbohydrate die

A: Low-protein diet R: Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. If the client has hepatic encephalopathy, a low-protein diet would be prescribed.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1.Malaise 2.Dark stools 3.Weight gain 4.Left upper quadrant discomfort

A: Malasie R: Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action? 1.Immobilize the affected extremity. 2.Remove jewelry and constricting clothing from the victim. 3.Place the extremity in a position so that it is below the level of the heart. 4.Move the victim to a safe area away from the snake and encourage the victim to rest.

A: Move the victim to a safe area away from the snake and encourage the victim to rest. R: In the event of a snakebite, the first priority is to move the victim to a safe area away from the snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity below heart level would be done next; these actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to the victim because these products may speed the absorption of the venom. The victim should be transported to an emergency facility as soon as is possible.

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial nursing action should the nurse take? 1.Call the health care provider (HCP). 2.Place the tube in a bottle of sterile water. 3.Replace the chest tube system. 4.Place a sterile dressing over the disconnection site.

A: Place the tube in a bottle of sterile water. R: If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified, but this is not the initial action. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection.

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? 1.Notify the health care provider (HCP). 2.Administer the prescribed pain medication. 3.Call and ask the operating room team to perform the surgery as soon as possible. 4.Reposition the client and apply a heating pad on the warm setting to the client's abdomen.

A: Notify the health care provider (HCP). R: On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the HCP probably would perform the surgery earlier than the prescheduled time.

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? 1.Milk 2.Oranges 3.Bananas 4.Chicken

A: Oranges R: Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins.

The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if she selects which items from her menu? 1.Nuts and milk 2.Coffee and tea 3.Cooked rolled oats and fish 4.Oranges and dark green leafy vegetables

A: Oranges and dark green leafy veggies R:Dark green leafy vegetables are a good source of iron and oranges are a good source of vitamin C, which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C.

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? 1.Have one of the client's family members interpret. 2.Have the Spanish-speaking triage receptionist interpret. 3.Page an interpreter from the hospital's interpreter services. 4.Obtain a Spanish-English dictionary and attempt to triage the client.

A: Page an interpreter from the hospital's interpreter services. R: The best action is to have a professional hospital-based interpreter translate for the client. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality as well as accurate information may be compromised when a family member or a non-health care provider acts as interpreter.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1.Cyanosis 2.Hypotension 3.Paradoxical chest movement 4.Dyspnea, especially on exhalation

A: Paradoxical chest movement R: Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? 1.Intact skin 2.Full-thickness skin loss 3.Exposed bone, tendon, or muscle 4.Partial-thickness skin loss of the dermis

A: Partial thickness skin loss of the dermis R: In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open or ruptured, serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? 1.Exhale slowly. 2.Stay very still. 3.Inhale and exhale quickly. 4.Perform the Valsalva maneuver.

A: Perform the Valsalva maneuver. R: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.

While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action? 1. Call the health care provider (HCP). 2. Reinsert the implant into the vagina. 3.Pick up the implant with gloved hands and flush it down the toilet. 4.Pick up the implant with long-handled forceps and place it in a lead container.

A: Pick up the implant with long-handled forceps and place it in a lead container. R: In the event that a radiation source becomes dislodged, the nurse would first encourage the client to lie still until the radioactive source has been placed in a safe closed container. The nurse would use a long-handled forceps to place the source in the lead container that should be in the client's room. The nurse should then call the radiation oncologist and then document the event and the actions taken. It is not within the scope of nursing practice to insert a radiation implant.

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? 1.Apply restraints to the client. 2.Ask the family to stay with the client. 3.Place a clock and calendar in the client's room. 4. Ask the laboratory to perform electrolyte studies.

A: Place a clock and calendar in the client's room. R: An inactive older adult may become disoriented because of lack of sensory stimulation. The most appropriate nursing intervention would be to reorient the client frequently and to place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and should not be applied unless specifically prescribed; agency policies and procedures should be followed before the application of restraints. The family can assist with orientation of the client, but it is inappropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.

The nurse is caring for a client with cirrhosis of the liver. 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 dietary measures to follow if the client states an intention to increase the intake of which food? 1.Pork 2.Milk 3.Chicken 4.Broccoli

A: Pork R: The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid.

The nurse is reviewing a health care provider's (HCP's) prescription sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the HCP to clarify that which medication should be given to the client and not withheld? 1.Prednisone 2.Ferrous sulfate 3.Cyclobenzaprine (Flexeril) 4.Conjugated estrogen (Premarin)

A: Prednisone R: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. These last three medications may be withheld before surgery without undue effects on the client.

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid? 1.Peas 2.Nuts 3.Cauliflower 4.Processed oat cereals

A: Processed oat cereals R: The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Nuts, cauliflower, and peas are good food sources of phosphorus. Peas are also a good source of magnesium. Processed foods are high in sodium content.

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. 1.Peas 2.Raisins 3.Potatoes 4.Cantaloupe 5.Cauliflower 6.Strawberries

A: Raisins, potatoes, cantaloupe, and strawberries R: The normal potassium level is 3.5 to 5.0 mEq/L. Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.

After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. Which description best describes "normal bowel sounds"? 1.Waves of loud gurgles auscultated in all four quadrants 2.Low-pitched swishing auscultated in one or two quadrants 3.Relatively high-pitched clicks or gurgles auscultated in all four quadrants 4. Very high-pitched loud rushes auscultated especially in one or two quadrants

A: Relatively high-pitched clicks or gurgles auscultated in all four quadrants R: 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. 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 1, 2, and 4 are incorrect.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because of which situation? 1.Sustained tissue damage 2.Requires nasogastric suction 3.Has a history of Addison's disease 4.Is taking a potassium-retaining diuretic

A: Requires Nasogastric suction R: The normal serum potassium level is 3.5 mEq/L to 5.0 mEq/L. A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client taking a potassium-retaining diuretic are at risk for hyperkalemia.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1.Return of distal pulses 2.Brisk bleeding from the site 3.Decreasing edema formation 4.Formation of granulation tissue

A: Return of distal pulses R: Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?

A: Rhythmic respirations with periods of apnea R: Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? 1.Tomato soup 2.Boiled shrimp 3.Instant oatmeal 4.Summer squash

A: Summer Squash R: Foods that are lower in sodium include fruits and vegetables (summer squash), because they do not contain physiological saline. Highly processed or refined foods (tomato soup, instant oatmeal) are higher in sodium unless their food labels specifically state "low sodium." Saltwater fish and shellfish are high in sodium.

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1.Right pneumothorax 2.Pulmonary embolism 3.Displaced endotracheal tube 4.Acute respiratory distress syndrome

A: Right pneumothorax R: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi.

The nurse is caring for a client following a supratentorial craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? 1.Semi-Fowler's 2.Trendelenburg's 3.Reverse Trendelenburg's 4.Flat

A: Semi-fowlers R: Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion and the head is maintained in a midline neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent displacement of the cranial contents. A flat position or Trendelenburg's position would increase intracranial pressure. A reverse Trendelenburg's position would not be helpful and may be uncomfortable for the client.

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1.Red, hard skin 2.Serous drainage 3.Purulent drainage 4.Warm, tender skin

A: Serous drainage R: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.

A client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client's pain. What type of pain is consistent with this diagnosis? 1.Burning and aching, located in the left lower quadrant and radiating to the hip 2.Severe and unrelenting, located in the epigastric area and radiating to the back 3.Burning and aching, located in the epigastric area and radiating to the umbilicus 4.Severe and unrelenting, located in the left lower quadrant and radiating to the groin

A: Severe and unrelenting, located in the epigastric area and radiating to the back R: The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. The other options are incorrect.

A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? 1.Side-lying with a pillow under the hip 2.Prone with a pillow under the abdomen 3.Prone in slight Trendelenburg's position 4.Side-lying with the legs pulled up and the head bent down onto the chest

A: Side-lying with the legs pulled up and the head bent down onto the chest R: A client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae and allows for easier needle insertion by the health care provider. The nurse remains with the client during the procedure to help the client maintain this position. The other options identify incorrect positions for this procedure.

The nurse is preparing a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client? 1.Urinary incontinence 2.Signs of skin breakdown 3.The presence of bowel sounds 4.Signs of infection around the pin sites

A: Signs of skin breakdown R: Skin traction is achieved by Ace wraps, boots, and slings that apply a direct force on the client's skin. Traction is maintained with 5 to 8 lb of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can occur as a result of immobility and monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction.

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food? 1.Apples 2.Bananas 3.Smoked sausage 4.Steamed vegetables

A: Smoked sausage R: Smoked foods are high in sodium, which is noted in the correct option. The remaining options are fruits and vegetables that are low in sodium.

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is most appropriate? 1.Continue to suction. 2.Notify the health care provider immediately. 3.Stop the procedure and reoxygenate the client. 4.Ensure that the suction is limited to 15 seconds.

A: Stop the procedure and reoxygenate the client. R: During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? 1.Stridor 2.Occasional pink-tinged sputum 3.Respiratory rate of 24 breaths/minute 4.A few basilar lung crackles on the right

A: Stridor R: Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the health care provider (HCP) immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Although the findings identified in the remaining options require monitoring, they do not require immediate notification of the health care provider.

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? 1.Prone 2.Reverse Trendelenburg's 3.Supine, with the amputated limb flat on the bed 4.Supine, with the amputated limb supported with pillows

A: Supine, with the amputated limb supported with pillows R: The amputated limb is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the amputated limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check health care provider prescriptions regarding positioning following amputation.

The nurse obtains an admission history for a client with suspected peptic ulcer disease. Which client factor documented by the nurse would increase the risk for peptic ulcer disease? 1.Recently retired from a job 2.Significant other has a gastric ulcer 3.Occasionally drinks one cup of coffee in the morning 4.Takes non steroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis

A: Takes non steroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis R: Risk factors for peptic ulcer disease include Helicobacter pylori infection, smoking (nicotine), chewing tobacco, corticosteroids, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), caffeine, alcohol, and stress. When an NSAID is taken as often as is typical for osteoarthritis, it will cause problems with the stomach. Certain medical conditions such as Crohn's disease, Zollinger-Ellison syndrome, and hepatic and biliary disease also can increase the risk for peptic ulcer disease by changing the amount of gastric and biliary acids produced. Recent retirement should decrease stress levels, rather than increase them. Ulcer disease in a first-degree relative also is associated with increased risk for an ulcer. A significant other is not a first-degree relative; therefore, no genetic connection is noted in this relationship. Although caffeinated drinks are a known risk factor for PUD, the option states that the client drinks one cup of coffee occasionally.

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? 1.The need for sensory stimulation 2.The amount of home care support available 3.The ability to perform activities of daily living 4.The type of transportation available for follow-up care

A: The need for sensory stimulation R: A psychosocial assessment of a client who is immobilized would most appropriately include the need for sensory stimulation. This assessment should also include such factors as body image, past and present coping skills, and coping methods used during the period of immobilization. Although home care support, the ability to perform activities of daily living, and transportation are components of an assessment, they are not as specifically related to psychosocial adjustment as is the need for sensory stimulation.

The nurse recognizes that which intervention is unlikely to facilitate effective communication between a dying client and family? 1.The nurse encourages the client and family to identify and discuss feelings openly. 2.The nurse assists the client and family in carrying out spiritually meaningful practices. 3.The nurse makes decisions for the client and family to relieve them of unnecessary demands. 4.The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

A: The nurse makes decisions for the client and family to relieve them of unnecessary demands. R: Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Option 1 describes encouraging discussion of feelings and is likely to enhance communications. Option 2 is also an effective intervention because spiritual practices give meaning to life and have an impact on how people react to crisis. Option 4 is also an effective technique because the client and family need to know that someone will be there who is supportive and nonjudgmental. The correct option describes the nurse removing autonomy and decision-making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. This is an ineffective intervention, which could impair communication further.

The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function? 1.The passage of flatus 2.Absent bowel sounds 3.The client's ability to tolerate food 4.Bloody drainage from the colostomy

A: The passage of flatus R: Following abdominal perineal resection, the nurse would expect the colostomy to begin to function within 72 hours after surgery, although it may take up to 5 days. The nurse should assess for a return of peristalsis, listen for bowel sounds, and check for the passage of flatus. Absent bowel sounds would not indicate the return of peristalsis. The client would remain NPO until bowel sounds return and the colostomy is functioning. Bloody drainage is not expected from a colostomy.

The nurse is reading a health care provider's (HCP) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse interprets that this type of fluid loss can occur through which route? 1.The skin 2.Urinary output 3.Wound drainage 4.The gastrointestinal trac

A: The skin R: Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1.This is a normal, expected event. 2.The client is experiencing early signs of ischemic bowel. 3.The client should not have the nasogastric tube removed. 4.This indicates inadequate preoperative bowel preparation.

A: This is a normal, expected event. R: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1.Twitching 2.Hypoactive bowel sounds 3.Negative Trousseau's sign 4.Hypoactive deep tendon reflexes

A: Twitching R: The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse monitors the client, knowing that this client is at risk for which vitamin deficiency? 1.Vitamin A 2.Vitamin B12 3.Vitamin C 4.Vitamin E

A: Vitamin B12 R: Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb vitamin B12. This leads to the development of pernicious anemia. The client is not at risk for vitamin A, C, or E deficiency.

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? 1.Vitamin A 2.Vitamin B12 3.Vitamin C 4.Vitamin E

A: Vitamin B12 R: Vegans do not consume any animal products. Vitamin B12 is found in animal products and therefore would most likely be lacking in a vegan diet. Vitamins A, C, and E are found in fresh fruits and vegetables, which are consumed in a vegan diet

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique?1.Using sterile sheets and linens 2.Performing strict handwashing technique 3.Wearing gloves and a gown only when giving direct care to the client 4.Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

A: Wearing gloves and a gown only when giving direct care to the client R: Thorough handwashing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used because of the client's high risk for infection. Protective garb, including gloves, cap, masks, shoe covers, gowns, and plastic apron, need to be worn when in the client's room and when directly caring for the client.

The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level? 1.The client who is taking diuretics 2.The client with hyperaldosteronism 3.The client with Cushing's syndrome 4.The client who is taking corticosteroids

A: he client who is taking diuretics R: Hyponatremia is evidenced by a serum sodium level less than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

The nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which sign that could indicate an evolving complication? 1.Increasing restlessness 2.A pulse of 86 beats/minute 3.Blood pressure of 110/70 mm Hg 4.Hypoactive bowel sounds in all four quadrants

A: increasing restlessness R: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all four quadrants are a normal occurrence.

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1.The client taking diuretics 2.The client with kidney disease 3.The client with an ileostomy 4.The client who requires gastrointestinal suctioning

A: the client with kidney disease R: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1.Assess the patency of the airway. 2.Check tubes or drains for patency. 3.Check the dressing to assess for bleeding. 4.Assess the vital signs to compare with preoperative measurements.

A:Assess the patency of the airway. R: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? 1.Dry cough 2.Hematuria 3.Bronchospasm 4.Blood-streaked sputum

Bronchospasm R: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs/symptoms of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.