HURST

B, D, E Correct: Think about fluid volume excess and heart failure. Things such as effervescent soluble medications and canned/processed foods should be avoided because they all contain a lot of sodium which increases fluid retention. Therefore, the chicken noodle soup and the cold cut deli-ham sandwiches should be avoided. 1. Incorrect: Fresh fish is a good, healthy selection that is low in sodium, which is what this client needs. Make sure to avoid smoked or cured fish/meats because these would have a higher sodium content. 3. Incorrect: Salt, as a seasoning, should be avoided because this would increase the fluid retention problem. However, a good alternative to salt for seasoning foods is to use lemon, lemon juice, and pepper. These are lower in sodium than salt.

The nurse is preparing a teaching plan for a client newly diagnosed with fluid retention and heart failure. What should the nurse advise the client to avoid? A. Broiled, fresh fish B. Effervescent soluble medications C. Seasoning with lemon pepper D. Chicken noodle soup E. Deli-ham sandwiches

4. Metabolic Alkalosis 4. Correct: Symptoms of alkalosis are often due to associated potassium loss and may include irritability, weakness, and cramping. Excessive vomiting eliminates gastric acid and potassium, leading to metabolic alkalosis. 1. Incorrect: Respiratory Acidosis signs and symptoms include decreased respiratory rate, hyportension and a decrease in level of consciousness. Remember, if it's respiratory acidosis, it traces back to the lungs. This problem describes a metabolic issue. 2. Incorrect: Respiratory Alkalosis signs and symptoms include an inability to concentrate, light-headedness, numbness and tingling, tinnitus and loss of consciousness. The loss of CO2 from the lungs would be the problem with respiratory alkalosis, but the problem described in the question is metabolic. 3. Incorrect: Metabolic Acidosis signs and symptoms include headache, confusion, increased respiratory rate and depth, drowsiness, and nausea and vomiting. This can occur in cases of diarrhea, when more bicarb is lost through the lower GI tract.

A client arrives at the clinic with reports of persistent vomiting, weakness and leg cramps. The nurse notes that the client is irritable. BP 102/58, HR 108, RR 14. Based on this data, what acid/base imbalance does the nurse expect? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Drink plenty of fluids on a daily basis 3. Perform isometric and stretching exercises in the lower extremities. 4. Need for weight management. 5. Walk around 4-6 times per day. 1., 3., 4., & 5. Correct: In order to get this question correct, you must first consider some of the risk factors for developing a DVT and PE. Some causes include: dehydration, venous stasis from prolonged immobility or surgery, obesity, birth control pills, clotting disorders, and heart arrhythmias like A-Fib. Therefore preventive measures would include such things as hydration by increasing fluid intake, prevention of stasis by isometric and stretching exercises of the feet, knees, and hips every 2 to 4 hours, prevention of obesity, and walking around at least 4 to 6 times per day. 2. The client does need to stop when traveling long distances, but it needs to be done more often than every 4 hours. This client has a history of DVT and PE, so it is very important that the client stop and move around at least every 2 hours. If you missed this question, go to section 2 of the respiratory video to review.

A client has a history of deep vein thrombosis (DVT) and pulmonary embolism (PE). What should be included in the teaching by the nurse as preventive measures for the development of a DVT and PE? SATA 1. Drink plenty of fluids on a daily basis. 2. Stop and move around every 4 hours when taking a long trip. 3. Perform isometric and stretching exercises in the lower extremities. 4. Need for weight management. 5. Walk around 4-6 times per day.

3. Needle decompression in the right 2nd intercostal space 3. Correct: Did you recognize the signs of a tension pneumothorax? This client may have developed this because of a high PEEP level and/or compromised lung status combined with mechanical ventilation. Regardless of the cause, this is an emergency situation and the initial treatment involves the insertion of a large bore needle into the 2nd intercostal space, midclavicular line of the affected side. In this case, you should recognize that the absence of breath sounds on the right side indicate that the problem is on the right side. Needle decompression is done to release the pressure that is building up in the pleural space and causing the organs and vessels to be compressed. The mediastinal shift occurs toward the opposite (left side. The client will most likely have a chest tube inserted on the right side, but the initial life saving measure for this would be the needle decompression. 1. Incorrect: What did you learn that is being removed when a chest tube is inserted low in the chest wall? That's right! Fluid. In this case, your clues were that the client was on mechanical ventilation and suddenly developed signs and symptoms of a tension pneumothorax. That means that air is accumulating and causing the problem. We need to remove this air that is compressing the vessels and causing decreased cardiac output. 2. Incorrect: This is a safety issue! Would you turn off a ventilator of a client that is needing this for ventilation ("artificial breathing")? No! You must deal with the problem and decompress the air that is accumulating in the pleural space. 4. Incorrect: The problem is on the right side. There is no need for a thoracentesis on the left side.

A client in the intensive care unit who is on the ventilator, suddenly exhibits signs of decreased cardiac output. A quick assessment reveals that the client has cyanosis, absence of breath sounds on the right side, neck vein distention, and the trachea is deviating to the left. What initial emergency measure should the nurse expect to be performed? 1. Insertion of a chest tube in the 7th intercostal space 2. Immediate removal of client from the ventilator 3. Needle decompression in the right 2nd intercostal space 4. Emergency thoracentesis of the left lung

2. Hypovolemia 3, third spacing 5. low CVP 6. increased urine specific gravity 2., 3., 5., & 6 Correct: Causes of fluid volume deficit (hypovolemia) include loss of fluid from anywhere as well as third spacing of fluid that occurs with such things as burns. Burns can result in fluid loss from the burn area as well as the third spacing, which increases the risk for hypovolemia and shock. As the fluid volume decreases, the BP and CVP both decrease. Remember, less volume, less pressure. Also, when the fluid volume becomes depleted, the urine output will decrease in an effort to hold on to the fluid (compensate) or the kidneys are not being perfused. You will see the urine specific gravity increase because the small amount of urine being produced will be very concentrated. 1. Incorrect: The client with a severe burn will lose fluids from the burn area and will also third space fluid to a place that does them no good. Therefore, they will go into a fluid volume deficit, not a fluid volume excess. 4. Incorrect: When the fluid volume becomes depleted, such as what occurs with burns, the urine output will decrease in an effort to hold on to the fluid (compensate) or the kidneys are not being perfused.

A client is admitted following a severe burn. What changes related to fluid status would the nurse anticipate? Select All That Apply 1. Fluid volume excess 2. Hypovolemia 3. Third spacing 4. Increased urine output 5. Low CVP 6. Increased urine specific gravity

4. Low urine specific gravity 4. Correct: Diabetes insipidus is a condition that results from decreased ADH production. Therefore, the client will be diuresing large volumes of water which leads to a fluid volume deficit. We worry about shock in these clients. Keep in mind that concentrated makes #s go up and dilute makes #s go down in reference to specific gravity, sodium, and hematocrit. Here, the urine is very dilute which means the urine specific gravity will be low. 1. Incorrect: As the client loses volume through the kidneys, the blood (serum) will become very concentrated. Therefore, you would expect the hematocrit to be high, not low. 2. Incorrect: Don't let the name diabetes insipidus trick you into thinking it affects the glucose level. It is an ADH problem, not a glucose problem. We are worried about fluid volume deficit here. 3. Incorrect: You do not expect to see protein in the urine in DI. In fact, protein is not seen in the urine unless there is a kidney problem. This is an ADH problem, not a kidney problem. You are worried about a large amount of water loss with this client.

A client is admitted to the ICU with diabetes insipidus following a head injury. Which finding would the nurse anticipate in this client? 1. Low serum hematocrit 2. High serum glucose 3. High urine protein 4. Low urine specific gravity

1.Spironolactone 1. Correct: The client's potassium level is low. Spironolactone is a potassium-sparing diuretic which causes the potassium to be retained. 2. Incorrect: Furosemide is apotassium-depletingg diuretic which would further deplete the potassium level. 3. Incorrect: Bumetanide is a potassium depleting diuretic which would further deplete the potassium level. 4. Incorrect: Hydrochlorothiazide also leads to potassium loss, which would further deplete the potassium level.

A client is admitted to the cardiac floor in heart failure. The lung sounds reveal crackles bilaterally, and the BP is 160/98. The client has been on diuretics at home and the potassium level is 3.3 mEq/L (3.3 mol/L). Which diuretic would the nurse anticipate being prescribed for this client to minimize potassium loss? 1.Spironolactone 2. Furosemide 3. Bumetanide 4. Hydrochlorothiazide

1. sob 4. cp 5. cough 6. subcutaneous emphysema ,4.,5., & 6. Correct: With a hemothorax, we recall that blood has accumulated in the pleural space, and with a pneumothorax, we know that it is air that has accumulated in the pleural space. The presence of either of these causes the lung to collapse. The signs that the nurse expects to see includes shortness of breath, chest pain, and cough. We may also see subcutaneous emphysema as the air that escaped from the lung becomes trapped in the surrounding tissues. 2. Incorrect: What happens to gas exchange when there is a hemothorax or a pneumothorax? That's right! It decreases. When hypoxia is present, the body responds by increasing the heart rate. Therefore, we would not expect the heart rate to be decreased in this situation. 3. Incorrect: Wheezing occurs when air tries to get through narrowed passages. With a hemothorax or pneumothorax, the lung sounds will be diminished over the affected area where the lung has collapsed. If you missed this question, go to section 1 of the respiratory video to review.

A client is admitted to the emergency department (ED) following blunt trauma to the chest from a motor vehicle accident. A hemothorax and pneumothorax are suspected. What signs and symptoms would the nurse anticipate recording to support this diagnosis? SATA 1. Shortness of breath 2. Decreased heart rate 3. Wheezing in the affected area 4. Chest pain 5. Cough 6. Subcutaneous emphysema

4. cover the fractured site with sterile dressing 4. Correct: An open fracture is when the bone has broken the skin and underlying soft tissue, and the bone is protruding from the wound.The nurse should cover the fracture site with a sterile dressing to prevent contamination of deeper tissues. 1. Incorrect: The leg was splinted as a temporary emergency intervention. Upon arrival in the emergency room, the fracture should not be reduced by the nurse. Once the skin has been broken at the fracture site, the wound is a portal of entry for contaminants. A surgical procedure is performed to clean the wound and the bone. 2. Incorrect: If the nurse externally rotates the left leg, there is an increased risk of additional trauma to the tissues from the movement of the fracture bone. Also, there is a risk of the bone slipping into the wound from the external rotation. 3. Incorrect: Placing the client in high Fowlers position is not an appropriate intervention. The fractured site and/or limb should be elevated. If you missed this question, go to section 1 of the orthopedic video to review.

A client is admitted to the emergency room with an open fracture of the left tibia which has been temporarily splinted. Which nursing intervention would the nurse implement? 1. Physically reduce the fracture. 2. Externally rotate the left leg. 3. Position the bed into a high Fowler's position. 4. Cover the fractured site with a sterile dressing.

1. PO CALCIUM 3. Vitamin D 4. Sevelamer Hydrochloride 1. , 3., & 4. Correct: Since this client has hypocalcemia, PO Calcium replacement would be an appropriate treatment. Now, let's look at the others that are not as obvious. Vitamin D helps to improve calcium absorption, which will help increase the calcium levels. So, what is sevelamer hydrochloride and how will this help hypocalcemia? Well, it is a phosphate binder. And remember that we said if you bind the phosphorus, the phosphorus levels go down. And since phosphorus and calcium have inverse relationships, as the phosphorus levels go down, the calcium levels will go up! 2. Incorrect: IV Calcium should be administered slowly or by slow infusion and the client should always be on a heart monitor. If you give calcium too rapidly by IV, the client may have vasodilation, hypotension bradycardia, cardiac arrhythmias, syncope, and cardiac arrest. Don't forget to be watching for the widening of the QRS complex when administering IV calcium! 5. Incorrect: Phosphate supplements would cause the calcium to be even lower in this client. Remember, phosphorus and calcium have an inverse relationship. We would give phosphate binders, not supplements.

A client is admitted with hypocalcemia. Which treatment would the nurse anticipate for this client? 1. PO Calcium 2. Rapid IV Push Calcium 3. Vitamin D 4. Sevelamer hydrochloride 5. Phosphate supplements

2. perform a neurological assessment 2. Correct: Did you recognize that the sodium level of 149 is too high? The normal sodium level is 135-145 mEq/L (135-145 mol/L). Think about the testing strategy that we mentioned to you. Look for neuro changes when the sodium level is not within normal limits. The brain does not like it when the sodium level is messed up. So, performing a neurological assessment on this client would be important. 1. Incorrect: What type of fluid is 3% NS? It's a hypertonic solution that contains a lot of sodium! That would be a killer answer here because this client's sodium level is already too high! 3. Incorrect: The sodium level is too high. The nurse would have the client to decrease, not increase, the oral intake of sodium. 4. Incorrect. With hypernatremia, there is too much sodium and not enough fluid. Therefore, you would want this client to increase, not decrease, the fluid intake to dilute the sodium level in the blood.

A client is admitted with prolonged nausea and vomiting. The client's admission sodium level is 149 mE/L (149 mol/L). What action by the nurse would be most appropriate at this time? 1. Administer 3% NS at 150 mL/hr 2. Perform neurological assessment 3. Increase oral intake of sodium 4. Decrease fluid intake

3. H2 Antagonist 5. Proton pump inhiitor 3., & 5. Correct: H2 antagonist or receptor blockers are used to decrease excess stomach acid seen with ulcers. Antisecretory agents like proton pump inhibitors are indicated for the treatment of peptic ulcer disease. Antisecretory agents decrease the secretion of gastric acids.Protein pump inhibitors, a combination of antibiotics and bismuth salts are most commonly used for treatment of H Pylori. 1. Incorrect: Mitotic inhibitors are chemotherapeutic agents that are indicated for the treatment of malignancies and cancerous cells. They are most often used in combination chemotherapy regimens to enhance the overall cytotoxic effect. 2. Incorrect: Serotonin antagonists are antiemetic agents that are indicated for the treatment of nausea and vomiting. Serotonin antagonists block the serotonin receptor sites located throughout the body responsible for the mediation of nausea and vomiting. 4. Incorrect: Acetylsalicylic acid is a non narcotic analgesic that inhibits the cox-2 protective mechanisms to the gastric mucosa. This could make the ulcer worse. Clients are advised to avoid the use of NSAIDs and acetylsalicylic acid due to increased bleeding potential. If you missed this question, go to section 3 of the GI video to review.

A client is diagnosed with a duodenal ulcer due to Helicobacter pylori (H Pylori). In addition to antibiotic therapy, the nurse anticipates that the client will also receive what class of pharmacologic agents? Select All That Apply 1. Miotic inhibitor 2. Serotonin antagonist 3. H2 antagonist 4. Acetylsalicyclic acid 5. Proton pump inhibitor

2. Respiratory alkalosis 2. Correct: This client has a high fever. Hyperventilation due to anxiety, pain, shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. Here, the ABGs reflect respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal. 1. Incorrect: The client is hyperventilating so CO2 (acid) is being blown off. The pH says alkalosis. 3. Incorrect: Not a metabolic problem since the HCO3 is in normal range and remember the pH says alkalosis. 4. Incorrect: Not a metabolic related acid/base imbalance since the HCO3 is in normal range.

A client presents to the emergency department (ED) with flu symptoms, fever, and chills. The nurse notes that the vital signs are: T 102.8°F (39.3°C), P 128, RR 30, B/P 154/88. ABG results are: pH-7.5, PaCO2 32, HCO 23. What acid/base imbalance does the nurse determine that this client has developed? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

3. Semi-Fowler's 3. Correct: After any major abdominal surgery, the position of choice is to elevate the head of the bed 35-45 degrees. This will decrease pressure on the abdomen and suture line. 1. Incorrect: Sims' is a semi-prone position where the client assumes a posture halfway between lateral and prone. This is used for clients who need their airway protected. 2. Incorrect: Prone is not recommended. This will put more pressure on the suture line and abdomen. 4. Incorrect: Slightly side lying would be okay if the head of the bed was elevated to decrease abdominal and suture line pressure. The best position is semi-fowler's immediatelv post op. If you missed this question, go to section 4of the Gl video to review.

A client returns to the room post appendectomy. In what position should the nurse place the client? 1. sims 2. prone 3. semi-fowler's 4. right lateral

C. Stop the IV potassium infusion. c. Correct: First, you need to recall that potassium is excreted by the kidneys. If the kidneys are not working well, the serum potassium will go up! You always monitor the urinary output before and during IV potassium administration. Since the urine output has decreased below 30 mL/hr, we know that the urinary output is not adequate. Therefore, the client could start retaining too much potassium. The priority action would be to stop the infusion and then follow this action by notifying the healthcare provider. 1. Incorrect: You may have picked up on the decreased output and thought that you could increase PO fluid intake to increase output. However, the priority action would be to first stop the potassium infusion until the urinary output is adequate. This is a safety issue. 2. Incorrect: We do not want to administer any more potassium to this client. The urine output is not adequate and the client could be retaining too much potassium. 4. Incorrect: Polystyrene sulfonate (Kayexalate®) is used as a treatment for clients with known hyperkalemia. We are trying to prevent this client from becoming hyperkalemic by stopping the IV potassium infusion as the urine output has decreased.

A client was admitted with reports of prolonged diarrhea. The client's admission potassium level was 3.3 mE/L (3.3 mol/L) and is receiving an IV of D5 ½ NS with 20 mEq KCL at 125 mL/hr. The UAP reports an 8-hour urinary output of 200 mL. The previous 8-hour urinary output was 250 ml. What should be the nurse's priority action? A. Encourage the client to increase PO fluid intake. B. Administer a supplemental PO dose of potassium. C. Stop the IV potassium infusion. D. Administer polystyrene sulfonate PO

2. The prescribed opioid does not relieve the pain. 4. The pain in the forearm is described as a 9 on a 10 scale and throbbing. 2. & 4. Correct: Compartment syndrome occurs when swelling occurs within the compartment. This results in increased pressure on the capillaries, nerves, and muscles in the compartment. The pain is very intense. The client is expressing pain at a 9 on a 10 scale and throbbing. The pain is also unrelieved by opioid administration. 1. Incorrect: The location of pain at the elbow area does not indicate the presence of compartment svndrome. The pain related to compartment syndrome would not occur in the elbow. The swelling and bleeding will occur in the compartment of the forearm due to the swelling or bleeding. 3. Incorrect: The swelling will not be reduced by elevating the forearm as result of the constant increased pressure in the compartment. 5. Incorrect: Applying a cold compress on the forearm that decreases the swelling is not a symptom of compartment syndrome. The increased pressure in the compartment results in a decrease of the blood flow to the muscles and nerves. If you missed this question, go to section 1 of the orthopedic video to review.

A client was diagnosed with a fractured ulna 8 hours ago. Which assessment data may indicate a compartment syndrome? SATA 1. The pain is located at the elbow area. 2. The prescribed opioid does not relieve the pain. 3. When forearm is elevated, the swelling in the forearm is reduced. 4. The pain in the forearm is described as a 9 on a 10 scale and throbbing. 5. When placing a cold compress on the forearm, the pain level is reduced.

1. respiratory acidosis 1. Correct: Causes of respiratory acidosis include any causes of decreased respiratory drive, such as drugs (narcotics) or central nervous system disorders. With a massive cerebral vascular accident (CVA or stroke), the respiratory center in the brain is impaired and affects oxygenation. Cheyne-Stokes respirations are characterized by progressively deeper and sometimes faster respirations followed by periods of apnea. This leads to acidosis and often times respiratory arrest. 2. Incorrect: Respiratory alkalosis includes hyperventilation and tachypnea which does not describe the characteristics of Cheyne-Stokes respirations. 3. Incorrect: Compensation for metabolic acidosis caused by disorders like DKA includes tachypnea with deep respirations called Kussmaul's respirations. Here, we have a respiratory problem, not a problem that started with a metabolic issue. 4. Incorrect: The most common cause of metabolic alkalosis is vomiting, and this is clearly a respiratory problem, not metabolic

A client who had a cerebral vascular accident (VA) is now having Cheyne-Stokes respirations ranging from 12-30 breaths/minute. BP 158/108, HR 46. Based on this assessment, which acid/base imbalance does the nurse anticipate that this client will develop? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

2. connect client to a cardiac monitor 2. Correct. These symptoms are indicative of hypokalemia and metabolic alkalosis. What do steroids do to the body? Steroids make you retain sodium and excrete potassium. So, you could become hypokalemic. Low potassium levels cause an increase in the reabsorption of bicarb by the kidneys. That is why you sometimes see metabolic alkalosis with Cushing's disease and prolonged steroid use. What electrolyte imbalance do we see with metabolic alkalosis? It's hypokalemia. So, if you have a client who is hypokalemic then they may have muscle weakness, hypotension and life threatening arrhythmias. And we know when the potassium is messed up, we should always think about the heart first. Connect the client to the cardiac monitor. 1. Incorrect. The priority is going to be checking the heart rhythm because a low potassium can cause a life-threatening arrhythmia. 3. Incorrect. The symptoms are most likely due to low potassium levels. This could lead to life-threatening arrhythmias. How would you fix this problem? Yes, give potassium, not oxygen. 4. . Incorrect. You can do this after you check the heart rhythm. The priority is going to be checking the heart rhythm because potassium can cause a life-threatening arrhythmia.

A client who has been given steroids for a prolonged period to treat asthma, reports dizziness, tingling of the fingers, and muscle weakness. What action should the nurse take first? 1. Determine current blood pressure 2. Connect client to a cardiac monitor 3. Administer oxygen 4. Obtain arterial blood gases

3. "You certainly are having scary thoughts." 3. CORRECT. The client is so fearful of being poisoned that physical harm has occurred secondary to personal starvation. The responsibility of the nurse is to address the client's fears and establish a trusting nurse/client relationship in order to meet the goal of helping the client feel safe enough to begin to eat. 1. INCORRECT. It is important not to focus on the client's perception of being poisoned by asking for information or clarification. Feeding into the delusion will reinforce that false reality for the client. This is an incorrect open-ended statement by the nurse. 2. INCORRECT. Even though the nurse is making an accurate statement, the client's perception of reality will negate anything that is stated by staff. The nurse is trying to refute what the client believes is true, which means the client will also distrust the nurse. Again the focus is on the poisoning instead of client's feelings. 4. INCORRECT. The client's fear and delusion about poisoning is strong enough to over-ride the pain of starvation. Such an ingrained thought would not be easily changed by this statement. Additionally, this comment by the nurse is belittling what the client assumes to be true, thus eliminating any chance for a trusting nurse/client interaction. If you missed this question, go to section 2 of the mental health video to review.

A client with a history of paranoid personality disorder is admitted to the hospital with extreme weight loss. Family states client has been refusing medications and food due to fears of being poisoned. What initial response by the nurse is most important? 1. "Tell me about your fears of being poisoned. 2. "No one is trying to poison your food or meds.! 3. "You certainly are having scary thoughts." • 4. "You are starving yourself needlessly."

1. FVD 1. Correct: Albumin is a hypertonic solution. This type of solution will draw fluid from the cell into the vascular space. This builds up the volume in the vascular space. Therefore, the nurse must watch for fluid volume excess. Hypertonic solutions are used in clients who have 3rd spacing, severe edema, or ascites. 2.Incorrect: Since hypertonic solutions, such as albumin, pull fluid from the cell into the vascular space, we would worry about cellular dehydration and shrinkage, not cellular edema. 3. Incorrect: As the fluid is pulled from the cells into the vascular space, you would expect to see an increase in the BP as the volume in the vascular space increases. You know... more volume, more pressure! We would be watching for hypertension, not hypotension. 4. Incorrect: Think about what we said about the BP when considering the CVP. Since the volume in the vascular space incre hypertonic solutions, you would also expect the CVP to increase as well. We have to watch closely to make sure that we do n signs that we are overloading the heart when administering hypertonic solutions. So we will watch this client carefully for an

A client with chronic liver disease has ascites and is being treated with an albumin infusion. What should the nurse anticipate and monitor in 1. Fluid volume excess 2. Cellular edema 3. Severe hypotension 4. Decreasing CVP

1. Pain 3. muscle spasm 4. bone displacement 1., 3., & 4. Correct: The purpose of traction is to stabilize and realign bone fractures and reduce pain. If the skeletal traction is interrupted by losing the traction on the bone, the result may include pain, muscle spasm, and bone displacement. 2. Incorrect: Foot drop is the weakness or paralysis of the muscles that lift the front part of the foot. Causes of foot drop may include; nerve injury, muscle or nerve disorders, brain and spinal cord disorders, and immobility. 5. Incorrect: The client would not experience any itching under any straps or cords due to the accidental release of the skeletal traction. If you missed this question, go to section 2 of the orthopedic video to review.

A client's skeletal traction has been accidently released. What signs/symptoms does the nurse expect to see? 1. Pain 2. Foot drop 3. Muscle spasm 4. Bone displacement 5. Itching under the straps

1. have the client take deep breaths Correct: This client had chest surgery and the pCO2 is high. What are you worried about? Hypoventilation. Yes, the client is probably hurting due to the incision and does not want to take deep breaths. In order to get rid of the excess CO2 the client needs to turn, cough, and deep breathe. Incentive spirometry can be provided to assist the client with this effort. 2. Incorrect: This client has mild respiratory acidosis after surgery. The nurse can fix this by waking the client up and instructing the client to take deep breaths or have the client use incentive spirometry. 3. Incorrect: Breathing faster will only work for a few minutes. The problem is the client needs to breathe deeper to get more oxygen to the tissue and more CO2 out of the lungs. Hyperventilating will lead to respiratory alkalosis. 4. Incorrect: No more sedation! The client is not breathing enough. This client needs to take deep breaths.

A client, admitted to the surgical unit post left thoracotomy, is drowsy. Vital signs on admit are T 99.8°F (37.6°C), HR 94, R 16/shallow, BP 100/68. ABGs are pH 7.33, PCO, 48, HCO 24. What action should the nurse initiate? 1. Have client take deep breaths. 2. Administer naloxone. 3. Tell the client to breathe faster. 4. Medicate for pain.

1. Have client take deep breaths. 1. Correct: This client had chest surgery and the pCO2 is high. What are you worried about? Hypoventilation. Yes, the client is probably hurting due to the incision and does not want to take deep breaths. In order to get rid of the excess CO2 the client needs to turn, cough, and deep breathe. Incentive spirometry can be provided to assist the client with this effort. 2. Incorrect: This client has mild respiratory acidosis after surgery. The nurse can fix this by waking the client up and instructing the client to take deep breaths or have the client use incentive spirometry. 3. Incorrect: Breathing faster will only work for a few minutes. The problem is the client needs to breathe deeper to get more oxygen to the tissue and more CO2 out of the lungs. Hyperventilating will lead to respiratory alkalosis 4. .Incorrect: No more sedation! The client is not breathing enough. This client needs to take deep breaths.

A client, admitted to the surgical unit post left thoracotomy, is drowsy. Vital signs on admit are T 99.8°F (37.6°C), HR 94, R 16/shallow, BP 100/68. ABGs are pH 7.33, PCO2 48, HCO 24. What action should the nurse initiate? 1. Have client take deep breaths. 2. Administer naloxone. 3. Tell the client to breathe faster. 4. Medicate for pain.

4. Reinforce the importance of the fluid restriction with the client. 4. Correct: Educate the client on appropriate choices and lifestyle changes that are necessary to manage the client's condition. 1. Incorrect: It is ultimately the client's choice to drink a soft drink. Education will help the client make an informed decision. 2. Incorrect: The nurse should reinforce the purpose of fluid restriction, not just document noncompliance. Perhaps it is just a matter of lack of knowledge. 3. Incorrect: The client has the right to make choices and the nurse should reinforce teaching. If you missed this question, go to section 3 of the renal video to review.

A client, who receives hemodialysis three times a week, has been placed on a fluid restriction of 1000 mL/day. What is the nurse's best action when the client is seen drinking a 12 ounce (360 mL) soft drink? 1. Take the soft drink away from the client. 2. Document the client is noncompliant. 3. Notify dietary to no longer send beverages with food trays. 4. Reinforce the importance of the fluid restriction with the client.

2. "I will be retaining sodium and water due to the increased amount of aldosterone." 2. Correct: Cushing's is a disease that results in increased secretion of aldosterone. Having too much aldosterone causes the client to be at risk for fluid volume excess (FVE) due to the increased retention of both sodium and water. 1. Incorrect: Cushing's is a problem associated with an increased production of aldosterone, not ADH. The client will be retaining both sodium and water. 3. Incorrect: The client would not be losing excess fluid as is seen in clients with Diabetes Insipidus (DI), an ADH problem. The client will be retaining both sodium and water due to the increased aldosterone and would be at risk for fluid volume excess. 4. Incorrect: Increased thyroxine levels is related to hyperthyroidism, not Cushing's disease. This client has a problem with too much aldosterone and a resulting FVE.

A nurse has performed teaching with a client diagnosed with Cushing's disease. Which statement by the client would best indicate understanding of the teaching? 1. "The increased level of ADH will cause my potassium level to be too high." 2. "I will be retaining sodium and water due to the increased amount of aldosterone." 3. "I will be losing lots of fluid due to the hormonal imbalance I have." 4. "I will feel jittery and nervous due to the elevated thyroxine levels."

4. No infiltrates noted on chest x-ray. 4. Correct: A fat embolism is caused by droplets of bone marrow fat that is released into the venous system. The droplets may lodge in the lungs. An x-ray of the lungs with the bone marrow fat will have a "snowstorm" appearance. A chest x-ray that does not identify any filtrates and does not have a "snowstorm" appearance is indicative the fat embolus is decreasing in size or completely resolved. 1. Incorrect: A respiratory rate of 24 is not within the normal range of respirations for an adult. If FES has resolved, you would expect the respiratory rate to be normal. 2. Incorrect: Oxygen saturation is the percentage of hemoglobin saturated with oxygen. A oxygen saturation value of 94% is not within the normal range of 95% to 100%. If FES has resolved, you would expect the oxygen saturation percentage to be normal. 3. Incorrect: The normal pH arterial blood gas range is 7.35-7.45. The client's pH level of 7.34 is not within the normal pH range. It is acidotic.The body regulates the pH level by changing the body's CO2, bicarbonate, oxygen levels. This lab value is not reflective of the resolution of a FES. If you missed this question, go to section 1 of the orthopedic video to review.

A nurse is caring for a client with fat embolus syndrome (FES). Which data would support the nurse's assessment that the FES has resolved? 1. Respirations - 24. 2. Oxygen saturation - 94%. 3. Arterial blood gas - pH 7.34. 4. No infiltrates noted on chest x-ray.

4. Aminoglycoside 4. Correct: Aminoglycoside antibiotics are nephrotoxic. Nephrotoxic medications can cause damage to the kidneys. Examples of aminoglycoside antibiotics are tobramycin, gentamicin, streptomycin, and paromomycin. Clients with kidney damage should not be prescribed aminoqlvcoside antibiotics. 1. Incorrect: Opioid medications are not classified as nephrotoxic. 2. Incorrect: Antidiabetic medications are not classified as nephrotoxic. 3. Incorrect: Corticosteroid medications are not classified as nephrotoxic. If you missed this question, go to section 2 of the renal video to review.

A nursing instructor is presenting a discussion on nephrotoxic medications? Which class of medications would the instructor discuss? 1. Opioids 2. Antidiabetic 3. Corticosteroids 4. Aminoglycoside

2. Gas exchange is improved, and the work of breathing is decreased. 3. It expands and realigns the ribs to aid in the healing process. 2., & 3. Correct: I hope that you were able to recognize that the signs and symptoms are characteristic of a flail chest. This occurs with multiple rib fractures. The client will have pain, be anxious, and short of breath. The classic sign of a flail chest is the paradoxical (see-saw) chest movement in which the affected part of the chest sucks inwardly on inspiration and puffs out on expiration (opposite of what the normal side is doing). Dyspnea, cyanosis, and tachycardia are also generally seen. So, what is done about this unstable chest? PEEP may be used because it helps to improve gas exchange and decreases the work of breathing. As it exerts pressure in the lungs, it also facilitates the expansion and realignment of the ribs so that they can start growing back together. 1. Incorrect: The ventilator exerts the positive pressure down into the lungs at the end of expiration to keep the alveoli open. 4. Incorrect: Do vou see the word "continuously"? This describes continuous positive airway pressure (CAP). This is often used for individuals with sleep apnea and infants with underdeveloped lungs. 5. Incorrect: With PEEP, the client is on the ventilator. If vou missed this question, go to section 2 of the respiratory video to review.

Assessment of a trauma client in the emergency department reveals paradoxical chest wall movement, respiratory distress, cyanosis, and tachycardia. The family is asking why the client needs positive end-expiratory pressure (PEEP). What should the nurse inform them regarding the rationale for this treatment?Select All That Apply 1. Ventilation is improved as positive pressure is exerted into the airways as the client begins to take in a breath. 2. Gas exchange is improved, and the work of breathing is decreased. 3. It expands and realigns the ribs to aid in the healing process. 4. Allows for positive pressure to be applied continuously during inspiration and expiration. 5. It is less invasive and does not require the client to be on the ventilator.

3 Metabolic acidosis 7. Fully compensated 3., & 7. Correct. These ABG values indicate metabolic acidosis. The pH is normal, but it is on the acidosis side of normal at 7.35. Now, which other chemical says acidosis? Look at the bicarb; the bicarb is low, indicating acidosis so there's your match! The bicarb matches the pH. What chemical problem does the bicarb relate to - respiratory or metabolic? It's metabolic. Metabolic acidosis. Has compensation begun? Yes. The lungs are compensating for the metabolic acidosis by getting rid of CO2, which is an acid. Therefore, the PaCO2 is below the normal range of 35-45. Since the pH is normal, full compensation has occurred.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? pH 7.35, PaCO2 30 mmHg, Bicarb 19 mfq/l, PaO2 89 Sao2 90% 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

3. "I plan to place my affected leg on the step first when ascending stairs." 3. Correct: This statement is incorrect and further client teaching is needed. When going up stairs, the client should lead with the unaffected leg. The unaffected leg will provide the support required to then move the affected leg to the step. 1. Incorrect: The crutches should be adjusted according to the client's height and arm length. The top of the crutches should be approximately 1 to 2 inches under the axilla. The hips should be even with the hand grips. Also, the crutch length should be measured from the client's axilla to approximately 6 inches in front of the toe. This is a true statement. 2. Incorrect: If the weight is supported by placing the top of the crutches against the axilla, then brachial nerve damage will occur. To prevent the damage to the brachial nerve the hands rest on the hand grips when resting. This is a correct statement by the client. 4. Incorrect: To prevent damage to the brachial nerve, the client should position the crutches 1 to 2 inches below the axilla when walking with crutches. With the shoulders relaxed the client should be able to also position 2 finger widths between the axilla and the crutch pads. If you missed this question, go to section 2 of the orthopedic video to review.

The client has been instructed on crutch safety. The nurse identifies that further teaching is needed when the client makes which statement? 1. "The crutches are adjusted according to my height." 2. "I will support my weight on the hand grips when not walking.! 3. "I plan to place my affected leg on the step first when ascending stairs." 4. "I will position the crutches 1 -2 inches below the axilla when walking with crutches."

1. pH 7.32 2. PaCO2 32 1., &2. Correct: In DKA, the client is acidotic. Normal pH is 7.35-7.45. A pH of 7.32 indicates acidosis and will be expected for a client in DKA. Normal PaCOz is 35-45. Remember COz is considered an acid. The client in DKA will have an increased respiratory rate, so the PaCO2 will either be normal or low. This value of 32 is low and is an expected finding as the body is compensating for the acidosis. 3. Incorrect: Normal HCO3 is 22-26. HCO3 is a base. Initially, the acids bind to the bicarb to reduce the acid levels. Therefore, the HCO3 would be less than 22. So, in DKA, the expected initial finding is a low HCO3. Keep in mind that with acidosis, as the body compensates later, the kidneys will retain bicarb and you will see the bicarb levels increase. 4. Incorrect: Normal Pa02 is 80-100. An expected finding in DKA will be normal or increased Pa02, not decreased. 5. Incorrect: The client in DKA is kussmauling to blow off the CO2 (acid), so the oxygen saturation of blood will be high if there is no respiratory issue. In this question you are not told that there is a respiratory problem, so you would not expect a low oxygen saturation level.

The emergency department nurse is monitoring a client being admitted in diabetic ketoacidosis (DKA). Which arterial blood gas value would be expected? 1. pH 7.32 2. PaCO2 32 3. HCO3 25 4. Pa02 78 5. Sa02 82

4. "This medication lowers the pressure in the liver, so bleeding stops." 4. Correct: Octreotide is a synthetic hormone that selectively inhibits the release of vasodilating hormones in the internal organs. By doing this it decreases blood flow to the liver. When you decrease blood flow to the liver, the pressure in the liver lowers. Less volume, less pressure. So, bleeding should stop. 1. Incorrect:Octreotide is not an antibiotic. 2. Incorrect: You might be thinking of sucralfate, which forms a barrier over an ulcer so acid can't get on the ulcer. 3. Incorrect: No, lactulose decreases ammonia. If you missed this question, go to section 2 of the GI video to review.

The family of a client being treated for bleeding esophageal varices asks the nurse why the client is receiving octreotide. How should the nurse respond? 1. "Octreotide is an antibiotic given to decrease the risk of developing an infection." 2. "Taking this medication forms a protective barrier over the varices to prevent bleeding recurrence." 3. "Octreotide helps eliminate ammonia from the body." 4. "This medication lowers the pressure in the liver, so bleeding stops."

2. "I will wrap my chest in an elastic bandage to support and immobilize my ribs." 2. Correct: Immobilizing, and therefore restricting the chest wall movement, with binders and straps is not recommended as it leads to shallow breathing, atelectasis, and pneumonia. The client should be taught to use the hands to support the injured area. 1. Incorrect: This would be an appropriate statement by the client and would be an indicator that the teaching was effective. Incentive spirometry is used to help prevent respiratory complications such as pneumonia and respiratory acidosis. 3. Incorrect: This would be an appropriate statement by the client and would be an indicator that the teaching was effective. Clients with rib fractures are generally prescribed non-narcotic analgesics. This is done to avoid narcotics suppressing the respirations even more than what occurs with the reluctance to deep breathe associated with the painful rib fractures. Don't you agree that the client needs to deep breathe? Some clients may have other conditions being treated with narcotic pain medications. Before continuing these at home, the client should discuss this with the healthcare provider. If the pain is severe, a nerve block by anesthesia may be needed to facilitate deep breathing and coughing. 4. Incorrect: This would be an appropriate statement by the client and would be an indicator that the teaching was effective. Do you recall some of the possible complications associated with rib fractures? They include pneumonia, respiratory acidosis, pneumothorax, and hemothorax. Therefore, the client should notify the healthcare provider if respiratory difficulty develops, secretions increase or change color, cough develops or worsens, or other respiratory symptoms develop. If you missed this question, go to section 2 of the respiratory video to review.

The nurse completed discharge teaching on a client with two fractured ribs. Which statement by the client would indicate the need for further teaching? 1. "I will take deep breaths using my incentive spirometer every 2 hours." 2. "I will wrap my chest in an elastic bandage to support and immobilize my ribs." 3. "I will talk to my healthcare provider before taking the narcotic pain medicine that I currently have at home." 4. "I will notify my healthcare provider if I develop any change in my respirations or secretions."

3. "I should keep a record of the headaches I experience over 3 months." 3. Correct: The client should report headaches sooner than 3 months to their primary healthcare provider. The headaches are related to the fluid retention due to the decreased filtration of the glomerulus. The retention of fluid will result in hypertension. This client will require additional discharge instructions. 1. Incorrect: This is a correct statement by the client. Due to the damage to the glomerulus, the kidneys will leak protein. The damage to the kidneys may take several months to heal properly. The kidneys will leak protein for several months. 2. Incorrect: When the glomeruli are restored, the kidneys will begin to diuresis. The diuresis usually starts in 1 to 3 weeks. This is a correct discharge statement by the client. 4. Incorrect: The glomerulus and the surrounding Bowman capsule create a renal corpuscle. The glomerulus filtrates the blood which results in urine formation. If you missed this question, go to section 1 of the renal video to review.

The nurse has initiated discharge instructions for a client diagnosed with glomerulonephritis. What statement by the client would indicate to the nurse that further teaching is needed? 1. "I will have protein in my urine for several months." 2. "My urinary output will increase in 1 to 3 weeks." 3. "I should keep a record of the headaches I experience over 3 months." 4. "I should notify my primary healthcare provider if my urinary output decreases."

2. Remove the occulusive dressing 2. Correct: Based on these signs and symptoms, we recognize that the client has developed a tension pneumothorax due to the occlusive dressing not only preventing air from getting in, but not allowing the air to escape. Therefore, management of this emergency situation would be the nurse's priority. Removal of the occlusive dressing would allow the air to escape and should help reduce the pressure that is causing the mediastinal shift. Needle decompression may also be needed to relieve the tension pneumothorax. If available, a good option for covering an open or "sucking" chest wound would be a petroleum gauze dressing which would be taped down on only three sides. This creates a flutter valve mechanism that allows air to escape but prevents air from re-entering through the open wound. 1. Incorrect: Although oxygen is used in clients experiencing hypoxia, it would not help to relieve or fix the tension pneumothorax. 3. Incorrect: This is an emergency and you, as the nurse, should recognize that the occlusive dressing has been trapping the air inside the chest and has created an emergency. You should carry out the intervention that you know will help to relieve the pressure that is building up as a result of air trapping in order to prevent further deterioration of the client's condition. Therefore, calling the healthcare provider first would be a delay of emergency care. 4. Incorrect: Did you see the word "deteriorating" and think shock and fluid resuscitation? The problem here is the trapping of air that is causing the tension pneumothorax. Administering IV fluids will not help to fix the problem. If you missed this question, go to section 1 of the respiratory video to review.

The nurse is caring for a client being admitted to the emergency department after being stabbed in the chest. An occlusive dressing is covering the chest wound upon arrival. The client's condition begins to deteriorate. Assessment reveals tracheal deviation, diminished breath sounds bilaterally, and asymmetrical chest wall movement. What would be the priority nursing intervention? 1. Administer high flow 02 per face mask. 2. Remove the occlusive dressing. 3. Notify the healthcare provider. 4. Initiate rapid IV resuscitation.

1. Drink between meals. 2. Reduce intake of carbohydrates. 3. Eat small, frequent meals daily. 4. Sit semi-recumbent for meals. 6. lie down on side after eating 1., 2, 3, 4., & 6. Correct: Clients are instructed to eliminate all fluids during meals. In some cases, clients may also need to eliminate fluids for one hour before and immediately after meals in order to control symptoms and slow the progress of food through the digestive tract. The symptoms described indicate the client is experiencing dumping syndrome, an adverse response following gastric or bariatric surgery. Clients may also experience tachycardia, nausea or cramping with the intake of food due to surgical restructuring of the gastrointestinal tract. Because this will be a lifetime issue, the nurse must teach the client to adjust eating habits and patterns. Reduction of carbohydrates will help decrease the problem since carbohydrates speed through the digestive track too quickly. Eating smaller, more frequent meals in a semi-recumbent position will further slow food through the digestive tract and eliminate most of the uncomfortable symptoms. After eating, the client should lie down on the left side to keep food in the stomach longer. 5. Incorrect: Sitting up after a meal is counterproductive, since this will increase the speed of food through the digestive tract. Therefore, clients are encouraged to lie down on the left side following meals to slow the processing of food. If vou missed this question, go to section 3 of the Gl video to review.

The nurse is caring for a client following a cholecystectomy. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms? Select All That Apply 1. Drink between meals. 2. Reduce intake of carbohydrates. 3. Eat small, frequent meals daily. 4. Sit semi-recumbent for meals. 5. Remain upright for one hour after eating 6. lie down on side after eating

3. Pulmonary angiography 3. Correct: Pulmonary angiography is the most sensitive and specific test for a PE. However, since it is very expensive and invasive, the computerized tomography angiogram (CT) is the most frequently used test to diagnose a PE. 1. Incorrect: The D-dimer will be increased if a pulmonary embolism is present. However, since the client had surgery, you know that the D-dimer will be increased already because it simply tells if a clot is located anywhere in the body. It is not specific to clots in the lungs. 2. Incorrect: Pulmonary function tests provide information about how well the lungs are working. Various aspects such as lung volume, lung capacity, gas exchange, and rates of air flow can be determined. Although these help diagnose a lung problem, they are not specific to diagnosing a pulmonary embolism. 4. Incorrect: Chest x-rays are not very sensitive nor specific for diagnosing pulmonary embolisms in clients. Although clots do not show up on the x-ray, other findings that are suggestive of a PE may be found to indicate the need for further testing. If you missed this question, go to section 2 of the respiratory video to review.

The nurse is caring for a surgical client who developed a pulmonary embolus (PE). Which diagnostic test would be the most sensitive for providing a definitive diagnosis for a PE? 1. D-dimer 2. Pulmonary function test 3. Pulmonary angiography 4. Chest X-ray

2.. PRODUCES clotting factor 3. detoxifies the liver 5. breaks down the medication 2., 3., & 5. Correct: Three of the four functions are listed: the liver produces clotting factors, detoxifies the body, and breaks down medications. It also synthesizes albumin. 1. Incorrect: The spleen, not the liver, removes old RBCs from the body. 4. Incorrect: The exocrine function of the pancreas releases digestive enzymes into the small intestine. If you missed this question, go to section 1 of the GI video to review.

The nurse is educating a client diagnosed with cirrhosis about the functions of the liver. What functions should the nurse include? Select All That Apply 1. . Removes old RBCs from the body. 2. Produces clotting factors. 3. Detoxifies the body. 4. Releases digestive enzymes. 5. Breaks down medications.

1. Rest cast on a soft pillow. 2. Keep the cast uncovered until air dried. 3. Mark the cast if there is breakthrough bleeding. 4. Place ice packs on side of the cast for first 24 hours. 1., 2., 3., & 4. Correct: Until the cast has dried completely, the cast care instructions are to prevent indentations on the cast, reduce swelling, and evaluate any breakthrough bleeding. 5. Incorrect: To prevent indentations in the plaster cast, the cast should be moved with the palms of hands for first 24 to 72 hours. If you missed this question, go to section 1 of the orthopedic video to review.

The nurse is implementing cast care instructions for a client with a plaster cast applied 2 hours ago. Which cast care instruction would be included? Select All That Apply 1. Rest cast on a soft pillow. 2. Keep the cast uncovered until air dried. 3. Mark the cast if there is breakthrough bleeding. 4. Place ice packs on side of the cast for first 24 hours. 5. Use the palms of hands when moving the cast for first 6 hours.

1. Encourage participation in light exercise. 2. Identify doors with pictures. 3. Monitor food intake. 6. Weigh weekly 1., 2., 3., & 6. Correct: It is important to keep the client as active as possible by participating in enjoyable things like light exercise, dancing, singing, simple games, and painting. Identify all doors with pictures or easily identifiable labels. Doors to rooms, closets, and bathrooms are especially important for the client to be able to recognize. Monitor food and liquid intake daily. The client can easily forget to eat and drink.This is one reason the client should be weighed weekly as well. 4. Incorrect: Have the client dress in their own clothes whenever possible and perform their own activities of daily living for as long as possible. This helps to maintain self-esteem. 5. Incorrect: Talk about meaningful things. Help the client focus on a successful life events to increase self-esteem. Talking about unsuccessful life events will not increase self-esteem or be helpful to the client. If you missed this question, go to section 3 of the mental health video to review.

The nurse is planning care for a client admitted with a diagnosis of Alzheimer's Disease. What interventions should the nurse include? Select All That Apply 1. Encourage participation in light exercise. 2. Identify doors with pictures. 3. Monitor food intake. 4. Assign unlicensed assistive personnel to bathe client daily. 5. Reminisce about successful and unsuccessful life events. 6. Weigh weekly.

1. Provide meticulous skin care. 2. Reposition every 2 hours. 4. Provide foods low in phosphate. 5. Monitor intake and output. 6. Give IV medications in the smallest volume allowed. 1., 2., 4., 5., & 6. Correct: The leading cause of death from acute renal injury is infection, so meticulous skin care and aseptic technique are critical. Repositioning every 2 hours will help to prevent pressure ulcers. Clients in acute renal injury have high phosphorus levels and low calcium levels (remember that inverse relationship?). So they need foods low in phosphorus. Monitor intake and output. The client cannot handle excess fluid at this time. This is also why all IV meds should be administered in the smallest possible volume allowed. 3. Incorrect: The client does need to be on a high carbohydrate, high fat diet to prevent protein breakdown. However, a low protein diet is needed because the kidnevs cannot excrete BUN and creatinine. If you missed this question, go to section 2 of the renal video to review.

The nurse is planning care for a client admitted with a diagnosis of acute renal injury. What interventions should the nurse include in this Select All That Apply 1. Provide meticulous skin care. 2. Reposition every 2 hours. 3. Maintain a high carbohydrate, high protein diet. 4. Provide foods low in phosphate. 5. Monitor intake and output. © 6. Give IV medications in the smallest volume allowed.

2. Respiratory 4. DTRs 5. Urine Output 2., 4., & 5 Correct: As you learned, magnesium acts like a sedative. Since we know that magnesium can cause respiratory depression, the nurse should always have a baseline respiratory assessment prior to initiating an infusion of magnesium. Muscle tone and DRs can also become depressed, so a baseline assessment of DTRs would be very important. How is magnesium excreted? That's right! Through the kidneys. The nurse should always assess kidney function and urinary output prior to and during IV magnesium administration because of the risk of magnesium toxicity if it is being retained. 1. Incorrect: Magnesium administration does not impair liver function, so although the alcoholic client may have altered liver function, this is not an assessment that the nurse would be most concerned about related to magnesium administration. In fact, hypomagnesemia is a common problem in alcoholics which may require increasing foods high in magnesium or magnesium supplementation by PO or IV routes. 3. Incorrect: Magnesium levels are not influenced by calcium levels, so this is not an assessment that would be a priority for the nurse at this time.

The nurse is preparing to administer magnesium sulfate IV to an alcoholic client with hypomagnesemia. Prior to the initiation of IV magnesium, which assessment data would be important for the nurse to document? 1. Liver function 2. Respiratory rate 3. Calcium levels 4. Deep Tendon Reflexes (DTRs) 5. Urinary output

3. "A compression sock is applied to shape the stump smaller and rounder on the bottom." 3. Correct: Wrapping the stump with an ace bandage will assist in configuring the stump into a cone shape. The cone shape is smaller and rounded on the bottom. The cone shaped stump will result in the stump fitting easier into the prosthesis. 1. Incorrect: The compression sock will not increase the client's balance when crutch walking. The compression sock will assist in shaping the stump. 2. Incorrect: This is an incorrect statement. The nurse's interventions to decrease phantom pain would include diversional activitv and administering the prescribed analgesic. 4. Incorrect: Applying a compression sock to the right stump is not an appropriate intervention to decrease the risk of a DVT. The risk for a DVT after surgery is increased in the left leg. Interventions to decrease a DVT are to move the extremities frequently and increasing fluid intake.

The nurse is providing stump care discharge instructions to the client with a right below-the-knee amputation (BA). The client responds, "What is the purpose of the compression sock on my stump?" Which statement by the nurse is appropriate? 1. "The compression sock on the stump will increase your balance when crutch walking. 2. "Phantom limb pain will decrease by applying the compression sock tightly around the stump." 3. "A compression sock is applied to shape the stump smaller and rounder on the bottom." 4. "The application of a compression sock will decrease the risk of the incidence of deep vein thrombosis (DVT)."

3. "I will notify my primary healthcare provider if the peritoneal drainage is cloudy." 3. Correct: The number 1 complication of peritoneal dialysis is infection. So, the client does need to monitor the drainage, which should be clear or straw-colored. If it is cloudy, that indicates infection and the primary healthcare provider should be notified. Incorrect: This client needs to increase protein intake because the client is losing protein through the peritoneal membrane with each exchange. Incorect: Do NOT put dialysate in the microwave! We don't want to burn the peritoneum. Take it out of the refrigerator and allow to warm to body temperature. 4. Incorrect: The APD cycler does exchanges automatically throughout the night while the client is sleeping. If you missed this question, go to section 3 of the renal video to review.

The nurse is teaching a client who has been prescribed peritoneal dialysis. What statement by the client indicates to the nurse that teaching was successful? 1. "I need to decrease protein in my diet since my kidneys no longer work." 2. "Heating the dialysate in the microwave for 30 seconds will prevent abdominal cramping." 3. "I will notify my primary healthcare provider if the peritoneal drainage is cloudy." 4. "The automated peritoneal dialysis (APD) cycler is used every few hours during the day."

4. Notify the healthcare provider. 4. Correct: Continuous bubbling in the water seal chamber indicates that there is an air leak in the system. The healthcare provider should be notified. The healthcare provider may prescribe for the tube to be clamped at intervals along the tube for only a few seconds to determine the location of the air leak, but clamping of the tube should never be done without a prescription. 1. Incorrect: Clamping of the tube should never be done without a prescription. Clamping a chest tube can lead to a tension pneumothorax, which can be a life-threatening situation. 2. Incorrect: Increasing the water level in the water seal chamber will not help the air leak problem. Also, the levels of water for the water seal chamber and the suction control chamber are prescribed by the healthcare provider and should be maintained at the prescribed levels 3. Incorrect: Will taking a deep breath and performing the Valsalva fix an air leak in the tube? No. So you need to notify the healthcare provider. Later, when it is time for the chest tube to be removed, you should instruct the client to take in a deep breath and do valsalva maneuver, but doing that in this situation will not help fix the problem. If you missed this question, go to section 1 of the respiratory video to review.

The nurse notes continuous bubbling in the water seal chamber of the chest tube system. What should be the nurse's initial action? 1. Clamp the chest tube closest to the chest wall. 2. Increase the water level in the water seal chamber. 3. Have the client take a deep breath and do valsalva maneuver. 4. Notify the healthcare provider.

1. malaise 2. Blood pressure 4. costovertebral angle tenderness 5. Urine specific gravity of 1.040 1., 2., 4., & 5. Correct: A client with glomerulonephritis is retaining toxins. The result is the client has a overall sense of being ill with possible fatigue and decrease interest in activities. A client with glomerulonephritis is producing less and less urine. Due to the retention of fluid, the client's blood pressure is elevated. Costovertebral angle tenderness (VAT) is elicited by percussing the flank area of the back over both the kidneys. If pain is present, the client would be assessed for a kidney infection. The normal range of urine specific gravity ranges from 1.010 to 1.030. An elevated urine specific gravity of 1.040 is reflective of highly concentrated urine. The client is not diuresing appropriately. The client's specific gravity of 1.040 supports glomerulonephritis. 3. Incorrect: The normal range for a 24 urinary output is 800-2000 mL. The listed 24 hour urinary output of 960 is within the normal range.Urinary output on a client with glomerulonephritis is less than 800 mL per 24 hours. If you missed this question, go to section 1 of the renal video to review.

The nurse on a medical unit is reviewing the data on a client admitted to a medical unit. Which data supports the diagnosis of glomerulonephritis? Select All That Apply 1. Malaise 2. Blood pressure - 160/92 3. 24 hour urinary output - 960 mL 4. Costovertebral angle tenderness 5. Urine specific gravity of 1.040

1. Dialysate is warmed to body temperature by allowing it to sit out for.a short period of time. 3. once infused, dialysate remains for prescribed for dwell time, 1., 3. Correct: These actions are correct. The dialysate should be warmed to body temperature by allowing it to sit out for a short period of time. The dwell time is the length of time that the dialysate stays in the peritoneal cavity. This allows for toxins to be drawn out of the blood and into the peritoneal cavity for removal. 2. Incorrect: The dialysate is infused through the peritoneal catheter into the peritoneal cavity. 4. Incorrect: Allow the dialysate to drain by gravity for 20-30 minutes. 5. Incorrect: The nurse should turn the client from side to side if all the drainage does not come out of the peritoneum. If you missed this question, go to section 3 of the renal video to review.

What actions would be appropriate for the nurse to take when performing peritoneal dialysis on a client diagnosed with renal injury? Select All That Apply 1. Dialysate is warmed to body temperature by allowing it to sit out for a short period of time. 2. The dialysate is infused through the catheter into the stomach. 3. Once infused, dialysate remains for prescribed dwell time. 4. Withdraws dialysate using a large piston syringe. 5. Assists client to stand if all the drainage is not removed.

3. Compare new bag with prescription prior to infusign 5. Cover TPN with dark bag 3., & 5. Correct: Remember safety and that TPN is a medication. You must make sure that what is in the bag is what was prescribed, so double check the bag against the prescription. Cover the IV bag with a dark bag to prevent chemical breakdown. 1. Incorrect: The IV tubing and filter must be changed with each new bag. Remember: A bag cannot hang more than 24 hours. 2. Incorrect: TPN must be placed on an IV pump. Relying on calculating to maintain a drip rate is dangerous. The client could get too much TPN too fast without having it on a pump at the prescribed rate per hour. This is a safety issue. 4. Incorrect: The client should be weighed daily. We want to make sure the client is not losing weight while on TPN. They should be maintaining or gaining weight. 6. Incorrect: Monitor urine for glucose and ketones. The only way protein will be in the urine is if the kidneys are damaged. If you missed this question, go to section 4 of the GI video to review.

What interventions should the nurse include when caring for a client who is receiving total parenteral nutrition (TPN)? SATA 1. Change tubing and filter every 48 hours. 2. Monitor IV drip rate hourly. 3. Compare new bag with prescription prior to infusing. 4. Weigh weekly. 5. Cover TPN with dark bag 6. Check urine for protein

1. Weigh daily 2. measure abdominal girth 3. provide skin care 5. intake and output 1., 2., 3., & 5. Correct: The client with nephrotic syndrome is producing less urine. Due to the decrease in urinary output the client is retaining fluid. The client should be weighed daily, and the girth would be measured to evaluate fluid retention. Edematous skin is prone to skin breakdown, so adequate skin care is necessary. Intake and output is required whenever there is a fluid volume problem. 4. Incorrect: This client with nephrotic syndrome does not require positioning in a semifowlers position. Any position of comfort is acceptable. If you missed this question, go to section 1 of the renal video to review.

What interventions would the nurse implement for a client diagnosed with nephrotic syndrome? Select All That Apply 1. Weigh daily 2. Measure abdominal girth 3. Provide skin care 4. Position in semifowlers 5. Intake and output

2. Sitting on side of bed and leaning over the bedside table 2. Correct: For maximum accessibility for the thoracentesis to be performed, the client should be positioned in a sitting position on the side of the bed, leaning over a bedside table, with arms propped on pillows and the feet supported. If the client is not able to sit up, the alternative position would be to lie on the unaffected side with the head of bed elevated 45 degrees. 1. Incorrect: The approach for a thoracentesis is generally a posterior approach, so the supine position would not be optimal. Also, if a client has a respiratory problem requiring a thoracentesis, the client may experience increased respiratory distress if placed in a supine position. You would never want to place a client in a position that would increase the respiratory effort or cause distress. 3. Incorrect: If the client is unable to sit up on the side of the bed, it is acceptable to be in a side lying position with the head of bed elevated 45 degrees. However, the client should be placed on the unaffected side, which in this case would be the left side. In this client, the right side is the affected side and should be in the superior position. 4. Incorrect: The best position is sitting up, leaning over the bedside table, with arms resting on pillows and the feet supported. The alternative position is side lying, with the head of bed elevated. The supine position is not a position of choice but may have to be used under certain circumstances. If placed in a supine position, the arm on the affected side would be placed over the head. In this case, the right arm would need to be raised, not the left arm. If you missed this question, go to section 1 of the respiratory video to review.

What is the best position for the nurse to place a client for a thoracentesis of the right lung? 1. Lying supine with pillow removed and head of bed flat 2. Sitting on side of bed and leaning over the bedside table 3. Lying on the right side with the head of bed at 45 degrees 4. Lying supine with the left arm raised over the head

3. Check clotting study results. 3. Correct: This is a priority question. All actions should be done by the nurse, however, the nurse better check the clotting study results. The client could hemorrhage if the clotting factors are too messed up. 1. Incorrect: Yes, the consent must be signed, but what is more life saving? Checking the clotting factor results. 2. Incorrect: Yes, the nurse will need to obtain pre-procedure vital signs. However, the procedure may not be done if the clotting study results are bad. 4. Incorrect: Yes, the client will need to be positioned so that the primary healthcare provider has access to the liver. But again, this is not the priority. If you missed this question, go to section 2 of the GI video to review.

What is the most important action for the nurse to take prior to a client having a liver biopsy? 1. Make certain the consent has been signed. 2. Obtain vital signs. 3. Check clotting study results. 4. Position client supine with right arm above head.

1. Asterixis 2. Fetor 5. Squiggly handwriting 1., 2., & 5. Correct: Signs and symptoms that a client diagnosed with cirrhosis is getting worse and headed for hepatic coma include asterixis, fetor, and handwriting changes. 3. Incorrect: Grey Turner's sign is seen with pancreatitis. 4. Incorrect: With hepatic coma, the client is full of toxins, so reflexes will be decreased. If you missed this question, go to section 2 of the GI video to review.

What signs/symptoms would lead the nurse to suspect that a client diagnosed with cirrhosis may be developing hepatic coma? SATA 1. Asterixis 2. Fetor 3. Grey Turner's sign 4. Hyperactive reflexes 5. Squiggly handwriting

1. Swelling 2. Deformity 3. Crepitus 4. Discoloration 1., 2., 3. & 4. Correct: Swelling, deformity, crepitus, and discoloration are signs of a fracture. The swelling is caused by fluids and blood that move into the soft tissues. The leaking of blood from the soft tissue or from the bone will result in a discoloration or bruising at the injury site. The most accurate sign of a broken bone is deformity of the bone. An example would be when a bone is bending in an inappropriate direction. 5. Incorrect: Tenting of the skin is not a sign of a fracture. Tenting is the slow return of skin after the skin has been pinched. If tenting is present, this indicates that the client is possibly dehydrated. If you missed this question, go to section 1 of the orthopedic video to review.

Which assessment findings would indicate to the nurse that a client may have a fracture? 1. Swelling 2. Deformity 3. Crepitus 4. Discoloration 5. Tenting of skin

4. pH 7.48, PaCO2 30, Pa02 88, Sa02 92, HCO3 24 4. Correct: This ABG result indicates respiratory alkalosis. Initially, acetylsalicylic acid stimulates the respiratory center and causes an increase in respiratory rate and depth. This causes respiratory alkalosis by blowing off COz and causing the pH to increase. Losing COz (acid) makes the client more alkalotic, which is reflected with an increased pH, decreased PaCO2 and normal HCO3. 1. Incorrect: This ABG result indicates metabolic alkalosis. The pH is high, PaCO2 is normal and HCO is high. Normal pH is 7.35-7.45, normal PaCO2 is 35-45, normal HC0з is 22-26. 2. Incorrect: The client with an initial aspirin overdose will have a respiratory alkalosis. This ABG result indicates metabolic acidosis. The pH is less than 7.35 (acidotic); the PaCO2 is within normal limits, and the bicarb is low (less than 22), which creates acidosis. 3. Incorrect: This ABG indicates partially compensated metabolic acidosis. The problem in the stem would initially result in a respiratory problem. The pH is low (acidosis). The PaCO2 is low (alkalosis as the body tries to compensate by decreasing the acid in the body. The metabolic chemical, bicarb, is low (acidosis) which matches the acidotic pH. Since the pH, PaCO2, and bicarb are all abnorm partial compensation has occurred.

Which initial arterial blood gas (ABG) results would the nurse likely see in a client who has overdosed on acetylsalicylic acid (ASA)? 1. pH 7.50, PaCO2 42, Pa02 63, Sa02 91, HCO3 28 2. pH 7.32, PaCO2 36, Pa02 83, Sa02 95, HCO3 19 3. pH 7.28, PaCO2 28, Pa02 72, Sa02 90, HCO3 16 4. pH 7.48, PaCO2 30, Pa02 88, Sa02 92, HCO3 24

1. ibuprofen Correct: The prescription of ibuprofen, a NSAID, would be questioned. Ibuprofen is a nonsteroidal ant-inflammatory medication. NSAIDs can cause acute interstitial nephritis and acute tubular nephritis. The client with nephrotic syndrome currently has damage to the micro blood vessels in the kidnevs. 2. Incorrect: Enalapril, an angiotensin converting enzyme inhibitor (ACE), is prescribed for nephrotic syndrome to decrease the intraglomerular pressure. The inhibition of the angiotensin converting enzyme (ACE) results in a reduction of proteinuria. Also an ACE inhibitor blocks aldosterone secretion. This prescription is appropriate. 3. Incorrect: Prednisone's classification is a corticosteroid. Client's with nephrotic syndrome leak protein from the blood into urine. Prednisone action is to reduce the inflammation of the kidneys, and results in decrease proteinuria. The prescription of a corticosteroid is applicable 4. Incorrect: Cyclophosphamide's pharmacology classification is an alkylating agent. This medication is prescribed for the treatment of nephrotic syndrome to suppress the body's immune system. The prescription of cyclophosphamide is appropriate for this cli If you missed this question, go to section 1 of the renal video to review.

Which medication prescription should the nurse question for a client diagnosed with nephrotic syndrome? 1. Ibuprofen 2. Enalapril 3. Prednisone 4. Cyclophosphamide