Level 4 Final Review

pt with a T4 injury experiences neurogenic shock as a result of sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition? A. tachyacardia B. hypotension C. increased cardiac output D. peripheral vasoconstriction

B. hypotension

During the oliguric phase of AKI the nurse monitors for (select all) A. hypotension B. ECG changes C. hypernatremia D. pulmonary edema E. urine with high specific gravity

B. ECG changes D. pulmonary edema

The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are A. Blood pressure, pulse, and respirations B. Breath sounds, blood pressure, and body temp C. Pulse pressure, LOC, pupillary response D. Level of consciousness, urine output, and skin color and temp

D. Level of consciousness, urine output, and skin color and temp

ECG on a post MI pt in the CCU indicates ventricular bigeminy with a rate of 50 bpm. The nurse should anticipate A. performing defibrillation B. treating with IV amiodarone C. inserting a temp pacemaker D. assessing pt response to the dysrhythmia

D. assessing pt response to the dysrhythmia

during refeeding of a malnourished pt, the nurse assesses for A. hyperkalemia B. hypoglycemia C. hypercalcemia D. hypophosphatemia

D. hypophosphatemia

Which S&S differentiate hypoxemic from hypercapnic resp failure (select all) A. cyanosis B. tachypnea C. morning headache D. paradoxic breathing E. use of pursed-lip breathing

A. cyanosis B. tachypnea D. paradoxic breathing

If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalances A. hyperkalemia and hyponatremia B. hyperkalemia and hypernatremia C. hypokalmeia and hyponatremia D. hypokalemia and hypernatremia

C. hypokalmeia and hyponatremia

A patient has a spinal cord injury at T4. Vitals show falling BP with bradycardia. This is A. relative hypovolemia B. absolute hypovolemia C. neurogenic shock from low blood flow D. neurogenic shock from massive vasodilation

D. neurogenic shock from massive vasodilation

a pt has an ICP, of 12 this indicates A. severe decrease in cerebral perfusion pressure B. alteration in production of CSF C. loss of autoregulatory control of ICP D. normal balance of brain tissue, blood, and CSF

D. normal balance of brain tissue, blood, and CSF

A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? (Select all that apply.) A. Temperature change from 37° C (98.6° F) pretransfusion to 37.2° C (99.0° F) B. Current blood pressure 178/90 mm Hg C. Heart rate change from 88/min pretransfusion to 120/min D. Client report of itching E. Client appears flushed

A temperature increase of 1 F (0.5 C) is an indication of a febrile transfusion reaction. B. Hypotension is an indication of a febrile transfusion reaction. C. CORRECT: Tachycardia is an indication of a febrile transfusion reaction. D. The client's report of itching is an indication of an allergic transfusion reaction. E. CORRECT: A flushed appearance of the client can indicate a febrile transfusion reaction.

chronic stable angina A. will always progress to myocardial infarction B. will be relived by rest, nitroglycerin, or both C. indicates that irreversible damage to the heart has occured D. frequently associated with vomiting and fatigue

B. will be relived by rest, nitroglycerin, or both

Nursing management of a patient with an artificial airway includes A. maintaining ET tube cuff pressures at 30cm H2O B. routine suctioning of the tube at least every 2 hours C. observing for cardiac dysrhythmias during suctioning D. preventing tube dislodgement by limiting mouth care to lubrication of the lips

C. observing for cardiac dysrhythmias during suctioning

ECG characteristic of myocardial ischemia A. sinus rhythm with pathologic Q wave B. sinus rhythm with ST elevation C. sinus rhythm with ST depression D. sinus rhythm with premature atrial contractions

C. sinus rhythm with ST depression

RIFLE defines three stages of AKI based on changes in A. blood pressure and urine osmolality B. fractional excretion of urinary sodium C. estimation of GFR with the MDRD equation D. serum creatinine or urine output from baseline

D. serum creatinine or urine output from baseline

A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increases the effort of the client's respiratory muscles should the nurse include in the plan of care? (Select all that apply.) A. Assist-control B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation E. Independent lung ventilation

.A. Assist-control mode takes over the work of breathing. B. CORRECT: Synchronized intermittent mandatory ventilation requires that the client generate force to take spontaneous breaths. C. CORRECT: Continuous positive airway pressure requires that the client generate force to take spontaneous breaths. D. CORRECT: Pressure support ventilation requires that the client generate force to take spontaneous breaths. E. Independent lung ventilation mode is used for unilateral lung disease to ventilate the lung individually.

A patient has no POA who is responsible for end of life decisions? A. notary and attorney B. Physician and family C. Wife and adult children D. Physician and nursing staff

C. Wife and adult children

A nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? A. "I will wear gloves while changing the pet litter box." B. "I will rinse raw fruits with water before eating them." C. "I will wear a mask when around family members who are ill." D. "I will cook vegetables before eating them."

A. A client who has AIDS should avoid changing the litter box to prevent acquiring toxoplasmosis. B. A client who has AIDS should avoid consuming raw fruits due to the presence of bacteria that can cause opportunistic infections. C. Due to compromised immune response, a client who has AIDS should avoid contact with family members who are ill. D. CORRECT: A client who has AIDS should cook vegetables before eating to kill bacteria that cause opportunistic infections.

A nurse is assessing a client who has prerenal AKI. Which of the following findings should the nurse expect? (Select all that apply.) A. Reduced BUN B. Elevated cardiac enzymes C. Reduced urine output D. Elevated serum creatinine E. Elevated serum calcium

A. A manifestation of prerenal AKI is an elevated BUN caused by the retention of nitrogenous wastes in the blood. B. Elevated cardiac enzymes is a manifestation of cardiac tissue injury, not AKI. C. CORRECT: A manifestation of prerenal AKI is reduced urine output. D. CORRECT: A manifestation of prerenal AKI is elevated serum creatinine. E. CORRECT: A manifestation of prerenal AKI is reduced calcium level.

A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include? A. Most clients exaggerate their level of pain. B. Pain must have an identifiable source to justify the use of opioids. C. Objective data are essential in assessing pain. D. Pain is whatever the client says it is.

A. A misconception about pain is that clients exaggerate their pain level. B. Clients can have pain without being able to identify the source. C. Objective data are not always present when clients have pain. D. CORRECT: The nurse should identify that pain is a subjective experience, and the client is the best source of information about it.

A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following findings pose an immediate concern? (Select all that apply.) A. Trace of bloody drainage on dressing B. Capillary refill of affected limb of 6 seconds C. Mottled appearance of the limb D. Throbbing pain of affected limb that is decreased following IV bolus analgesic E. Pulse of 2+ in the affected limb

A. A trace of bloody drainage on the dressing is an expected finding and does not require immediate concern. B. CORRECT: Capillary refill greater than 2 to 4 seconds is outside the expected reference range and should be reported to the provider. C. CORRECT: Mottled appearance of the affected extremity is an unexpected finding and should be reported to the provider. D. Pain that is decreased following IV bolus analgesia is an expected finding and does not require immediate concern. E. Pulse of 2+ in the affected extremity is an expected finding and does not require immediate concern.

drugs to treat unstable angina (select all) A. ACE inhibitor B. antiplatelet therapy C. thrombolytic therapy D. prophylactic antibiotics E. IV nitroglycerin

A. ACE inhibitor B. antiplatelet therapy E. IV nitroglycerin

A nurse is caring for a client who develops disequilibrium syndrome after receiving hemodialysis. Which of the following actions should the nurse take? A. Administer an opioid medication. B. Monitor for hypertension. C. Assess level of consciousness. D. Increase the dialysis exchange rate.

A. An altered level of consciousness is a manifestation of disequilibrium syndrome. The nurse should not administer an opioid medication. The provider may prescribe medication to decrease seizure activity. B. The nurse should monitor for hypotension due to rapid change in fluids and electrolytes causing disequilibrium syndrome. C. CORRECT: The nurse should assess the client's level of consciousness. A change in urea levels can cause increased intracranial pressure. Subsequently, the client's level of consciousness decreases. D. The nurse should decrease the dialysis exchange rate to slow the rapid changes in fluid and electrolyte status when a client develops disequilibrium syndrome.

A nurse in a clinic is caring for a client who has suspected anemia. Which of the following laboratory test results should the nurse expect? A. Iron 90 mcg/dL B. RBC 6.5 million/uL C. WBC 4,800 mm3 D. Hgb 10 g/dL

A. An iron level of 90 mcg/dL is within the expected reference range and is not an expected finding of anemia. B. RBC count of 6.5 million/uL is above the expected reference range. A decreased RBC count is an expected finding of anemia. C. WBC count of 4800 mm3 is below the expected reference range and is not an expected finding of anemia. D. CORRECT: Hgb of 10 g/dL is below the expected reference range and is an expected finding of anemia.

A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy? (Select all that apply.) A. Anorexia B. Change in orientation C. Asterixis D. Ascites E. Fetor hepaticus

A. Anorexia is present in a client who has liver dysfunction, but it is not an indication of hepatic encephalopathy. B. CORRECT: A change in orientation indicates hepatic encephalopathy in a client who has advanced cirrhosis. C. CORRECT: Asterixis, a coarse tremor of the wrists and fingers, is observed as a late complication in a client who has cirrhosis and hepatic encephalopathy. D. Ascites can be present in a client who has liver dysfunction, but it is not an indication of hepatic encephalopathy. E. CORRECT: Fetor hepaticus, a fruity breath odor, is a finding of hepatic encephalopathy in the client who has advanced cirrhosis.

A nurse is assessing a client who is reporting pain despite analgesia. Which of the following actions should the nurse take to assess the intensity of the client's pain? A. Ask the client what precipitates his pain. B. Question the client about the location of his pain. C. Offer the client a pain scale to measure his pain. D. Use open-ended questions to identify the sensation of his pain.

A. Assessment of pain triggers will provide valuable information to help select pain-control interventions, but it does not provide information about the intensity of pain. B. Identification of the location of the client's pain provides valuable information to help select pain-control interventions, but it does not provide information about the intensity of pain. C. CORRECT: The nurse should use a pain scale to help the client measure the amount of pain he has and its intensity. D. Asking open-ended questions is important in pain assessment, but it does not provide for quantification of pain intensity.

A nurse is caring for a client who has DIC. Which of the following medications should the nurse anticipate administering? A. Heparin B. Vitamin K C. Mefoxin D. Simvastatin

A. CORRECT Heparin can be administered to decrease the formation of microclots, which deplete clotting factors. B. Vitamin K promotes blood coagulation and is not prescribed for a client who has DIC. C. Mefoxin is an antibiotic given to treat bacterial infection and is not a medication that the nurse should anticipate being administered to a client who has DIC. D. Simvastatin is an antilipemic given to treat hyperlipidemia and is not a medication that the nurse should anticipate being administered to a client who has DIC.

Nurses must teach patients at risk for developing chronic kidney disease. Individuals considered to be at risk include (select all) A. older African Americans B. patients older than 60 C. hx of pancreatitis D. hx of hypertension E. hx type 2 beetus

A. older African Americans B. patients older than 60 D. hx of hypertension E. hx type 2 beetus

A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client indicates understanding of the teaching? A. "I will notify the airport screeners about my pacemaker." B. "I will expect to have occasional hiccups." C. "I will have to disconnect my garage door opener." D. "I will take my pulse every 2 to 3 days."

A. CORRECT The client should notify airport screening personnel about a pacemaker. B. The client should report hiccups to the provider because they can indicate improper lead placement. C. The use of household appliances, such as microwaves and garage door openers, does not affect pacemaker function. D. The client should check her pulse at the same time every day to ensure the pacemaker is maintaining the prescribed heart rate.

A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary artery bypass grafting with a group of nurses. Which of the following statements should the nurse include in the discussion? (Select all that apply.) A. "The client's demand for oxygen is lowered." B. "Motion of the heart ceases." C. "Rewarming of the client takes place." D. "The client's metabolic rate is increased." E. "Blood flow to the heart is stopped."

A. CORRECT The use of cardiopulmoanry bypass reduces the client's demand for oxygen, which reduces the risk of inadequate oxygenation of vital organs. B. CORRECT: Motion of the heart ceases during cardiopulmonary bypass to allow for placement of the graft near the affected coronary artery. C. CORRECT: The core body temperature is lowered for the procedure, and rewarming then occurs through heat exchanges on the cardiopulmonary bypass machine. D. The use of cardiopulmonary bypass decreases the rate of metabolism. E. Blood flow to the heart is maintained by the action of the cardiopulmonary bypass machine.

A client who is scheduled for kidney transplantation surgery is assessed by the nurse for risk factors of surgery. Which of the following findings increase the client's risk of surgery? (Select all that apply.) A. Age older than 70 years B. BMI of 41 C. Administering NPH insulin each morning D. Past history of lymphoma E. Blood pressure averaging 120/70 mm Hg

A. CORRECT: A client older than 70 years has an increased risk for complications from surgery, lifelong immunosuppression, and organ rejection. B. CORRECT: A client who has a BMI of 41 is morbidly obese and is at an increased risk for complications of surgery, lifelong immunosuppression, and organ rejection. C. CORRECT: A client who requires NPH insulin for type 1 diabetes mellitus is at an increased risk from complication of surgery, lifelong immunosuppression, and organ rejection. D. CORRECT: A client who has a history of cancer, such as lymphoma, is at an increased risk for complications of surgery, lifelong immunosuppression, and organ rejection. E. Blood pressure averaging 120/70 mm Hg is within the expected reference range does not place the client at a greater risk for complication of surgery, lifelong immunosuppression, and organ rejection.

A nurse at a provider's office is reviewing the laboratory test results for a group of clients. The nurse should identify that which of the following results indicates the client is at risk for heart disease? (Select all that apply.) A. Cholesterol (total) 245 mg/dL B. HDL 90 mg/dL C. LDL 140 mg/dL D. Triglycerides 125 mg/dL E. Troponin I 0.02 ng/mL

A. CORRECT: A client who has a total cholesterol level greater than 200 mg/dL is at increased risk for heart disease. B. An HDL level greater than 55 mg/dL for a female client or greater than 45 mg/dL for a male client decreases the client's risk for heart disease. C. CORRECT: A client who has an LDL level greater than 130 mg/dL is at increased risk for heart disease. D. A triglyceride level between 35 and 135 mg/dL for a female client or 40 and 160 mg/dL for a male client is within the expected reference range and does not indicate an increased risk for heart disease. E. Troponin I level is monitored to detect cardiac injury due to an MI rather than to identify a client's risk for heart disease. A Troponin I level less than 0.03 ng/mL is within the expected reference range.

A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? (Select all that apply.) A. A client who has metabolic alkalosis B. A client who has a serum potassium level of 4.3 mEq/L C. A client who has an SaO2 of 96% D. A client who has COPD E. A client who underwent stent placement in a coronary artery

A. CORRECT: A client who has an acid-base imbalance such as metabolic alkalosis is at risk for a dysrhythmia. B. A serum potassium of 4.3 mEq/L is within the expected reference range and does not increase the risk of a dysrhythmia. C. SaO2 of 96% is within the expected reference range and does not increase the risk of a dysrhythmia. D. CORRECT: A client who has lung disease, such as COPD, is at risk for a dysrhythmia. E. CORRECT: A client who has cardiac disease and underwent a stent placement is at risk for a dysrhythmia

A nurse is caring for a client following the insertion of a temporary venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70/min. Which of the following findings should the nurse report to the provider? (Select all that apply.) A. Cool and clammy foot with capillary refill of 5 seconds B. Observed pacing spike followed by a QRS complex C. Persistent hiccups D. Heart rate 84/min E. Blood pressure 104/62 mm H

A. CORRECT: A cool, clammy foot can be an indication of a femoral hematoma secondary to insertion of the lead wires and should be reported. B. A pacing spike followed by a QRS complex is an expected finding. C. CORRECT: Persistent hiccups can indicate lead wire perforation and stimulation of the diaphragm and should be reported. D. A heart rate of 84/min is an expected finding. E. A blood pressure of 104/62 mm Hg is an expected finding.

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse expect? (Select all that apply.) A. Decreased serum sodium B. Urine specific gravity 1.001 C. Serum osmolarity 230 mOsm/L D. Polyuria E. Increased thirst

A. CORRECT: A decrease in serum sodium is caused by an increase in the secretion of ADH. B. A urine specific gravity greater than 1.030 is caused by an increase in the secretion of ADH. C. CORRECT: A decrease in serum osmolarity is caused by an increase in the secretion of ADH. D. Reduced urine output is caused by the increase in the secretion of ADH. E. Increased thirst is an expected finding in a client who has diabetes insipidus.

A nurse is caring for a client who was in a motor-vehicle accident. The client reports chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax. Which of the following arterial blood gas findings should the nurse expect? A. pH 7.06 PaO2 86 mm Hg PaCO2 52 mm Hg HCO3− 24 mEq/L B. pH 7.42 PaO2 100 mm Hg PaCO2 38 mm Hg HCO3− 23 mEq/L C. pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3− 18 mEq/L D. pH 7.58 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3− 29 mEq/

A. CORRECT: A pneumothorax can cause alveolar hyperventilation and increased carbon dioxide levels, resulting in a state of respiratory acidosis. B. These ABGs are within the expected reference range and reflect homeostasis. C. Metabolic acidosis is not indicated for this client. D. Metabolic alkalosis is not indicated for this client.

A nurse is admitting a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI? A. Angina can be relieved with rest and nitroglycerin. B. The pain of an MI resolves in less than 15 min. C. The type of activity that causes an MI can be identified. D. Angina can occur for longer than 30 min.

A. CORRECT: Angina can be relieved by rest and nitroglycerin. B. Pain associated with an MI usually lasts longer than 30 min and requires opioid analgesics for relief. C. There is no specific type of activity that causes an MI. It can occur following rest. D. The pain of angina usually occurs for 15 min or less.

A nurse is assessing a client who has end-stage kidney disease. Which of the following findings should the nurse expect? (Select all that apply.) A. Anuria B. Marked azotemia C. Crackles in the lungs D. Increased calcium level E. Proteinuria

A. CORRECT: Anuria is a manifestation of end-stage kidney disease. B. CORRECT: Marked azotemia is elevated BUN and serum creatinine, is a manifestation of end-stage kidney disease. C. CORRECT: Crackles in the lungs can indicate the client has pulmonary edema, caused from hypervolemia due to end-stage kidney disease. D. Calcium levels are decreased due to increase in serum phosphate levels when the client has end-stage kidney disease. E. CORRECT: Proteinuria is a manifestation of end-stage kidney disease.

A nurse is caring for a client who asks why her provider prescribed a daily aspirin. Which of the following is an appropriate response by the nurse? A. "Aspirin reduces the formation of blood clots that could cause a heart attack." B. "Aspirin relieves the pain due to myocardial ischemia." C. "Aspirin dissolves clots that are forming in your coronary arteries." D. "Aspirin relieves headaches that are caused by other medications."

A. CORRECT: Aspirin decreases platelet aggregation that can cause a myocardial infarction. B. One aspirin per day is not sufficient to alleviate ischemic pain. C. Aspirin does not dissolve clots. D. Other medications can cause headaches, but one aspirin per day is not administered as an analgesic.

A nurse is caring for a client who has lung cancer and is exhibiting manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider? (Select all that apply.) A. Behavioral changes B. Client report of headache C. Urine output 40 mL/hr D. Client report of nausea E. Increased urine specific gravity

A. CORRECT: Behavioral changes indicate cerebral edema due to SIADH. This finding should be reported to the provider. B. CORRECT: A client report of headache indicates cerebral edema due to SIADH. This finding should be reported to the provider. C. Urine output of 40 mL/hr is a finding consistent with suspected SIADH and does not need to be reported to the provider. D. CORRECT: A client report of nausea can indicate cerebral edema due to SIADH and should be reported to the provider. E. An increased urine specific gravity is a finding consistent with SIADH and does not need to be reported to the provider.

A nurse is preparing to initiate hemodialysis for a client who has acute kidney injury. Which of the following actions should the nurse take? (Select all that apply.) A. Review the medications the client currently takes. B. Assess the AV fistula for a bruit. C. Calculate the client's hourly urine output. D. Measure the client's weight. E. Check serum electrolytes. F. Use the access site area for venipuncture.

A. CORRECT: By reviewing the medications the client currently takes, the nurse can determine which medications to withhold until after dialysis. B. CORRECT: Assessing the AV fistula for a bruit determines the patency of the fistula for dialysis. C. The client's hourly urine output can vary with the remaining kidney function and does not determine the need for dialysis. D. CORRECT: Measuring the client's weight before dialysis is essential for comparing it with the client's weight after dialysis. E. CORRECT: Checking the serum electrolytes determines the need for dialysis. F. The nurse should never use the access site area for venipuncture because compression from the tourniquet can cause loss of the vascular access.

A nurse is completing an assessment of a client who has increased intracranial pressure (ICP). Which of the following are expected findings? (Select all that apply.) A. Disoriented to time and place B. Restlessness and irritability C. Unequal pupils D. ICP 15 mm Hg E. Headache

A. CORRECT: Changes in level of consciousness are an early indicator of increased ICP. B. CORRECT: Increased ICP can cause behavior changes, such as restlessness and irritability. C. CORRECT: Unequal pupils indicates pressure on the oculomotor nerve secondary to increased ICP. D. An ICP of 15 mm Hg is within the expected reference range. E. CORRECT: A headache is a manifestation of increased ICP.

A nurse is caring for a client who has type 2 diabetes mellitus and will have excretory urography. Prior to the procedure, which of the following actions should the nurse take? (Select all that apply.) A. Identify an allergy to seafood. B. Withhold metformin for 24 hr. C. Administer an enema. D. Obtain a serum coagulation profile. E. Assess for asthma

A. CORRECT: Clients who have an allergy to seafood are at higher risk for an allergic reaction to the contrast dye they will receive during the procedure. B. CORRECT: Clients who take metformin are at risk for lactic acidosis from the contrast dye with iodine they will receive during the procedure. C. CORRECT: Clients should receive an enema to remove fecal contents, fluid, and gas from the colon for a more clear visualization. D. A serum coagulation profile is essential for a client prior to a kidney biopsy because of the risk of hemorrhage from the procedure. E. CORRECT: Clients who have asthma have a higher risk of an exacerbation as an allergic response to the contrast dye they will receive during the procedure.

A nurse is planning postoperative care for a client following a kidney transplant surgery. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Obtain daily weights. B. Assess dressings for bloody drainage. C. Replace hourly urine output with IV fluids. D. Expect oliguria in the first 4 hr. E. Monitor serum electrolytes.

A. CORRECT: Daily weights are obtained to assess fluid status. B. CORRECT: Drainage on the dressing is assessed to monitor for hemorrhage or hematoma. C. CORRECT: Hourly urine output with IV fluid replacement is monitored to detect abrupt decrease in urine output, which can indicate rejection or other serious conditions of the transplant kidney. D. Oliguria can indicate ischemia, acute kidney injury, rejection, or hypovolemia. Report oliguria immediately to the provider. E. CORRECT: Serum electrolytes is monitored because electrolytes loss can occur with postoperative diuresis.

A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? (Select all that apply.) A. "It is given to reduce swelling of the brain." B. "You will need to monitor for low blood sugar." C. "You may notice weight gain." D. "Tumor growth will be delayed." E. "It can cause you to retain fluids."

A. CORRECT: Dexamethasone is a common steroid prescribed to reduce cerebral edema. B. The client can experience hyperglycemia as an adverse effect of dexamethasone. C. CORRECT: Weight gain is an adverse effect of dexamethasone. D. Dexamethasone does not affect tumor growth. It is given to prevent cerebral edema. E. CORRECT: Fluid retention is an adverse effect of dexamethasone.

A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? (Select all that apply.) A. Diuretic B. Beta-blocking agent C. Opioid analgesic D. Lactulose E. Sedative

A. CORRECT: Diuretics facilitate excretion of excess fluid from the body in a client who has cirrhosis. B. CORRECT: Beta-blocking agents are prescribed for a client who has cirrhosis to prevent bleeding from varices. C. Opioid analgesics are metabolized in the liver. They should not be administered to a client who has cirrhosis. D. CORRECT: Lactulose is prescribed for a client who has cirrhosis to aid in the elimination of ammonia in the stool. E. Sedatives are metabolized in the liver. They should not be administered to a client who has cirrhosis.

A nurse is providing discharge teaching to a client who has experienced diabetic ketoacidosis. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Drink 2 L fluids daily. B. Monitor blood glucose every 4 hr when ill. C. Administer insulin as prescribed when ill. D. Notify the provider when blood glucose is 200 mg/dL. E. Report ketones in the urine after 24 hr of illness.

A. CORRECT: Drinking 2 L fluids daily can prevent dehydration if the client develops diabetic ketoacidosis. B. CORRECT: Blood glucose tends to increase during illness. Blood glucose should be monitored every 4 hr. C. CORRECT: Illness often causes blood glucose to increase. Regular doses of insulin should be administered. D. Notify the provider when blood glucose is greater than 250 mg/dL. E. CORRECT: The provider should be notified if there are ketones in the urine after 24 hr of illness.

A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.) A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A. CORRECT: Headache is a finding associated with increased ICP. B. CORRECT: Dilated pupils is a finding associated with increased ICP. C. Bradycardia, not tachycardia, is a finding associated with increased ICP. D. CORRECT: Decorticate or decerebrate posturing is a finding associated with increased ICP. E. Hypertension, not hypotension, is a finding associated with increased ICP.

A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? A. Diabetic ketoacidosis B. Heart failure C. Cushing's syndrome D. Thyroidectomy

A. CORRECT: Hyperkalemia, an increase in serum potassium, is a laboratory finding associated with diabetic ketoacidosis. B. Hyponatremia, a decrease in serum sodium, is a laboratory finding associated with heart failure. C. Hypernatremia, an increase in serum sodium, is a laboratory finding associated with Cushing's syndrome. D. Hypocalcemia, a decrease in serum calcium, is a laboratory finding is found in clients following a thyroidectomy.

A nurse is preoperative teaching with a client who is scheduled for a kidney transplant about rejection of a transplanted kidney. Which of the following statements should the nurse include in the teaching? (Select all that apply.) A. "Expect an immediate removal of the donor kidney for a hyperacute rejection." B. "You may need to begin dialysis to monitor your kidney function for a hyperacute rejection." C. "A fever is a manifestation of an acute rejection." D. "Fluid retention is a manifestation of an acute rejection." E. "Your provider will increase your immunosuppressive medications for a chronic rejection."

A. CORRECT: Immediate removal of the donor kidney is treatment for hyperacute rejection. B. Dialysis can be required as a conservative treatment to monitor the client's kidney function for the progression of chronic kidney failure following kidney transplant. C. CORRECT: Fever is a manifestation of an acute rejection. D. CORRECT: Fluid retention is a manifestation of an acute rejection. E. Immunosuppressants are increased to treat an acute rejection.

A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following laboratory values indicates the client's clotting factors are depleted? (Select all that apply.) A. Platelets 100,000/mm3 B. Fibrinogen levels 57 mg/dL C. Fibrin degradation products 4.3 mcg/mL D. D-dimer 0.03 mcg/mL E. Sedimentation rate 38 mm/hr

A. CORRECT: In DIC, platelet levels are decreased, causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage. B. CORRECT: In DIC, fibrinogen levels are decreased, causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage. C. Fibrin degradation products are increased when DIC occurs. D. A D-dimer level is increased when DIC occurs. E. The sedimentation rate is increased, but it is not an indicator of DIC.

Which description characterizes acute kidney injury (select all that apply) A. primary cause of death is infection B. almost always affects older people C. disease course is potentially reversible D. most common cause is diabetic nephropathy E. CV disease is most common cause of death

A. primary cause of death is infection C. disease course is potentially reversible

A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates the teaching has been effective? A. "Metabolic acidosis can occur due to diabetic ketoacidosis." B. "Metabolic acidosis can occur in a client who has myasthenia gravis." C. "Metabolic acidosis can occur in a client who has asthma." D. "Metabolic acidosis can occur due to cancer."

A. CORRECT: Metabolic acidosis results from an excess production of hydrogen ions, which occurs in diabetic ketoacidosis. B. Respiratory acidosis can occur in a client who has myasthenia gravis. C. Respiratory acidosis can occur in a client who has asthma. D. Respiratory acidosis can occur due to cancer.

A nurse is assessing the pain level of a client who came to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing which of the following components of a pain assessment? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors

A. CORRECT: Nausea and vomiting are common manifestations clients have when they are in pain. B. The location of the pain is where the client feels the pain. C. Pain quality is what the pain feels like, such as throbbing and dull. D. Aggravating and relieving factors are what might make the pain better or worse.

A nurse is assessing a client for HIV. The nurse should identify that which of the following are risk factors associated with this virus? (Select all that apply.) A. Perinatal exposure B. Pregnancy C. Monogamous sex partner D. Older adult woman E. Occupational exposure

A. CORRECT: Perinatal exposure is a risk factor associated with HIV. Women who are pregnant should take precautionary measures to prevent HIV exposure. B. Women who are pregnant should be tested for HIV, but pregnancy is not a risk factor associated with this virus. C. Having a monogamous sex partner is not a risk factor associated with the HIV virus. D. CORRECT: Being an older adult woman is a risk factor associated with the HIV virus due vaginal dryness and the thinning of the vaginal wall. E. CORRECT: Occupational exposure, such as being a health care worker, is a risk factor associated with the HIV virus.

A nurse is caring for a client who is suspected of having HIV. The nurse should identify that which of the following diagnostic tests and laboratory values are used to confirm HIV infection? (Select all that apply.) A. Western blot B. Indirect immunofluorescence assay C. CD4+ T-lymphocyte count D. HIV RNA quantification test E. Cerebrospinal fluid (CSF) analysis

A. CORRECT: Positive results of a Western blot test confirm the presence of HIV infection. B. CORRECT: Positive results of an indirect immunofluorescence assay confirm the presence of HIV infection. C. CD4+ T-lymphocyte count assists with classifying the stage of HIV infection. D. HIV RNA quantification tests are used to determine vial level and to monitor treatment. E. CSF analysis can be used to confirm meningitis.

A nurse is reviewing the health record of a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following laboratory findings should the nurse expect? (Select all that apply.) A. Low sodium B. High potassium C. Increased urine osmolality D. High urine sodium E. Increased urine specific gravity

A. CORRECT: SIADH results in water retention, causing a low sodium level. B. SIADH does not affect potassium levels. C. CORRECT: SIADH results in an increase in urine osmolality due to the decreased urine volume. D. CORRECT: SIADH results in water retention, causing a high urine sodium level. E. CORRECT: SIADH results in water retention, causing an increase in urine specific gravity.

A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should be included in the plan of care? (Select all that apply.) A. Obtain a capillary blood glucose four times daily. B. Administer prescribed medications through a secondary port on the TPN IV tubing. C. Monitor vital signs three times during the 12-hr shift. D. Change the TPN IV tubing every 24 hr. E. Ensure a daily aPTT is obtained.

A. CORRECT: The client is at risk for hyperglycemia during the administration of TPN and can require supplemental insulin. B. No other medications or fluids should be administered through the IV tubing being used to administer TPN due to the increased risk of infection and disruption of the rate of TPN infusion. C. CORRECT: Vital signs are recommended every 4 to 8 hr to assess for fluid volume excess and infection. D. CORRECT: It is recommended to change the IV tubing that is used to administer TPN every 24 hr. E. aPTT measures the coagulability of the blood, which is unnecessary during the administration of TPN.

A nurse is caring for a client who is receiving TPN solution. The current bag of solution was hung 24 hr ago, and 400 mL remains to infuse. Which of the following is the appropriate action for the nurse to take? A. Remove the current bag and hang a new bag. B. Infuse the remaining solution at the current rate and then hang a new bag. C. Increase the infusion rate so the remaining solution is administered within the hour and hang a new bag. D. Remove the current bag and hang a bag of lactated Ringer's.

A. CORRECT: The current bag of TPN should not hang more than 24 hr due to the risk of infection. B. The current bag of TPN should not hang more than 24 hr due to the risk of infection. C. The rate of TPN infusion should never be increased abruptly due to the risk of hyperglycemia. D. Administration of TPN should never be discontinued abruptly due to the sudden change in blood glucose that can occur.

A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair

A. CORRECT: The greatest risk to the client during the acute phase of an SCI is further damage to the spinal cord. When planning care, the priority intervention the nurse should take is to prevent further damage to the spinal cord by administration of corticosteroids, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord. B. The nurse should implement ROM exercise to prevent contractures. However, another action is the priority. C. The nurse should implement a turning schedule to prevent skin breakdown. However, another action is the priority. D. The nurse should slowly move the client to an upright position to prevent postural hypotension. However, another action is the priority.

A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement

A. CORRECT: The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. The priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled out. B. Insertion of a nasogastric tube is not the priority nursing action at this time. C. Frequent monitoring of pulse and blood pressure is important but not the priority nursing action at this time. D. Establishing IV access for fluid replacement is important but not the priority nursing action at this time.

A nurse is caring for a client who has a serum potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations? A. ECG changes B. Constipation C. Polyuria D. Hypotension

A. CORRECT: The nurse should assess for ECG changes. Potassium levels can affect the heart and result in arrhythmias. B. Constipation is a manifestation of hypokalemia. C. Polyuria is a manifestation of hypokalemia. D. Hypotension is a manifestation of hypokalemia

A nurse is planning care for a client who has Stage 4 chronic kidney disease. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Assess for jugular vein distention. B. Provide frequent mouth rinses. C. Auscultate for a pleural friction rub. D. Provide a high-sodium diet. E. Monitor for dysrhythmias.

A. CORRECT: The nurse should assess for jugular vein distention, which can indicate fluid overload and heart failure. B. CORRECT: The nurse should provide frequent mouth rinses due to uremic halitosis caused by urea waste in the blood. C. CORRECT: The nurse should auscultate for a pleural friction rub related to respiratory failure and pulmonary edema caused by acid base imbalances and fluid retention. D. The nurse should monitor serum sodium and reduce the client's dietary sodium intake. E. CORRECT: The nurse should monitor for dysrhythmias related to increased serum potassium caused by Stage 4 chronic kidney disease.

A nurse is planning care for a client who has Hgb 7.5 g/dL and Hct 21.5%. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Provide assistance with ambulation. B. Monitor oxygen saturation. C. Weigh the client weekly. D. Obtain stool specimen for occult blood. E. Schedule daily rest periods.

A. CORRECT: The nurse should assist the client when ambulating to prevent a fall because the client who has anemia can experience dizziness. B. CORRECT: The nurse should monitor oxygen saturation when the client has anemia due to the decreased oxygen-carrying capacity of the blood. C. The nurse should weigh the client daily to determine if the client is losing weight from inadequate oral intake or gaining weight, which can indicate a complication of heart failure due to lack of oxygen from low hemoglobin level. D. CORRECT: The nurse should obtain the client's stool to test for occult blood, which can identify a possible cause of anemia caused from gastrointestinal bleeding. E. CORRECT: The nurse should schedule the client to rest throughout the day because the client who has anemia can experience fatigue. Rest periods should be planned to conserve energy

A nurse is caring for a client who has a prescription for an afterload-reducing medication. The nurse should identify that this medication is administered for which of the following types of shock? A. Cardiogenic B. Obstructive C. Hypovolemic D. Distributive

A. CORRECT: The nurse should identify that a prescription to reduce afterload will allow the heart to pump more effectively, which is needed for the client who has cardiogenic shock. B. In obstructive shock, the high afterload is due to obstruction of blood flow. Afterload-reducing agents will not remove the obstruction. C. Fluid replacement and reduction of further fluid loss are the focus of management of hypovolemic shock. D. Afterload-reducing medication is not administered to a client who has distributive shock because the client already has decreased afterload.

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse expect if an allergic transfusion reaction is suspected? (Select all that apply.) A. Stop the transfusion. B. Monitor for hypertension. C. Maintain an IV infusion with 0.9% sodium chloride. D. Position the client in an upright position with the feet lower than the heart. E. Administer diphenhydramine

A. CORRECT: The nurse should immediately stop the infusion if an allergic transfusion reaction is suspected. B. The nurse should monitor for hypotension if an allergic transfusion reaction is suspected due to the risk for shock. C. CORRECT: The nurse should administer 0.9% sodium chloride solution through new IV tubing if an allergic transfusion reaction is suspected. D. The nurse should position the client in an upright position with the feet lower than the level of the heart if a circulatory overload is suspected. E. CORRECT: The nurse should administer an antihistamine, such as diphenhydramine, if an allergic transfusion reaction is suspected

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? A. Condom catheter B. Intermittent urinary catheterization C. Credé's method D. Indwelling urinary catheter

A. CORRECT: The nurse should implement the noninvasive use of a condom catheter, because the bladder will empty on its own due to the client having an upper motor neuron injury, which is manifested by a spastic bladder. B. The nurse should implement intermittent urinary catheterization method for a client who has a flaccid bladder. C. The nurse should implement the Credé's method for a client who has a flaccid bladder. D. An indwelling urinary catheter is an invasive procedure. The nurse should not implement this bladder management method for the client.

A nurse is having difficulty arousing a client following an esophagogastroduodenoscopy (EGD). Which of the following is the priority action by the nurse? A. Assess the client's airway. B. Allow the client to sleep. C. Prepare to administer an antidote to the sedative. D. Evaluate preprocedure laboratory findings.

A. CORRECT: The nurse should instruct the client to check with the provider about taking current medication, because some medications can be withheld when taking polyethylene glycol due to their lack of absorption. B. The nurse should instruct the client to consume a clear liquid diet prior to starting the bowel prep. C. The nurse should instruct the client that the actions of polyethylene glycol begin within 2 to 3 hr after consumption. D. The nurse should instruct the client to consume the full amount prescribed.

A nurse is planning care for a client who will undergo peritoneal dialysis. Which of the following actions should the nurse take? (Select all that apply.) A. Monitor serum glucose levels. B. Report cloudy dialysate return. C. Warm the dialysate in a microwave oven. D. Assess for shortness of breath. E. Check the access site dressing for wetness. F. Maintain medical asepsis when accessing the catheter insertion site.

A. CORRECT: The nurse should monitor serum glucose levels because the dialysate solution contains glucose. B. CORRECT: The nurse should monitor for cloudy dialysate return, which indicates an infection. Clear, light-yellow solution is typical during the outflow process. C. The nurse should avoid warming the dialysate in a microwave oven, which causes uneven heating of the solution. D. CORRECT: The nurse should assess for shortness of breath, which can indicate inability to tolerate a large volume of dialysate. E. CORRECT: The nurse should check the access site dressing for wetness and look for kinking, pulling, clamping, or twisting of the tubing, which can increase the risk for exit-site infections. F. The nurse should maintain surgical, not medical, asepsis when accessing the catheter insertion site to prevent infection from contamination.

A nurse in an outpatient clinic is assessing a client who reports night sweats and fatigue. He states he has had a cough along with nausea and diarrhea. His temperature is 38.1° C (100.6° F) orally. The client is afraid he has HIV. Which of the following actions should the nurse take? (Select all that apply.) A. Perform a physical assessment. B. Determine when manifestations began. C. Teach the client about HIV transmission. D. Draw blood for HIV testing. E. Obtain a sexual history.

A. CORRECT: The nurse should perform a physical assessment to gather data about the client's condition. B. CORRECT: The nurse should gather more data to determine whether the manifestations are acute or chronic. C. Teaching the client about HIV transmission is not an appropriate action by the nurse at this time. D. Drawing blood for HIV testing is not an appropriate action by nurse at this time. E. CORRECT: The nurse should obtain a sexual history to determine how the virus was transmitted.

A nurse is planning care for a client who has postrenal AKI due to metastatic cancer. The client has a serum creatinine of 5 mg/dL. Which of the following interventions should the nurse include in the plan? (Select all that apply.) A. Provide a high-protein diet. B. Assess the urine for blood C. Monitor for intermittent anuria. D. Weight the client once per week. E. Provide NSAIDs for pain.

A. CORRECT: The nurse should provide a high-protein diet due to the high rate of protein breakdown that occurs with acute kidney injury. B. CORRECT: The nurse should assess urine for blood, stones, and particles indicating an obstruction of the urinary structures that leave the kidney. C. CORRECT: The nurse should assess for intermittent anuria due to obstruction or damage to kidneys or urinary structures. D. The nurse should weigh the client daily to monitor for fluid retention due to acute kidney injury. E. The nurse should not administer NSAIDs, which are toxic to the nephrons in the kidney.

A nurse planning care for a client who has a PICC line in the right arm. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Use a 10 mL syringe to flush the PICC line. B. Apply gentle force if resistance is met during injection. C. Cleanse ports with alcohol for 15 seconds prior to use. D. Maintain a transparent dressing over the insertion site. E. Flush with 10 mL heparin before and after medication administration.

A. CORRECT: The nurse should use a 10 mL syringe to flush the PICC line to avoid excess pressure that could cause catheter fracture/rupture. B. The nurse should avoid the application of force if resistance is met during injection. C. CORRECT: The nurse should cleanse insertion ports with alcohol for 15 seconds and allow it to air dry prior to use. This action decreases the risk for bacterial contamination. D. CORRECT: The nurse should maintain a transparent dressing over the insertion site to decrease the risk for infection and allow for visualization. The nurse should plan to change the dressing at least every 7 days and when wet, loose, or soiled. E. The nurse should flush the PICC line with 10 mL 0.9% sodium chloride before, between, and after medications. A flush of 5 mL heparin (10 units/mL) is recommended when the PICC is not actively in use.

A nurse is admitting a client to the coronary care unit following placement of a temporary pacemaker. Which of the following nursing actions should the nurse use to promote client safety? (Select all that apply.) A. Wear gloves when handling pacemaker leads. B. Ensure electronic equipment has three-pronged grounding plugs. C. Minimize the client's shoulder movements. D. Hold the lead wires taut when turning the client. E. Keep extra pacemaker batteries at least 300 ft away from the client.

A. CORRECT: The nurse should wear gloves when handling pacemaker leads. B. Three-pronged grounding plugs reduce the risk of accidental electrical discharge by equipment being used. C. CORRECT: The client should wear a sling to minimize shoulder movement and promote secure anchoring of the lead wires. D. The nurse should hold the lead wires with some slack in them to prevent dislodging the wires when the client is turned. E. The nurse should keep additional batteries at the client's bedside for quick access when needed.

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Encourage use of the incentive spirometer every 2 hr. B. Instruct the client to splint the incision when coughing and deep breathing. C. Reposition the client every 2 hr. D. Administer antibiotic therapy. E. Assist with early ambulation.

A. CORRECT: Use of the incentive spirometer every 2 hr expands the lungs and prevents atelectasis. B. CORRECT: Incisional splinting with a pillow or blanket supports the incision during coughing and deep breathing, which prevents atelectasis. C. CORRECT: Repositioning the client every 2 hr will mobilize secretions and allow the client to deep breathe and expand the lungs to prevent atelectasis. D. Antibiotic therapy is used to prophylactically prevent or treat infection and does not prevent atelectasis. E. CORRECT: Early ambulation expands the lungs through deep breathing and prevents atelectasis.

A nurse administered captopril to a client during a renal scan. Which of the following actions should the nurse take? A. Assess for hypertension. B. Limit the client's fluid intake. C. Monitor for orthostatic hypotension. D. Encourage early ambulation

A. Captopril is an antihypertensive medication. The nurse should assess the client for hypotensive effects. B. Increasing the client's fluid intake can help resolve hypotensive effects following the administration of captopril. C. CORRECT: The nurse should monitor for orthostatic hypotension because this is an adverse effect of captopril. This results in a change in blood flow to the kidneys after the initial dose. D. The client is at risk for falls when ambulating due to the hypotensive effects of captopril. The nurse should encourage the client to remain in bed.

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.) A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure

A. Confusion is a late manifestation of hypoxemia. B. CORRECT: Pale skin is an early manifestation of hypoxemia. C. Bradycardia is a late manifestation of hypoxemia. D. Hypotension is a late manifestation of hypoxemia. E. CORRECT: Elevated blood pressure is an early manifestation of hypoxemia.

A nurse is reviewing the common emergency management protocol for clients who have asystole. Which of the following actions should the nurse plan to take during this cardiac emergency? A. Perform defibrillation. B. Prepare for transcutaneous pacing. C. Administer IV epinephrine. D. Elevate the client's lower extremities.

A. Defibrillation is not indicated for asystole, because this is not considered a shockable cardiac rhythm. B. Transcutaneous pacing is not indicated for the treatment of asystole. C. CORRECT: Administering epinephrine during asystole is an appropriate action by the nurse because it increases heart rate, improves cardiac output, and promotes bronchodilation. D. Elevating the client's lower extremities is indicated for the treatment of a client who is in shock, rather than asystole.

A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. The nurse should anticipate that which of the following management strategies will be used for this client? A. Defibrillation B. Pacemaker insertion C. Synchronized cardioversion D. Administration of IV lidocaine

A. Defibrillation is used when a client has ventricular fibrillation or pulseless ventricular tachycardia. B. CORRECT: A client who has bradycardia is a candidate for a pacemaker to increase his heart rate. C. Synchronized cardioversion is used when a client has a dysrhythmia such as atrial fibrillation, supraventricular tachycardia (SVT), or ventricular tachycardia with pulse. D. The administration of IV lidocaine is used in clients who have a pulseless ventricular dysrhythmia to stimulate cardiac electrical function

A nurse is providing teaching to a client who has a new diagnosis of diabetes insipidus. Which of the following client statements indicates an understanding of the teaching? A. "I can drink up to 2 quarts of fluid a day." B. "I will need to use insulin to control my blood glucose levels." C. "I should expect to gain weight during this illness." D. "Muscle weakness is a symptom of diabetes insipidus."

A. Excessive thirst is a manifestation of diabetes insipidus. Consumption of 4 to 30 L/day can be expected, and fluid intake should not be limited. B. Elevated blood glucose levels are a manifestation of diabetes mellitus. C. Weight loss is a manifestation of diabetes insipidus. D. CORRECT: Muscle weakness, weight loss, extreme thirst, headache, constipation, and dizziness are manifestations of dehydration that occurs with diabetes insipidus.

A nurse is caring for a client who has diabetes insipidus. Which of the following urinalysis laboratory findings should the nurse anticipate? A. Absence of glucose B. Decreased specific gravity C. Presence of ketones D. Presence of red blood cells

A. Glucose in the urine is indicative of diabetes mellitus. B. CORRECT: The urine of a client who has diabetes insipidus will be dilute with a urine specific gravity of less than 1.005. C. Ketones in the urine is indicative of diabetes mellitus. D. Red blood cells in the urine is indicative of diabetes mellitus.

A nurse is teaching a client who has chronic kidney disease and is to begin hemodialysis. Which of the following information should the nurse include in the teaching? A. Hemodialysis restores kidney function. B. Hemodialysis replaces hormonal function of the renal system. C. Hemodialysis allows an unrestricted diet. D. Hemodialysis returns a balance to serum electrolytes.

A. Hemodialysis does not restore kidney function, but it sustains the life of a client who has kidney disease. B. Hemodialysis does not replace hormonal function of the renal system due to tissue damage causing dysfunction of the renin-angiotensin-aldosterone system. C. Hemodialysis does not allow an unrestricted diet. It requires a diet high in folate and more protein than predialysis restrictions allowed, and low in sodium, potassium, and phosphorus. D. CORRECT: The nurse should explain to the client that hemodialysis restores electrolyte balance by removing excess sodium, potassium, fluids, and waste products, and also restores acid-base balance.

A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? A. Initiate contact precautions. B. Weigh the client weekly. C. Measure abdominal girth 7.5 cm (3 in) above the umbilicus. D. Provide a high-calorie, high-carbohydrate diet.

A. Hepatitis B is transmitted via blood. Standard precautions are adequate. B. Daily weights are obtained to monitor fluid status. C. The client's abdominal girth is measured over the largest part of the abdomen, which will vary by client. D. CORRECT: The client who has hepatitis B should have a diet high in calories and carbohydrates

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria

A. Hyperglycemia is not an adverse effect of mannitol. B. CORRECT: Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances, such as hyponatremia. C. Hypovolemia is an adverse effect of mannitol and should be monitored. D. Polyuria is an adverse of mannitol and should be monitored.

During rehabilitation. a pt with spinal cord injury begins to ambulate with long leg braces, what level of injury does the nurse associate with this degree of recovery? A. L1-2 B. T6-7 C. T1-2 D. C7-8

A. L1-2

A nurse is teaching a client who has angina about a new prescription for metoprolol. Which of the following statements by the client indicates understanding of the teaching? A. "I should place the tablet under my tongue." B. "I should have my clotting time checked weekly." C. "I will report any ringing in my ears." D. "I will call my doctor if my pulse rate is less than 60.

A. Lopressor is administered orally, not sublingually. B. Lopressor does not affect bleeding or clotting time. The client should have CBC and blood glucose checked periodically. C. Ringing in the ears is not an adverse effect of the medication. Dry mouth and mucous membranes can occur. D. CORRECT: The client is advised to notify the provider if bradycardia (pulse rate less than 60) occurs

A nurse administered midazolam IV bolus to a client before a procedure. His blood pressure is 86/40 mm Hg, and his pulse is 134/min. Which of the following IV medications should the nurse administer? A. Naloxone B. Morphine C. Flumazenil D. Atropine

A. Naloxone reverses respiratory depression resulting from an opioid medication. B. Morphine relieves pain and can cause hypotension and respiratory depression. C. CORRECT: Midazolam is a benzodiazepine. The nurse should administer flumazenil to reverse its effects. D. Atropine sulfate treats bradycardia.

A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following types of prescribed medications should the nurse clarify with the provider? A. Glucocorticoids B. Plasma expanders C. H2 antagonists D. Muscle relaxants

A. The nurse should administer glucocorticoids to decrease edema of the spinal cord. B. The nurse should administer plasma expanders to treat hypotension caused by the SCI. C. The nurse should administer H2 antagonists to decrease the complication of developing a gastric ulcer from stress. D. CORRECT: The nurse should clarify with the provider the need for the client to receive muscle relaxants. The client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time

A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates an understanding of PSV? A. "It keeps the alveoli open and prevents atelectasis." B. "It allows preset pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilator." D. "It delivers a preset ventilatory rate and tidal volume to the client."

A. PEEP maintains pressure in the lungs to keep alveoli open or prevent atelectasis. B. CORRECT: PSV allows preset pressure delivered during spontaneous ventilation to decrease the work of breathing. C. PSV does not guarantee minimal minute ventilation because no ventilator breaths are delivered. D. Assist-control (AC) mode delivers a preset ventilatory rate and tidal volume to the client.

A nurse in a cardiac unit is assisting with the admission of a client who is to undergo hemodynamic monitoring. Which of the following actions should the nurse anticipate performing? A. Administer large volumes of IV fluids. B. Assist with insertion of pulmonary artery catheter. C. Obtain Doppler pulses of the extremities. D. Gather supplies for insertion of a peripheral IV catheter

A. Patency of the catheter is maintained with a slow continuous infusion of 0.9% sodium chloride. The catheter is used for blood sampling and pressure monitoring, not fluid administration. B. CORRECT: A pulmonary artery catheter and pressure-monitoring system are inserted for hemodynamic monitoring. C. ECG monitoring is performed prior to hemodynamic monitoring. D. An arterial line is needed to obtain blood samples for ABGs and other blood tests as part of hemodynamic monitoring.

A nurse is caring for a client who has pericarditis. Which of the following findings should the nurse expect? A. Petechiae B. Murmur C. Rash D. Friction rub

A. Petechiae are an expected finding in a client who has endocarditis. B. A murmur is an expected finding in a client who has myocarditis and endocarditis. C. Rash is an expected finding in a client who has rheumatic endocarditis. D. CORRECT: A friction rub can be heard during auscultation of a client who has pericarditis.

A nurse is admitting a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? A. Propranolol B. Metoclopramide C. Ranitidine D. Vasopressin

A. Propranolol is not used for clients who are actively bleeding. It can be given prophylactically to decrease portal hypertension. B. Metoclopramide decreases motility of the esophagus and stomach. C. Histamine2-receptor antagonists are administered following surgical procedures for bleeding esophageal varices. D. CORRECT: Vasopressin constricts blood vessels and is used to treat bleeding esophageal varices.

A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following findings should the nurse expect? A. Rubor of the affected leg when elevated B. 3+ dorsal pedal pulse in left foot C. Thin, peeling toenails of left foot D. Report of intermittent claudication in the affected leg

A. Reddening (rubor) of a leg affected by peripheral artery disease occurs when it is placed in a dependent position. B. Pulses are decreased or absent in the feet in cases of peripheral artery disease. C. Toenails are thickened in cases of peripheral artery disease. D. CORRECT: A client who has peripheral artery disease might report that numbness or burning pain in the extremity ceases with rest (intermittent claudication).

A nurse is obtaining arterial blood gases for a client who has vomited for 24 hr. The nurse should expect which of the following acid-base imbalances to result from vomiting for 24 hr? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis is not indicated for this client. B. Respiratory alkalosis is not indicated for this client. C. Metabolic acidosis is not indicated for this client. D. CORRECT: Excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in the blood, resulting in metabolic alkalosis.

A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. Which of the following findings should the nurse suspect? A. Retroperitoneal bleeding B. Cardiac tamponade C. Bleeding from the incisional site D. Heart failure

A. Retroperitoneal bleeding is internal bleeding. B. Cardiac tamponade includes manifestations of bleeding in the pericardial sac, which is internal. C. CORRECT: Bleeding is occurring from the incision site and then draining under the client. The nurse should assess the incision for hematoma, apply pressure, monitor the client, and notify the provider. D. Heart failure does not including findings of blood underneath the client's lower back.

A nurse is providing care to a client who is 1 day postoperative following a paracentesis. The nurse observes clear, pale-yellow fluid leaking from the operative site. Which of the following is an appropriate nursing intervention? A. Place a clean towel near the drainage site. B. Apply a dry, sterile dressing. C. Apply direct pressure to the site. D. Place the client in a supine position.

A. Sterile dressings should be applied to the operative site to prevent infection and allow for assessment of drainage. B. CORRECT: Application of a sterile dressing will contain the drainage and allow continuous assessment of color and quantity. C. Application of direct pressure can cause discomfort and potential harm to the client. The nurse should apply a sterile dressing to the site and monitor the quantity and characteristic of the drainage. D. The client should be placed with the head of the bed elevated to promote lung expansion.

A nursing is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.) A. Suction the endotracheal tube frequently. B. Decrease the noise level in the client's room C. Elevate the client's head on two pillows. D. Administer a stool softener. E. Keep the client well hydrated.

A. Suctioning increases ICP and should be performed only when indicated. B. CORRECT: Decreasing the noise level and restricting the number of people in the client's room can help prevent increases in ICP. C. Hyperflexion of the client's neck with pillows carries the risk of increasing ICP and should be avoided. The head of the bed should be raised to at least 30°, but the head should be maintained in an upright, neutral position. D. CORRECT: Administration of a stool softener will decrease the need to bear down (Valsalva maneuver) during bowel movements, which can increase ICP. E. Overhydration carries the risk of increasing ICP and should be avoided. The nurse should monitor fluid and electrolyte levels closely for the client who has increased ICP.

A nurse assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate? A. Bradycardia B. Hypertension C. Epistaxis D. Xerostomia

A. Tachycardia is a finding that is indicative of DIC. B. Hypotension is a finding that is indicative of DIC. C. CORRECT: Epistaxis is unexpected bleeding of the gums and nose and is a finding indicative of DIC. D. Xerostomia is dryness of the mouth and is not indicative of DIC.

A nurse is assessing a client who has pancreatitis. The client's arterial blood gases reveal metabolic acidosis. Which of the following are expected findings? (Select all that apply.) A. Tachycardia B. Hypertension C. Bounding pulses D. Hyperreflexia E. Dysrhythmia F. Tachypnea

A. Tachycardia is an expected finding for a client who has respiratory acidosis or metabolic alkalosis. B. Hypertension is an expected finding of respiratory acidosis. C. Bounding pulses is an expected finding for respiratory acidosis due to hypertension. D. Hyperreflexia is an expected finding for a client who has metabolic alkalosis. E. CORRECT: Dysrhythmia is an expected finding in a client who has pancreatitis and metabolic acidosis. F. CORRECT: Tachypnea is an expected finding in a client who has pancreatitis and metabolic acidosis

A nurse in the emergency department is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect? (Select all that apply.) A. Heart rate 60/min B. Seizure activity C. Respiratory rate 42/min D. Increased urine output E. Weak, thready pulse

A. Tachycardia is an expected finding in a client who is in shock. B. CORRECT: Seizure activity can be present in a client who is in shock. C. CORRECT: Tachypnea is an expected finding in a client who is in shock. D. Decreased urine output is in expected finding in a client who is in shock. E. CORRECT: A weak, thready pulse is an expected finding in a client who is in shock.

A student nurse is observing a cardioversion procedure and hears the team leader call out, "Stand clear." The student should recognize the purpose of this action is to alert personnel that A. the cardioverter is being charged to the appropriate setting. B. they should initiate CPR due to pulseless electrical activity. C. they cannot be in contact with equipment connected to the client. D. a time-out is being called to verify correct protocols.

A. The cardioverter is charged prior to the delivery of the shock during cardioversion. B. The team leader calls out "Initiate CPR" when members of the team are to begin CPR. C. CORRECT: A safety concern for personnel performing cardioversion is to "stand clear" of the client and equipment connected to the client when a shock is delivered to prevent them from also receiving a shock. D. A "time-out" is called by personnel during a procedure to verify that proper protocols are being followed.

A nurse is monitoring a client who had a kidney biopsy for postoperative complications. Which of the following complications should the nurse identify as causing the greatest risk to the client? A. Infection B. Hemorrhage C. Hematuria D. Pain

A. The client is at risk for infection of the kidney because a biopsy is an invasive procedure. However, another complication is the priority. B. CORRECT: The greatest risk to the client following a kidney biopsy is hemorrhage due to a lack of clotting at the puncture site. The nurse should report this finding to the provider immediately. C. The client is at risk for hematuria, which is a common complication the first 48 to 72 hr after the biopsy. However, another complication is the priority. D. The client is at risk for pain after a kidney biopsy because blood in and around the kidney causes pressure on the nerves in the area; however, another complication is the priority.

A nurse is preparing to administer IV fluids to a client who has diabetic ketoacidosis. Which of the following actions should the nurse take? A. Administer an IV infusion of regular insulin at 0.3 unit/kg/hr. B. Administer an IV infusion of 0.45% sodium chloride. C. Rapidly administer an IV infusion of 0.9% sodium chloride. D. Add glucose to the IV infusion when serum glucose is 350 mg/dL.

A. The nurse should administer an IV infusion of regular insulin at 0.1 unit/kg/hr to gradually lower blood glucose to prevent cerebral edema. B. The administration of an IV infusion of 0.45% sodium chloride should follow the isotonic fluid and is used as maintenance fluids. C. CORRECT: The nurse should rapidly administer an IV infusion of 0.9% sodium chloride, an isotonic fluid, as prescribed to maintain blood perfusion to vital organs. D. The nurse should add glucose to the IV infusion when the serum glucose is 250 mg/dL, not 350 mg/dL, to prevent hypoglycemia and minimize cerebral edema.

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following client statements indicates that the client understands how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop after I use this device." D. "I will ask my son to push the dose button when I am sleeping."

A. The client may use the device when he begins to feel pain. It will help prevent unnecessary worsening of the pain and more doses of analgesia to provide relief. B. A feature of PCA devices is the timing control or lockout mechanism, which enforces a preset minimum interval between medication doses. This safety feature is one means of preventing an overdose because the client cannot self-administer another dose of medication until that time interval has passed. C. CORRECT: The nurse should identify that PCA is a method of delivering pain medication through an electronic infusion device that allows the client to self-administer pain medication on an as-needed basis. If the client is not achieving adequate pain control, he should let the nurse know so that she can initiate a reevaluation of the client's pain management plan. D. The client is the only one who should operate the PCA pump. In situations where the client is not able to do so, the provider may authorize a nurse or a family member to operate the pump.

A nurse is planning care for client who has acromegaly and is postoperative following a transsphenoidal hypophysectomy. Which of the following interventions should the nurse include in the plan? A. Maintain the client in a low-Fowler's position. B. Encourage deep breathing and coughing. C. Encourage the client to brush his teeth when awake and alert. D. Observe dressing drainage for the presence of glucose.

A. The client should be placed into a high-Fowler's position. B. Coughing should be limited in the client who is postoperative, as this increases intracranial pressure and can cause a leak of CSF. C. Oral care for the client who is postoperative following a transsphenoidal hypophysectomy includes oral rinses and flossing. Brushing teeth can cause a leak of CSF and is contraindicated. D. CORRECT: The nurse should monitor the drainage to the mustache dressing and observe for the presence of glucose, which would indicate the presence of CSF. Notify the provider if this occurs.

A nurse is providing teaching for a client who has stage 2 HIV disease and is having difficulty maintaining a normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching. A. "I will choose a diet high in fat to help gain weight." B. "I will be sure to eat three large meals daily." C. "I will drink up to 1 liter of liquid each day." D. "I will add high-protein foods to my diet."

A. The client should be taught to avoid high-fat foods to gain weight because fat intolerance—causing flatus, bloating, and diarrhea—is common in clients who have HIV/AIDS. B. The client should be taught that small frequent meals (such as six meals daily) are better tolerated than three large meals. C. The client should be taught to drink 2 to 3 L of liquids daily to maintain nutrition status. D. CORRECT: The client should be taught to add high-protein, high-calorie foods to the diet daily as the best way to gain weight and maintain health.

A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching? A. "You should make an appointment to donate blood 8 weeks prior to the surgery." B. "If you need an autologous transfusion, the blood your brother donates can be used." C. "You can donate blood each week if your hemoglobin is stable." D. "Any unused blood that is donated can be used for other clients."

A. The client should donate blood for an autologous transfusion no sooner than 6 weeks prior to surgery. B. An autologous donation refers to the client's donation of blood for his own personal use. C. CORRECT: Beginning 6 weeks prior to surgery, the client can donate blood each week for autologous transfusion if his Hgb and Hct remain stable. D. An autologous donation is for use only by the client.

A nurse is teaching a client who is postoperative following a kidney transplant and is taking cyclosporine. Which of the following instructions should the nurse include? A. "Decrease your intake of protein-rich foods." B. "Take this medication with grapefruit juice." C. "Monitor for and report a sore throat to your provider." D. "Expect your skin to turn yellow."

A. The client should not decrease protein-rich foods in the diet, which promote healing and rebuilds muscle. There are no restrictions of protein intake for a client taking cyclosporine following a kidney transplant. B. The client should not drink grapefruit juice, which can reduce cyclosporine metabolism and cause increased cyclosporine levels. C. CORRECT: The client should report any manifestations of an infection because this medication causes immunosuppression. D. The client should report manifestations of hepatotoxicity, such as jaundice, and abdominal pain.

A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a CVP of 7 mm Hg and a PAWP of 17 mm Hg. Which of the following findings should the nurse expect? (Select all that apply.) A. Poor skin turgor B. Bilateral crackles in the lungs C. Jugular vein distension D. Dry mucous membranes E. Hepatomegaly

A. The client's CVP and PAWP are above the expected reference range. The nurse should expect the client to have poor skin turgor for a decreased CVP and PAWP. B. CORRECT: The nurse should expect the client to have bilateral crackles in the lungs for an increased CVP and PAWP. C. CORRECT: The nurse should expect the client to have jugular vein distension for an increased CVP and PAWP. D. The nurse should expect the client to have dry mucous membranes for a decreased CVP and PAWP. E. CORRECT: The nurse should expect the client to have hepatomegaly for an increased CVP and PAWP.

A nurse on a cardiac unit is reviewing the laboratory findings of a client who has a diagnosis of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the MI occurred 14 days ago? A. CK-MB B. Troponin I C. Troponin T D. Myoglobin

A. The creatinine kinase MB levels are no longer evident after 3 days. B. Troponin I levels are no longer evident after 7 to 10 days. C. CORRECT: The Troponin T level will still be evident 10 to 14 days following an MI. D. Myoglobin levels are no longer evident after 24 hr.

purpose of adding PEEP to positive pressure ventillation is A. increase functional residual capacity and improve oxygenation B. increase FiO2 in an attempt to wean the pt and avoid O2 toxicity C. determine if the pt is in synch with the ventilator or needs to be paralyzed D. determine if the pt is able to be weaned and avoid the risk of pneumomediastinum

A. increase functional residual capacity and improve oxygenation

A nurse in the emergency department is caring for a client who had an allergic reaction related to a bee sting. The client is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first? A. Methylprednisolone IV bolus B. Diphenhydramine subcutaneously C. Epinephrine IV D. Albuterol inhale

A. The nurse should administer methylprednisolone to treat the inflammatory response to the bee sting. However, the nurse should administer another medication first. B. The nurse should administer diphenhydramine to treat the client's itching related to the bee sting. However, the nurse should administer another medication first. C. CORRECT: When using the airway, breathing, circulation approach to client care, the nurse should place the priority on administering epinephrine to the client. This is a rapid-acting medication that promotes effective oxygenation and is used to treat anaphylactic shock. D. The nurse should administer albuterol to assist with the client's breathing. However, the nurse should administer another medication first

A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? A. Apply a vest restraint if self-extubation is attempted. B. Monitor ventilator settings every 8 hr. C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 1 to 2 hr.

A. The nurse should apply soft wrist restraints to prevent self-extubation or according to facility policy. B. The nurse should monitor ventilator settings hourly. C. The nurse should document tube placement in centimeters at the client's teeth or lips. D. CORRECT: The nurse should assess the breath sounds of a client on mechanical ventilation every 1 to 2 hr.

A nurse is reviewing client laboratory data. The nurse should recognize that which of the following findings is expected for a client who has Stage 4 chronic kidney disease? A. Blood urea nitrogen (BUN) 15 mg/dL B. Glomerular filtration rate (GFR) 20 mL/min C. Serum creatinine 1.1 mg/dL D. Serum potassium 5.0 mEq/L

A. The nurse should expect the BUN to be above the expected reference range, about 10 to 20 times the BUN finding. B. CORRECT: The GFR is severely decreased to approximately 20 mL/min, which is indicative of stage 4 chronic kidney disease. C. In stage 4 chronic kidney disease, a creatinine level can be as high as 15 to 30 mg/dL. D. A client in stage 4 chronic kidney disease would have a potassium level greater than 5.0 mEq/L.

A nurse is teaching a client who is scheduled for an angiography. Which of the following statements should the nurse include in the teaching? A. "You should have nothing to eat or drink for 4 hours prior to the procedure." B. "You will be given general anesthesia during the procedure." C. "You should not have this procedure done if you are allergic to eggs." D. "You will need to keep your affected leg straight following the procedure."

A. The nurse should instruct the client to remain NPO for at least 8 hr prior to the procedure to decrease the risk for aspiration while lying flat during the angiography. B. The nurse should instruct the client that he is awake and sedated during the procedure and that a local anesthetic is used at the catheter insertion site. C. The nurse should assess the client for an allergy to iodine/shellfish due to the use of contrast dye. An allergy to eggs is not a contraindication to angiography. D. CORRECT: The nurse should instruct the client of the need to remain on bed rest in the supine position with the affected leg straight for a prescribed amount of time. This positioning decreases the client's risk for bleeding and hematoma formation at the catheter insertion site.

2. A nurse is planning care for a client who has septic shock. Which of the following actions is the priority for the nurse to take? A. Maintain adequate fluid volume with IV infusions. B. Administer antibiotic therapy. C. Monitor hemodynamic status. D. Administer vasopressor medication.

A. The nurse should maintain the client's fluid volume by administration of IV fluids. However, another action is the priority. B. CORRECT: The greatest risk to the client is injury from elimination endotoxins and mediators from bacteria, which will reduce the vasodilation from occurring. The priority intervention for the nurse is to administer antibiotics. C. The nurse should monitor hemodynamic status to monitor the blood pressure inside the veins, arteries and heart. However, another action is the priority. D. The nurse should administer vasopressor medication to increase the contractility of the heart muscle and to cause vasoconstriction. However, another action is the priority.

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise

A. The nurse should monitor for neurogenic chock, which is a response of the sympathetic nervous system of a client who has a SCI. However, another complication is the priority. B. The nurse should monitor for a paralytic ileus, which is a complication immediately following a SCI. However, another complication is the priority. C. The nurse should monitor for a stress ulcer, which is a response to changes caused from the SCI. However, another complication is the priority. D. CORRECT: When using the airway, breathing, and circulation (ABC) approach to client care, the priority complication is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilatory support as needed is the priority intervention.

A nurse is planning care for a client who has prerenal acute kidney injury (AKI) following abdominal aortic aneurysm repair. Urinary output is 60 mL in the past 2 hr, and blood pressure is 92/58 mm Hg. The nurse should anticipate which of the following interventions? A. Prepare the client for a CT scan with contrast dye. B. Plan to administer nitroprusside. C. Prepare to administer a fluid challenge. D. Plan to position the client in Trendelenburg.

A. The nurse should not plan for a CT scan. Contrast dye is contraindicated for a client who has possible acute kidney injury. B. Nitroprusside is a rapid-acting vasodilator used to rapidly reduce blood pressure for clients who have hypertensive crisis.It is contraindicated for clients who have hypotension. C. CORRECT: The nurse should plan to administer a fluid challenge for hypovolemia, which is indicated by the client's low urinary output and blood pressure. D. The nurse should position the client in reverse Trendelenburg, with the head down and feet up, to treat hypotension.

The purpose of adding PEEP to positive pressure ventilation is to A. increased functional residual capacity and improve oxygenation B. increase FIO2 in an attempt to wean the patient and avoid O2 toxicity C. determine if the patient is in synchrony with the ventilator or needs to be paralyzed D. determine if the patient is able to be weaned and avoid the risk of pneumomediastinum

A. increased functional residual capacity and improve oxygenation

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first? A. Notify the provider. B. Sit the client upright in bed. C. Check the urinary catheter for blockage. D. Administer antihypertensive medication

A. The nurse should notify the provider. However, another action is the priority. B. CORRECT: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated blood pressure caused by autonomic dysreflexia. The first action the nurse should take is to elevate the head of the bed until the client is in an upright position, which should lower the blood pressure secondary to postural hypotension. C. The nurse should check the client's catheter for blockage. However, another action is the priority. D. The nurse should administer an antihypertensive medication if indicated. However, another action is the priority.

A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion? A. Obtain consent from the client for the transfusion. B. Assess for an acute hemolytic reaction. C. Explain the transfusion procedure to the client. D. Obtain blood culture specimens to send to the lab

A. The nurse should obtain consent from the client for the transfusion prior to initiating the transfusion. B. CORRECT: The nurse should assess for an acute hemolytic reaction during the first 15 min of the transfusion. This form of a reaction can occur following the transfusion of as little as 10 mL of blood product. C. The nurse should explain the transfusion procedure to the client prior to initiating the transfusion. D. The nurse should obtain blood culture specimens from the client if a bacterial reaction is suspected.

A nurse is admitting a client who has complete heart block as demonstrated by ECG. The client's heart rate is 34/min and blood pressure is 83/48 mm Hg. The client is lethargic and unable to complete sentences. Which of the following actions should the nurse perform first? A. Transport the client to the cardiovascular laboratory. B. Prepare the client for insertion of a permanent pacemaker. C. Obtain a signed informed consent form for a pacemaker. D. Apply transcutaneous pacemaker pads.

A. The nurse should plan to transport the client to the cardiovascular laboratory for placement of a permanent pacemaker to control the client's heart rate; however, there is another action the nurse should take first. B. The nurse should plan to prepare the client for insertion of a permanent pacemaker by cleansing the skin and clipping excess hair; however, there is another action the nurse should take first. C. The nurse should obtain informed consent for placement of a permanent pacemaker if an individual with authority to make decisions for the client is present; however, there is another action the nurse should take first. Emergency procedures can be performed without consent if the client is not coherent. D. CORRECT: The greatest risk to this client is injury or death from inadequate tissue perfusion; therefore, the first action the nurse should take is to apply transcutaneous pacemaker pads and begin external pacing of the heart until a permanent pacemaker can be placed.

A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching? A. "Air should be instilled into the monitoring system prior to the procedure." B. "The client should be positioned on the left side during the procedure." C. "The transducer should be level with the second intercostal space after the line is placed." D. "A chest x-ray is needed to verify placement after the procedure."

A. The nurse should purge air from, rather than instill air into, the monitoring system. B. The nurse should place the client in the supine or Trendelenburg position. C. For hemodynamic monitoring, the nurse should place the transducer level with the 4th intercostal space, which is at the base of the right atrium. D. CORRECT: The nurse should ensure that a chest x-ray is obtained to confirm proper placement of the lines following placement.

A nurse is presenting a community education program on recommended lifestyle changes to prevent angina and myocardial infarction. Which of the following changes should the nurse recommend be made first? A. Diet modification B. Relaxation exercises C. Smoking cessation D. Taking omega-3 capsules

A. The nurse should recommend changing the diet to decrease consumption of sodium and saturated fat; however, there is another change the clients should plan to make first. B. The nurse should recommend using relaxation exercise to cope with stress; however, there is another change the clients should plan to make first. C. CORRECT: According to the airway, breathing, and circulation (ABC) priority-setting framework, the first change the nurse should recommend the clients take is to stop smoking. Nicotine causes vasoconstriction, elevates blood pressure, and narrows coronary arteries. D. The nurse should recommend taking omega-3 capsules to increase consumption of good cholesterol; however, there is another change the clients should plan to make first.

A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include in the teaching? A. Stools will be dark red. B. Take with a glass of milk if gastrointestinal distress occurs. C. Foods high in vitamin C will promote absorption. D. Take for 14 days.

A. The nurse should teach the client that stools will be dark green to black in color when taking iron. B. The nurse should instruct the client that milk binds with iron and decreases its absorption. C. CORRECT: The nurse should teach the client that vitamin C enhances the absorption of iron by the intestinal tract. D. The nurse should instruct the client that iron therapy usually takes 4 to 6 weeks for Hgb and Hct to return to the expected reference range.

A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Inserts an 18-gauge IV catheter in the client B. Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP) C. Administers dextrose 5% in 0.9% sodium chloride IV with the transfusion D. Obtains vital signs every 15 min throughout the procedure.

A. The nurse should use no larger than a 19-gauge needle in the older adult client. B. The nurse should verify the client's identity and blood compatibility, and expiration date of the blood with another nurse. This task is beyond the scope of practice for an assistive personnel. C. The nurse should administer blood products with 0.9% sodium chloride. IV solutions containing dextrose cannot be used. D. CORRECT: The nurse should check the older adult client's vital signs every 15 min throughout the transfusion to allow for early detection of fluid overload or other transfusion reaction

A nurse is assessing a client's laboratory values before surgery. Which of the following results should the nurse report to the provider? (Select all that apply.) A. Potassium 3.9 mEq/L B. Sodium 145 mEq/L C. Creatinine 2.8 mg/dL D. Blood glucose 235 mg/dL E. WBC 17,850/mm3

A. The potassium level is within the expected reference range. B. The sodium level is within the expected reference range. C. CORRECT: The nurse should report an elevated creatinine level, which can indicate impaired renal function. D. CORRECT: The nurse should report an elevated blood glucose, which needs treatment prior to surgery. E. CORRECT: The nurse should report an elevated WBC count, which indicates a need for antibiotic therapy before surgery.

A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (Select all that apply.) A. Explain to the client the purpose of having the procedure. B. Inform the client of risks to having the procedure. C. Ensure the client understands information about the procedure. D. Witness the client signing the informed consent form. E. Determine if the client is capable of understanding the reason for the procedure.

A. The provider should explain the purpose of the procedure. B. The provider should inform the client of risks to having the procedure. C. CORRECT: The nurse should ensure the client understands the information about the procedure. D. CORRECT: The nurse should witness the client sign the informed consent. E. CORRECT: The nurse should determine if the client is capable of understanding the reason for the procedur

A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal blood pressure 104/72 mm Hg, heart rate 116/min with regular rhythm, and respiratory rate 42/min and deep. Which of the following arterial blood gas findings should the nurse expect? A. pH 7.68 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3− 28 mEq/L B. pH 7.48 PaO2 100 mm Hg PaCO2 28 mm Hg HCO3− 23 mEq/L C. pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3− 18 mEq/L D. pH 7.58 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3− 29 mEq/L

A. These arterial blood gases indicate metabolic alkalosis. B. These arterial blood gases indicate respiratory alkalosis. C. CORRECT: An aspirin overdose would result in arterial blood gas findings of metabolic acidosis. D. These arterial blood gases indicate metabolic alkalosis.

A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting (CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, then refuses to cough because he is tired and it hurts too much. Which of the following actions should the nurse take? A. Allow the client to rest, and return in 1 hr. B. Administer IV bolus analgesic, and return in 15 min. C. Document the 200 mL as an appropriate inspired volume. D. Tell the client that he must try to cough if he does not want to get pneumonia.

A. Turning, coughing, and deep breathing should be performed every 2 hr to promote oxygenation and circulation. B. CORRECT: Providing adequate analgesia and returning in 15 min will reduce pain and improve coughing effectiveness. C. This is not an adequate inspired air volume to promote effective oxygenation. D. This intervention is non-therapeutic communication.

A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? (Select all that apply.) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea

A. Urinary retention, not urinary incontinence, is a common adverse effect of opioid analgesia. B. Constipation, not diarrhea, is a common adverse effect of opioid analgesia. C. CORRECT: Respiratory depression, which causes respiratory rates to drop to dangerously low levels, is a common adverse effect of opioid analgesia. D. CORRECT: Dizziness or lightheadedness when changing positions is a common adverse effect of opioid analgesia. E. CORRECT: Nausea and vomiting are common adverse effects of opioid analgesia

A nurse is caring for a client who is receiving warfarin for anticoagulation therapy. Which of the following laboratory test results indicates to the nurse that the client needs an increase in the dosage? A. aPTT 38 seconds B. INR 1.1 C. PT 22 seconds D. D-dimer negative

A. aPTT is monitored for clients receiving heparin therapy. An aPTT of 38 seconds is within the expected reference range for clients not receiving heparin therapy. B. CORRECT: INR of 1.1 is within the expected reference range for a client who is not receiving warfarin. However, this value is subtherapeutic for anticoagulation therapy. The nurse should expect the client to receive an increased dosage of warfarin until the INR is 2 to 3. C. PT of 22 seconds is above the expected reference range for a client receiving warfarin therapy. This result indicates the client is at an increased risk for bleeding. D. A negative D-dimer test indicates the absence of a pulmonary embolus or deep vein thrombosis and is not used to determine the dosage needs for warfarin therapy.

A kidney transplant recipient complains of having fever, chills, and dysuria over the past 2 days. What is the first action the nurse should take? A. assess temperature and initiate workup to rule out infection B. reassure the patient that this is common after transplantation C. provide warm cover for the patient and give 1g acetaminophen orally D. notify the nephrologist that the patient has developed symptoms of acute rejection

A. assess temperature and initiate workup to rule out infection

Appropriate treatment for management of cardiogenic shock include (select all) A. dobutamine to increase myocardial contractility B. vasopressors to increase SVR C. circulatory assist devices (IABP) D. corticosteroids to stabilize cell wall in infarcted myocardium E. Trendelenburg position to facilitate venous return and increase preload

A. dobutamine to increase myocardial contractility C. circulatory assist devices (IABP)

The most common early clinical manifestations of ARDS that the nurse may observe are A. dyspnea and tachypnea B. cyanosis and apprehension C. hypotension and tachycardia D. respiratory distress and frothy sputum

A. dyspnea and tachypnea

Nutritional support and management are essential across the entire continuum of CKD. which statements would be conidered true related to nutritional therapy? A. fluid is not usually restricted for patients receiving peritoneal dialysis B. Na and K may be restricted in someone with advanced CKD C. decreased fluid intake and low potassium diet are hallmarks of the diet for a patient receiving hemodialysis D. decreased fluid intake and a low potassium diet are hallmarks of the diet for a patient receiving peritoneal dialysis E. decreased fluid intake and a diet with phosphate-rich foods are hallmarks of a diet for a patient receiving hemodialysis

A. fluid is not usually restricted for patients receiving peritoneal dialysis B. Na and K may be restricted in someone with advanced CKD C. decreased fluid intake and low potassium diet are hallmarks of the diet for a patient receiving hemodialysis

Patients with CKD experience an increased incidence of CV disease related to (select all) A. hypertension B. vascular calcifications C. genetic predisposition D. hyperinsulinemia causeing dyslipidemia E. increased high-density lipoprotein levels

A. hypertension B. vascular calcifications D. hyperinsulinemia causeing dyslipidemia

An 80 year old female is receiving palliative care for heart failure. The primary purpose of her receiving palliative care is (select all) A. improve quality of life B. assess coping ability with disease C. have time to teach patient and family about the disease D. focus on reducing the severity of disease symptoms E. provide care that the family is unwilling or unable to give

A. improve quality of life D. focus on reducing the severity of disease symptoms

A patient is admitted with CKD. The nurse understands this is condition is characterized by A. progressive irreversible destruction of the kidneys B. a rapid decrease in urine output with an elevated BUN C. an increasing creatinine clearance with a decreased in urine output D. prostration, somnolenece, and confusion with coma and imminent death

A. progressive irreversible destruction of the kidneys

An ESRD patient receiving hemodialysis is considering asking a relative to donate a kidney for transplantation. In assisting the patient to make a decision about treatment, the nurse informs the patient that A. successful transplantation usually provides better quality of life than that offered by dialysis B. if rejection of the transplanted kidney occurs, no further treatment for the renal failure is available C. hemodialysis replaces the normal function of the kidneys and patients fo not have to live with the continual fear of rejection D. the immunosupressive therapy following transplantation makes the person ineligible to receive other forms of treatment if the kidney fails

A. successful transplantation usually provides better quality of life than that offered by dialysis

A major advantage of peritoneal dialysis is A. the diet is less restricted and dialysis can be performed at home B. the dialysate is biocompatible and causes no long-term consequences C. high glucose concentrations of the dialysate cause a reduction in appetite, promoting weight loss D. no medications are required because of the enhanced efficiency of the peritoneal membrane in removing toxins

A. the diet is less restricted and dialysis can be performed at home

In a person havign an acute rejection of a transplanted kidney what would help the nurse understand the course of events (select all) A. a new transplant should be considered B. acute rejection can be treated with OKT3 C. acute rejection usually leads to chronic rejection D. corticosteroids are the most successful drugs used to treat acute rejection E. acute rejection is common after a transplant and can be treated with drug therapy

B. acute rejection can be treated with OKT3 E. acute rejection is common after a transplant and can be treated with drug therapy

hemodynamic changes expected after starting intra aortic balloon pump therapy in a pt with cardiogenic shock (select all) A. decreased SV B. decreased SVR C. decreased PAWP D. increased diastolic bp E. decreased myocardial O2 consumption

B. decreased SVR C. decreased PAWP D. increased diastolic bp E. decreased myocardial O2 consumption

the best way to position a pt with increased ICP A. keep head of bed flat B. elevate head of bed to ~30 degrees C. maintain pt on left side with head on pillow D. use continuous-rotation bed to continually change pt position

B. elevate head of bed to ~30 degrees

The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that A. a lack of clotting factors promotes the collection of blood in the abdominal cavity B. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space C. decreased peristalsis in the GI tract contribute to gas formation and distention of the bowel D. bile salts in the blood irritate peritoneal membranes causing edema and pocketing of fluid

B. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space

78-year-old man with confusion, temp 104. He is diabeticx with purulent drainage from the right heel. After 3L infusion of NS BP is 84/40, HR 110, RR 42 and shallow, CO 8L/min and PAWP 4mmHg. This is most indicative of A. sepsis B. septic shock C. multiple organ dysfunction syndrome D. systemic inflammatory response syndrome

B. septic shock

A pt with spinal cord injury is experiencing severe neurologic deficits. What is the most likely mechanism of injury for this patient A. Compression B. hyperextension C. Flexion-rotation D. Extension-rotation

C. Flexion-rotation

DIC is a disorder in which A. the coagulation pathway is genetically altered, leading to thrombus formation in all major blood vessels B. an underlying disease depletes hemolytic factors in the bllod, leading to diffuse thrombotic episodes and infarct C. a disease process stimulates coagulation processes with resultant thrombosis, as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage. D. an inherited predisposition causes a deficiency of clotting factors that leads to overstimulation of coagulation processes in the vasculature.

C. a disease process stimulates coagulation processes with resultant thrombosis, as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage.

Maintenance of fluid balance in the patient with ARDS involves A. hydration using colloids B. administration of surfactant C. fluid restriction and diuretics as necessary D. keeping hemoglobin at levels above 9 g/dL

C. fluid restriction and diuretics as necessary

typical fluid replacement for the patient with a fluid volume deficit A. dextran B. 0.45% saline C. lactated ringers D. 5% dex in 0.45 saline

C. lactated ringers

nursing management of a pt with an artificial airway includes A. maintaining ET tube cuff pressure at 30 cm H2O B. routine suctioning of the tube at least every 2 hours C. observing for cardiac dysrhythmias during suctioning D. preventing tube dislodgement by limiting mouth care to lubrication of the lips

C. observing for cardiac dysrhythmias during suctioning

To assess the patency of a newly placed arteriovenous graft for dialysis, the nurse should (select all that apply) A. monitor BP in the affected arm B. irrigate the graft daily with low-dose heparin C. palpate the area of the graft to feel a normal thrill D. listen with a stethoscope over the graft to detect a bruit E. frequently monitor the pulses and neurovascular status distal to the graft

C. palpate the area of the graft to feel a normal thrill D. listen with a stethoscope over the graft to detect a bruit E. frequently monitor the pulses and neurovascular status distal to the graft

the nurse monitors the pt with positive pressure mechanical ventilation for A. paralyutic ileus because the pressure on the abdominal contents affects bowel motility B. diuresis and Na depletion because of increased release of ANP C. signs of CV insufficiency because pressure in the chest impedes venous return D. respiratory acidosis in a pt with COPD because of alveolar hyperventilation and increased PaO2 levels.

C. signs of CV insufficiency because pressure in the chest impedes venous return

The nurse monitors the patient with positive pressure mechanical ventillation for A. paralytic ileus because pressure on the abdominal contents affects bowel motility B. diuresis and sodium depletion because of increased release of atrial natriuretic peptide C. signs of cardiovascular insufficiency because pressure in the chest impedes venous return D. respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO2 levels

C. signs of cardiovascular insufficiency because pressure in the chest impedes venous return

A pt with C7 injury says "I think I have the flu cause I have a bad headache". Nurse's first priority is A. call HCP B. check pt temperature C. take pt's blood pressure D. elevate head of the bed to 90 degrees

C. take pt's blood pressure

Which intervention is most likely to prevent or limit barotrauma in a patient with ARDS who is mechanically ventilated A. decreasing PEEP B. increasing tidal volume C. use of permissive hypercapnia D. use of positive pressure ventillation

C. use of permissive hypercapnia

What accurately describes rejection following transplantation? A. hyperacute rejection can be treated with OKT3 B. acute rejection can be treated with sirolimus or tacrolimus C. chronic rejection can be treated with tacrolimus or cyclosporine D. hyperacute reaction can usually be avoided if crossmatching is done before the transplant

D. hyperacute reaction can usually be avoided if crossmatching is done before the transplant

The nurse is unable to flush a CVAD and suspects occlusion. The best intervention would be to A. apply warm moist compress to the insertion site B. attempt to force 10mL NS into the device C. place pt on left side with head-down position D. instruct pt to change position, raise arm, and cough

D. instruct pt to change position, raise arm, and cough

The O2 delivery system for patient in respiratory failure should A. always be low-flow device (NC or face mask) B. administer continuous positive pressure ventilation to prevent CO2 narcosis C. correct the PaO2 to a normal level as quickly as possible using mechanical ventilation D. maintain the PaO2 at greater than or equal to 60 mmHg at the lowest O2 concentration possible

D. maintain the PaO2 at greater than or equal to 60 mmHg at the lowest O2 concentration possible