Med surg exam 2

1. A client in the intensive care unit with acute kidney injury (AKI) must maintain a mean arterial pressure (MAP) of 65 mm Hg to promote kidney perfusion. What is the clients MAP if the blood pressure is 98/50 mm Hg? (Record your answer using a whole number.) _____ mm Hg

ANS: 66 mm Hg

2. A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best? a. Being able to sleep doesnt mean pain doesnt exist. b. Have you ever experienced any type of pain? c. The client should be assessed for drug addiction. d. Youre right; I would put the medication back.

ANS: A A clients description is the most accurate assessment of pain. The nurse should believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them should not supersede the clients descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant, and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the clients report of pain serves no useful purpose

24. A postoperative client is reluctant to participate in physical therapy. What action by the nurse is best? a. Ask the client about pain goals and if they are being met. b. Ask the client why he or she is being uncooperative with therapy. c. Increase the dose of analgesia given prior to therapy sessions. d. Tell the client that physical therapy is required to regain function.

ANS: A A comprehensive pain management plan includes the clients goals for pain control. Adequate pain control is necessary to allow full participation in therapy. The first thing the nurse should do is to ask about the clients pain goals and if they are being met. If not, an adjustment to treatment can be made. If they are being met, the nurse can assess for other factors influencing the clients behavior. Asking the client why he or she is being uncooperative is not the best response for two reasons. First, why questions tend to put people on the defensive. Second, labeling the behavior is inappropriate. Simply increasing the pain medication may not be advantageous. Simply telling the client that physical therapy is required does not address the issue.

1. A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure? a. A 36-year-old woman with aortic stenosis b. A 42-year-old man with pulmonary hypertension c. A 59-year-old woman who smokes cigarettes daily d. A 70-year-old man who had a cerebral vascular accident

ANS: A Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.

6. A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this clients teaching? a. Avoid using salt substitutes. b. Take your medication with food. c. Avoid using aspirin-containing products. d. Check your pulse daily.

ANS: A Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the clients pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated.

4. A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.

ANS: A Anxiety can interfere with learning and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious.

9. A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia. The client scores a zero. What action by the nurse is best? a. Assess physiologic indicators and vital signs. b. Do not give pain medication as no pain is indicated. c. Document the findings and continue to monitor. d. Try a small dose of analgesic medication for pain.

ANS: A Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this population. The nurse should next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean the client does not have pain; he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for effectiveness. However, if the client has a condition that could reasonably cause pain (i.e., recent surgery), the nurse does need to treat the client for pain.

7. A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm

ANS: A Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the circulation assessment, as is cardiac rhythm.

11. A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? a. Assess the clients respiratory status. b. Draw blood to assess the clients serum electrolytes. c. Administer intravenous furosemide (Lasix). d. Ask the client about current medications.

ANS: A Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take priority over assessing respiratory status.

26.A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The clients blood glucose level is 160 mg/dL. Which action should the nurse take? a. Document the finding in the clients chart. b. Administer a bolus of regular insulin IV. c. Call the surgeon to cancel the procedure. d. Draw blood gases to assess the metabolic state.

ANS: A Clients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL throughout the perioperative period. The nurse should document the finding and proceed with other operative care. The need for a bolus of insulin, canceling the procedure, or drawing arterial blood gases is not required.

5. A nurse cares for a client with right-sided heart failure. The client asks, Why do I need to weigh myself every day? How should the nurse respond? a. Weight is the best indication that you are gaining or losing fluid. b. Daily weights will help us make sure that youre eating properly. c. The hospital requires that all inpatients be weighed daily. d. You need to lose weight to decrease the incidence of heart failure.

ANS: A Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds. The other responses do not address the importance of monitoring fluid retention or loss.

16. The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates more teaching is needed? a. I am thrilled that I can continue to eat fast food. b. I will cut out bacon with my eggs every morning. c. My cooking style will change by not adding salt. d. I will probably lose weight by cutting out potato chips.

ANS: A Fast food restaurants usually serve food that is high in sodium. This statement indicates that more teaching needs to occur. The other statements show a correct understanding of the teaching

8. A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer? a. Flumazenil (Romazicon) 0.2 to 1 mg b. Flumazenil (Romazicon) 2 to 10 mg c. Naloxone (Narcan) 0.4 to 2 mg d. Naloxone (Narcan) 4 to 20 mg

ANS: A Flumazenil is a benzodiazepine antagonist and would be the correct drug to use in this situation. The correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist.

12. A client in the operating room has developed malignant hyperthermia. The clients potassium is 6.5 mEq/L. What action by the nurse takes priority? a. Administer 10 units of regular insulin. b. Administer nifedipine (Procardia). c. Assess urine for myoglobin or blood. d. Monitor the client for dysrhythmias.

ANS: A For hyperkalemia in a client with malignant hyperthermia, the nurse administers 10 units of regular insulin in 50 mL of 50% dextrose. This will force potassium back into the cells rapidly. Nifedipine is a calcium channel blocker used to treat hypertension and dysrhythmias, and should not be used in a client with malignant hyperthermia. Assessing the urine for blood or myoglobin is important, but does not take priority. Monitoring the client for dysrhythmias is also important due to the potassium imbalance, but again does not take priority over treating the potassium imbalance.

12. A client is taking furosemide (Lasix) 40 mg/day for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best? a. Obtain daily weights of the client. b. Auscultate heart and breath sounds. c. Palpate the clients abdomen. d. Assess the clients diet history.

ANS: A Furosemide (Lasix) is a loop diuretic that helps reduce fluid overload and hypertension in clients with early stages of CKD. One kilogram of weight equals about 1 liter of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication. Heart and breath sounds should be assessed if there is fluid retention, as in heart failure. Palpation of the clients abdomen is not necessary, but the nurse should check for edema. The diet history of the client would be helpful to assess electrolyte replacement since potassium is lost with this diuretic, but this does not assess the effect of the medication.

6.A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this clients plan of care to delay the onset of microvascular and macrovascular complications? a. Maintain tight glycemic control and prevent hyperglycemia. b. Restrict your fluid intake to no more than 2 liters a day. c. Prevent hypoglycemia by eating a bedtime snack. d. Limit your intake of protein to prevent ketoacidosis.

ANS: A Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Restricting fluid intake is not part of the treatment plan for clients with diabetes. Preventing hypoglycemia and ketosis, although important, are not as important as maintaining daily glycemic control.

8. A client in the intensive care unit is started on continuous venovenous hemofiltration (CVVH). Which finding is the cause of immediate action by the nurse? a. Blood pressure of 76/58 mm Hg b. Sodium level of 138 mEq/L c. Potassium level of 5.5 mEq/L d. Pulse rate of 90 beats/min

ANS: A Hypotension can be a problem with CVVH if replacement fluid does not provide enough volume to maintain blood pressure. The specially trained nurse needs to monitor for ongoing fluid and electrolyte replacement. The sodium level is normal and the potassium level is slightly elevated, which could be normal findings for someone with acute kidney injury. A pulse rate of 90 beats/min is normal.

3. A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate? a. Assess other indicators of oxygenation. b. Call the Rapid Response Team. c. Notify the anesthesia provider. d. Prepare to intubate the client.

ANS: A If a postoperative clients oxygen saturation (SaO2) drops below 95% (or the clients baseline), the nurse should notify the anesthesia provider. If the SaO2 drops by 10% or more, the nurse should call the Rapid Response Team. Since this is approximately a 3% drop, the nurse should further assess the client. Intubation (if the client is not intubated already) is not warranted.

24.After teaching a client who is recovering from pancreas transplantation, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional education? a. If I develop an infection, I should stop taking my corticosteroid. b. If I have pain over the transplant site, I will call the surgeon immediately. c. I should avoid people who are ill or who have an infection. d. I should take my cyclosporine exactly the way I was taught.

ANS: A Immunosuppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immunosuppressive therapy endangers the transplanted organ. The other statements are correct. Pain over the graft site may indicate rejection. Anti-rejection drugs cause immunosuppression, and the client should avoid crowds and people who are ill. Changing the routine of anti- rejection medications may cause them to not work optimally.

42.A nurse prepares to administer insulin to a client at 1800. The clients medication administration record contains the following information: Insulin glargine: 12 units daily at 1800 Regular insulin: 6 units QID at 0600, 1200, 1800, 2400 Based on the clients medication administration record, which action should the nurse take? a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. b. Draw up and inject the insulin glargine first, wait 20 minutes, and then draw up and inject the regular insulin. c. First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together. d. First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together.

ANS: A Insulin glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an unpredictable alteration in the onset of action and time to peak action. The correct instruction is to draw up and inject first the glargine and then the regular insulin right afterward.

15.A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, Can I ask my niece to prefill my syringes and then store them for later use when I need them? How should the nurse respond? a. Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up. b. Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light. c. Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes. d. No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container.

ANS: A Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled plastic syringes are stable for up to 3 weeks. They should be stored in the refrigerator in the vertical position with the needle pointing up to prevent suspended insulin particles from clogging the needle.

18.An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102 F (38.9 C) d. Severe orthostatic hypotension

ANS: A Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation. Tremors, elevated temperature, and orthostatic hypotension are not associated with ketoacidosis.

20. An emergency department (ED) manager wishes to start offering clients nonpharmacologic pain control methodologies as an adjunct to medication. Which strategy would be most successful with this client population? a. Listening to music on a headset b. Participating in biofeedback c. Playing video games d. Using guided imagery

ANS: A Listening to music on a headset would be the most successful cognitive-behavioral pain control method for several reasons. First, in the ED, the nurse does not have time to teach clients complex modalities such as guided imagery or biofeedback. Second, clients who are anxious and in pain may not have good concentration, limiting the usefulness of video games. Playing music on a headset only requires the client to wear the headset and can be beneficial without strong concentration. A wide selection of music will make this appealing to more people.

6. A client is having surgery. The circulating nurse notes the clients oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best? a. Assess the clients end-tidal carbon dioxide level. b. Document the findings in the clients chart. c. Inform the anesthesia provider of these values. d. Prepare to administer dantrolene sodium (Dantrium).

ANS: A Malignant hyperthermia is a rare but serious reaction to anesthesia. The triad of early signs include decreased oxygen saturation, tachycardia, and elevated end-tidal carbon dioxide (CO2) level. The nurse should quickly check the end-tidal CO2 and then report findings to the anesthesia provider and surgeon. Documentation is vital, but not the most important action at this stage. Dantrolene sodium is the drug of choice if the client does have malignant hyperthermia.

10. A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client? a. Allow the client to keep hearing aids in until anesthesia begins. b. Pad the table as appropriate for the surgical procedure. c. Position the client for maximum visualization of the site. d. Stay with the client, providing emotional comfort and support.

ANS: A Many older clients have sensory loss. To help prevent disorientation, facilities often allow older clients to keep their eyeglasses on and hearing aids in until the start of anesthesia. The other actions are appropriate for all operative clients.

1. An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment? a. Change in behavior b. Daily white blood cell count c. Presence of fever and chills d. Tolerance of increasing activity

ANS: A Older people have an age-related decrease in immune system functioning and may not show classic signs of infection such as increased white blood cell count, fever and chills, or obvious localized signs of infection. A change in behavior often signals an infection or onset of other illness in the older client.

15. A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern? a. Albumin level of 2.5 g/dL b. Phosphorus level of 5 mg/dL c. Sodium level of 135 mmol/L d. Potassium level of 5.5 mmol/L

ANS: A Protein restriction is necessary with chronic renal failure due to the buildup of waste products from protein breakdown. The nurse would be concerned with the low albumin level since this indicates that the protein in the diet is not enough for the clients metabolic needs. The electrolyte values are not related to the protein- restricted diet.

5.A nurse cares for a client who has a family history of diabetes mellitus. The client states, My father has type 1 diabetes mellitus. Will I develop this disease as well? How should the nurse respond? a. Your risk of diabetes is higher than the general population, but it may not occur. b. No genetic risk is associated with the development of type 1 diabetes mellitus. c. The risk for becoming a diabetic is 50% because of how it is inherited. d. Female children do not inherit diabetes mellitus, but male children will.

ANS: A Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and HLA-DQ tissue types. Clients who have one parent with type 1 diabetes are at increased risk for its development. Diabetes (type 1) seems to require interaction between inherited risk and environmental factors, so not everyone with these genes develops diabetes. The other statements are not accurate.

13. A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best? a. A rapid heart rate requires more effort by the heart. b. Anesthesia has bad effects if the client is tachycardic. c. The client may have an undiagnosed heart condition. d. When the heart rate goes up, the blood pressure does too.

ANS: A Tachycardia increases the workload of the heart and requires more oxygen delivery to the myocardial tissues. This added strain is not needed on top of the physical and emotional stress of surgery. The other statements are not accurate.

8. A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate? a. Facilitate marking the site with the client and surgeon. b. Have the client mark the operative site. c. Mark the operative site with a waterproof marker. d. Tell the surgeon it is time to mark the surgical site.

ANS: A The Joint Commission now recommends that both the client and the surgeon mark the operative site together in order to prevent wrong-site surgery. The nurse should facilitate this process.

14. The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices.

ANS: A The SCIP project contains core measures that are mandatory for all surgical clients and focuses on preventing infection, serious cardiac events, and venous thromboembolism. The managers should start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation.

Which statement made by the client indicates a need for additional teaching? a. The lower abdomen is the best location because it is closest to the pancreas. b. I can reach my thigh the best, so I will use the different areas of my thighs. c. By rotating the sites in one area, my chance of having a reaction is decreased. d. Changing injection sites from the thigh to the arm will change absorption rates.

ANS: A The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas. The other statements are accurate assessments of insulin administration.

15. A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use? a. Standard Precautions b. Bleeding precautions c. Reverse isolation d. Contact isolation

ANS: A The client with infective endocarditis does not pose any specific threat of transmitting the causative organism. Standard Precautions should be used. Bleeding precautions or reverse or contact isolation is not necessary.

14.A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first? a. Administer 1 mg of intramuscular glucagon. b. Encourage the client to drink orange juice. c. Insert a new intravenous access line. d. Administer 25 mL dextrose 50% (D50) IV push

ANS: A The clients blood glucose level is dangerously low. The nurse needs to administer glucagon IM immediately to increase the clients blood glucose level. The nurse should insert a new IV after administering the glucagon and can use the new IV site for future doses of D50 if the clients blood glucose level does not rise. Once the client is awake, orange juice may be administered orally along with a form of protein such as a peanut butter.

11. A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse? a. Discuss what the treatment regimen means to him. b. Refer the client to a mental health nurse practitioner. c. Reschedule the appointments to another date and time. d. Discuss the option of peritoneal dialysis

ANS: A The initial action for the nurse is to assess anxiety, coping styles, and the clients acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all viable options, assessment of the clients acceptance of the treatment should come first.

16. A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best? a. Ask the client to describe current feelings. b. Determine if the client wants a chaplain. c. Reassure the client this surgery is common. d. Tell the client there is no need to be anxious.

ANS: A The nurse needs to conduct further assessment of the clients anxiety. Asking open-ended questions about current feelings is an appropriate way to begin. The client may want a chaplain, but the nurse needs to do more for the client. Reassurance can be good, but false hope is not, and simply reassuring the client may not be helpful. Telling the client not to be anxious belittles the clients feelings.

18. A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate? a. Explain the rationale for giving the medicine now. b. Leave the room and come back in 15 minutes. c. Provide holistic client care and come back later. d. Tell the client you must start the medication now.

ANS: A The preoperative antibiotic must be given within 60 minutes of the surgical start time to ensure the proper amount is in the tissues when the incision is made. The nurse should explain the rationale to the client for this timing. The other options do not take this timing into consideration and do not give the client the information needed to be cooperative.

4. While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.

ANS: A The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.

6. A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse? a. Place the client on a cardiac monitor immediately. b. Teach the client to limit high-potassium foods. c. Continue to monitor the clients intake and output. d. Ask to have the laboratory redraw the blood specimen.

ANS: A The priority action by the nurse should be to check the cardiac status with a monitor. High potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action

3. A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question should the nurse ask first when taking this clients history? a. Have you been taking any aspirin, ibuprofen, or naproxen recently? b. Do you have anyone in your family with renal failure? c. Have you had a diet that is low in protein recently? d. Has a relative had a kidney transplant lately?

ANS: A There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the client since both the serum creatinine and BUN are elevated, indicating some renal problems. A family history of renal failure and kidney transplantation would not be part of the questioning and could cause anxiety in the client. A diet high in protein could be a factor in an increased BUN

18. A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best? a. Check the clients digoxin (Lanoxin) level. b. Administer an anti-nausea medication. c. Ask if the client is able to eat crackers. d. Get a referral to a gastrointestinal provider.

ANS: A These signs and symptoms are indications of digoxin (Lanoxin) toxicity. The nurse should check the level of this medication. Administering antiemetics, asking if the client can eat, and obtaining a referral to a specialist all address the clients symptoms but do not lead to the cause of the symptoms.

2. A marathon runner comes into the clinic and states I have not urinated very much in the last few days. The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority? a. Give the client a bottle of water immediately. b. Start an intravenous line for fluids. c. Teach the client to drink 2 to 3 liters of water daily. d. Perform an electrocardiogram.

ANS: A This athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure. The nurse can start hydrating the client with a bottle of water first, followed by teaching the client to drink 2 to 3 liters of water each day. An intravenous line may be ordered later, after the clients degree of dehydration is assessed. An electrocardiogram is not necessary at this time

15. A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a. Consult the surgeon about a postoperative dietitian referral. b. Document the findings thoroughly in the clients chart. c. Encourage the client to eat more after recovering from surgery. d. Refer the client to Meals on Wheels after discharge.

ANS: A This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the surgeon about prescribing a consultation with a dietitian in the postoperative period. The nurse should document the findings but needs to do more. Encouraging the client to eat more may be helpful, but the client needs a professional nutritional assessment so that the appropriate diet and supplements can be ordered. The client may or may not need Meals on Wheels after discharge.

31.A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the clients clinical manifestations have not changed. Which action should the nurse take next? a. Administer another half-cup of orange juice. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg of glucagon intramuscularly.

ANS: A This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse should administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment should be repeated. The client does not need intravenous dextrose, insulin, or glucagon.

7. The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is on the light constantly asking for more pain medication. When assessing this clients pain, what statement or question by the nurse is most appropriate? a. Help me understand how pain is affecting you right now. b. I wish I could do more; is there anything I can get for you? c. You cannot have more pain medication for 3 hours. d. Why do you think the medication is not helping your pain?

ANS: A This is an example of therapeutic communication. A client who is preoccupied with physical symptoms and is demanding may have some psychosocial impact from the pain that is not being addressed. The nurse is providing the client the chance to explain the emotional effects of pain in addition to the physical ones. Saying the nurse wishes he or she could do more is very empathetic, but this response does not attempt to learn more about the pain. Simply telling the client when the next medication is due also does not help the nurse understand the clients situation. Why questions are probing and often make clients defensive, plus the client may not have an answer for this question.

4.A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? (Select all that apply.) a. Stroke b. Kidney failure c. Blindness d. Respiratory failure e. Cirrhosis

ANS: A, B, C Complications of diabetes mellitus are caused by macrovascular and microvascular changes. Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Microvascular complications include nephropathy, retinopathy, and neuropathy. Respiratory failure and cirrhosis are not complications of diabetes mellitus.

1. The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.) a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis d. Firefighter with severe burns e. Young woman with lupus

ANS: A, B, C Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes post-renal AKI. Severe burns would be a pre-renal cause. Lupus would be an intrarenal cause for AKI.

6. A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes

ANS: A, B, C, D Older adults have many age-related physiologic changes that put them at higher risk of falling and other complications after surgery. Some of these include decreased cardiac output, decreased oxygenation of tissues, nocturia, and mobility alterations. They also have a decreased ability to adapt to new surroundings, but that is not the same as being unable to adapt.

5. What actions by the circulating nurse are important to promote client comfort? (Select all that apply.) a. Correct positioning b. Introducing ones self c. Providing warmth d. Remaining present e. Removing hearing aids

ANS: A, B, C, D The circulating nurse can do many things to promote client comfort, including positioning the client correctly and comfortably, introducing herself or himself to the client, keeping the client warm, and remaining present with the client. Removing hearing aids does not promote comfort and, if the client is still awake when they are removed, may contribute to disorientation and anxiety.

5. A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.) a. Apply stimulation to the contralateral leg. b. Assess the clients willingness to try meditation. c. Elevate the clients operative leg and apply ice. d. Reduce the noise level in the clients environment. e. Turn the TV on loudly to distract the client.

ANS: A, B, C, D There are many nonpharmacologic comfort measures for pain, including applying stimulation to the opposite leg, providing opportunities for meditation, elevation of the leg, applying ice, and reducing noxious stimuli in the environment. Participating in diversional activities is another approach, but simply turning the TV on loudly does not provide a good diversion.

3. A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the clients plan of care to minimize the potential for this occurring? (Select all that apply.) a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. d. Place the client in a room secluded at the end of the hall. e. Provide the client with uninterrupted periods of sleep.

ANS: A, B, C, E Older clients may have difficulty adjusting to the stress of the hospital environment and illness or surgery. Techniques that are helpful include allowing liberal visitation, assisting the client to use successful coping techniques, and keeping the client bathed and groomed. Sleep deprivation can contribute to confusion, so the nurse ensures the client receives adequate sleep. Secluding the client at the end of the hall may lead to sensory deprivation and loneliness.

3. The circulating nurse reviews the days schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include? (Select all that apply.) a. A 75-year-old client scheduled for an elective procedure b. Client who drinks a 6-pack of beer each day c. Client with a serum creatinine of 3.8 mg/dL d. Client who is taking birth control pills e. Young male client with a RYR1 gene mutation

ANS: A, B, C, E People at higher risk for anesthetic overdose or other anesthesia-related complications include people with a slowed metabolism (older adults generally have slower metabolism than younger adults), those with kidney or liver impairments, and those with mutations of the RYR1 gene. Drinking a 6-pack of beer per day possibly indicates some liver disease; a creatinine of 3.8 is high, indicating renal disease; and the genetic mutation increases the chance of malignant hyperthermia. Taking birth control pills is not a risk factor.

4. A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.) a. Check all over-the-counter medications for acetaminophen. b. Do not take more pills each day than you are prescribed. c. Eat a diet that is high in fiber and drink lots of water. d. If this gives you diarrhea, loperamide (Imodium) can help. e. You shouldnt drive while you are taking this medication.

ANS: A, B, C, E Percocet is a common opioid analgesic that contains acetaminophen. The client should be taught to check all over-the-counter medications for acetaminophen and to not take more than the prescribed amount of Percocet, as the maximum daily dose of acetaminophen is 3000 mg. Percocet, like all opioid analgesics, can cause constipation, and the client can minimize this by eating a high-fiber diet and drinking plenty of water. Since Percocet can cause drowsiness, the client taking it should not drive or operate machinery. The medication is more likely to cause constipation than diarrhea.

6. A client is undergoing hemodialysis. The clients blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.) a. Adjust the rate of extracorporeal blood flow. b. Place the client in the Trendelenburg position. c. Stop the hemodialysis treatment. d. Administer a 250-mL bolus of normal saline. e. Contact the health care provider for orders.

ANS: A, B, D Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Modest decreases in blood pressure, as is the case with this client, can be maintained with rate adjustment, Trendelenburg positioning, and a fluid bolus. If the blood pressure drops considerably after two boluses and cooling dialysate, the hemodialysis can be stopped and the health care provider contacted.

7. A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? (Select all that apply.) a. You will not need vascular access to perform PD. b. There is less restriction of protein and fluids. c. You will have no risk for infection with PD. d. You have flexible scheduling for the exchanges. e. It takes less time than hemodialysis treatments.

ANS: A, B, D PD is based on exchanges of waste, fluid, and electrolytes in the peritoneal cavity. There is no need for vascular access. Protein is lost in the exchange, which allows for more protein and fluid in the diet. There is flexibility in the time for exchanges, but the treatment takes a longer period of time compared to hemodialysis. There still is risk for infection with PD, especially peritonitis.

5.A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members should the nurse include in this interdisciplinary team meeting? (Select all that apply.) a. Registered dietitian b. Clinical pharmacist c. Occupational therapist d. Health care provider e. Speech-language pathologist

ANS: A, B, D When planning care for a client newly diagnosed with diabetes mellitus, the nurse should collaborate with a registered dietitian, clinical pharmacist, and health care provider. The focus of treatment for a newly diagnosed client would be nutrition, medication therapy, and education. The nurse could also consult with a diabetic educator. There is no need for occupational therapy or speech therapy at this time.

7. A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.) a. Allow the client to assume a position of comfort. b. Allow the clients family to remain at the bedside. c. Give the client a warm, non-caffeinated drink. d. Provide warm blankets or cool washcloths as desired. e. Pull the curtains around the bed to provide privacy.

ANS: A, B, D, E There are many nonpharmacologic comfort measures the nurse can employ, such as allowing the client to remain in the position that is most comfortable, letting the family stay with the client, providing warmth or cooling measures as requested by the client, and providing privacy. The client in the preoperative holding area is NPO, No so drinks should not be provided.

5. A student nurse learns that there are physical consequences to unrelieved pain. Which factors are included in this problem? (Select all that apply.) a. Decreased immune response b. Development of chronic pain c. Increased gastrointestinal (GI) motility d. Possible immobility e. Slower healing

ANS: A, B, D, E There are many physiologic impacts of unrelieved pain, including decreased immune response; development of chronic pain; decreased GI motility; immobility; slower healing; prolonged stress response; and increased heart rate, blood pressure, and oxygen demand.

4. A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.) a. Assessing distal circulation to the operative arm after positioning b. Keeping the client warm during the operative procedure c. Padding the clients shoulder and arm on the operating table d. Preparing to suction the clients airway if the client vomits e. Speaking in a low, quiet voice as anesthesia is administered

ANS: A, C After regional anesthesia is administered, the client loses all sensation distally. The nurse ensures client safety by assessing distal circulation and padding the shoulder and arm appropriately. Although awake, the client will not be able to report potential injury. Keeping the client warm is not related to this anesthesia, nor is suctioning or speaking quietly.

3.A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Do not walk around barefoot. b. Soak your feet in a tub each evening. c. Trim toenails straight across with a nail clipper. d. Treat any blisters or sores with Epsom salts. e. Wash your feet every other day.

ANS: A, C Clients who have diabetes mellitus are at high risk for wounds on the feet secondary to peripheral neuropathy and poor arterial circulation. The client should be instructed to not walk around barefoot or wear sandals with open toes. These actions place the client at higher risk for skin breakdown of the feet. The client should be instructed to trim toenails straight across with a nail clipper. Feet should be washed daily with lukewarm water and soap, but feet should not be soaked in the tub. The client should contact the provider immediately if blisters or sores appear and should not use home remedies to treat these wounds.

3. A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.) a. Metformin (Glucophage) b. Omega-3 fatty acids (Sea Omega 30) c. Phenytoin (Dilantin) d. Pilocarpine hydrochloride (Isopto Carpine) e. Warfarin (Coumadin)

ANS: A, C, D, E Although the client will be on NPO status before surgery, the nurse should check with the provider about allowing the client to take medications prescribed for diabetes, hypertension, cardiac disease, seizure disorders, depression, glaucoma, anticoagulation, or depression. Metformin is used to treat diabetes; phenytoin is for seizures; pilocarpine is for glaucoma, and warfarin is an anticoagulant. The omega-3 fatty acids can be held the day of surgery.

5. A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.) a. A malnourished client will have fragile skin. b. Malnourished clients always have other problems. c. Many drugs are bound to protein in the body. d. Protein stores are needed for wound healing. e. Weakness and fatigue are common in malnutrition.

ANS: A, C, D, E Malnutrition can lead to poorer surgical outcomes for several reasons, including fragile skin that might break down, altered pharmacokinetics, poorer wound healing, and weakness or fatigue that can interfere with recovery. Malnutrition can exist without other comorbidities.

6. A nursing student is studying pain sources. Which statements accurately describe different types of pain? (Select all that apply.) a. Neuropathic pain sometimes accompanies amputation. b. Nociceptive pain originates from abnormal pain processing. c. Deep somatic pain is pain arising from bone and connective tissues. d. Somatic pain originates from skin and subcutaneous tissues. e. Visceral pain is often diffuse and poorly localized.

ANS: A, C, D, E Neuropathic pain results from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can arise from superficial sources such as skin, or deep sources such as bone and connective tissues. Visceral pain originates from organs or their linings and is often diffuse and poorly localized. Nociceptive pain is normal pain processing and consists of somatic and visceral pain.

7. A nurse on the postoperative unit administers many opioid analgesics. What actions by the nurse are best to prevent unwanted sedation as a complication of these medications? (Select all that apply.) a. Avoid using other medications that cause sedation. b. Delay giving medication if the client is sleeping. c. Give the lowest dose that produces good control. d. Identify clients at high risk for unwanted sedation. e. Use an oximeter to monitor clients receiving analgesia.

ANS: A, C, D, E Sedation is a side effect of opioid analgesics. Some sedation can be expected, but protecting the client against unwanted and dangerous sedation is a critical nursing responsibility. The nurse should identify clients at high risk for unwanted sedation and give the lowest possible dose that produces satisfactory pain control. Avoid using other sedating medications such as antihistamines to treat itching. An oximeter can alert the nurse to a decrease in the clients oxygen saturation, which often follows sedation. A postoperative client frequently needs to be awakened for pain medication in order to avoid waking to out-of-control pain later.

2.A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension

ANS: A, C, E DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.

3. A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the clients spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.) a. Lower sodium b. Higher calcium c. Lower potassium d. Higher phosphorus e. Higher calories

ANS: A, C, E Many clients with AKI are too ill to meet caloric goals and require tube feedings with kidney-specific formulas that are lower in sodium, potassium, and phosphorus, and higher in calories than are standard formulas.

2. A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.) a. Urine output of 100 mL in 4 hours b. Urine output of 500 mL in 12 hours c. Large amount of sediment in the urine d. Amber, odorless urine e. Blood pressure of 90/60 mm Hg

ANS: A, C, E The low urine output, sediment, and blood pressure should be reported to the provider. Postoperatively, the nurse should measure intake and output, check the characteristics of the urine, and report sediment, hematuria, and urine output of less than 0.5 mL/kg/hour for 3 to 4 hours. A urine output of 100 mL is low, but a urine output of 500 mL in 12 hours should be within normal limits. Perfusion to the kidneys is compromised with low blood pressure. The amber odorless urine is normal.

8. A client reports a great deal of pain following a fairly minor operation. The surgeon leaves a prescription for the nurse to administer a placebo instead of pain medication. What actions by the nurse are most appropriate? (Select all that apply.) a. Consult with the prescriber and voice objections. b. Delegate administration of the placebo to another nurse. c. Give the placebo and reassess the clients pain. d. Notify the nurse manager of the physicians request. e. Tell the client what the prescriber ordered.

ANS: A, D Nurses should never give placebos to treat a clients pain (unless the client is in a research study). This practice is unethical and, in many states, illegal. The nurse should voice concerns with the prescriber and, if needed, contact the nurse manager. The nurse should not delegate giving the placebo to someone else, nor should the nurse give it. The nurse should not tell the client unless absolutely necessary (the client asks) as this will undermine the prescriber-client relationship.

2. A faculty member explains the concepts of addiction, tolerance, and dependence to students. Which information is accurate? (Select all that apply.) a. Addiction is a chronic physiologic disease process. b. Physical dependence and addiction are the same thing. c. Pseudoaddiction can result in withdrawal symptoms. d. Tolerance is a normal response to regular opioid use. e. Tolerance is said to occur when opioid effects decrease.

ANS: A, D, E Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with a neurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seen when the effect of the analgesic decreases (either therapeutic effect or side effects). Dependence and addiction are not the same; dependence occurs with regular administration of analgesics and can result in withdrawal symptoms when they are discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease.

1. A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.) a. Dressing the surgical wound b. Grafting new or synthetic skin c. Reattaching severed nerves d. Suctioning the surgical site e. Suturing the surgical wound

ANS: A, D, E The CRNFA can perform tasks under the direction of the surgeon such as suturing and dressing surgical wounds, cutting away tissue, suctioning the wound to improve visibility, and holding retractors. Reattaching severed nerves and performing grafts would be the responsibility of the surgeon.

1.A nurse assesses clients at a health fair. Which clients should the nurse counsel to be tested for diabetes? (Select all that apply.) a. 56-year-old African-American male b. Female with a 30-pound weight gain during pregnancy c. Male with a history of pancreatic trauma d. 48-year-old woman with a sedentary lifestyle e. Male with a body mass index greater than 25 kg/m2 f. 28-year-old female who gave birth to a baby weighing 9.2 pounds

ANS: A, D, E, F Risk factors for type 2 diabetes include certain ethnic/racial groups (African Americans, American Indians, Hispanics), obesity and physical inactivity, and giving birth to large babies. Pancreatic trauma and a 30-pound gestational weight gain are not risk factors.

2. The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.) a. Ensuring the clients safety b. Accounting for all sharps c. Documenting all care given d. Maintaining the sterile field e. Monitoring traffic in the room

ANS: A, E The circulating nurse has several functions, including maintaining client safety and privacy, monitoring traffic in and out of the operating room, assessing fluid losses, reporting findings to the surgeon and anesthesia provider, anticipating needs of the team, and communicating to the family. The circulating nurse and scrub person work together to ensure accurate counts of sharps, sponges, and instruments. The circulating nurse also documents care, but in the perioperative area, the preoperative or holding room nurse would also document care received there. Maintaining the sterile field is a joint responsibility among all members of the surgical team.

20. The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse? a. My sodium level changes by movement from the blood into the dialysate. b. Dialysis works by movement of wastes from lower to higher concentration. c. Extra fluid can be pulled from the blood by osmosis. d. The dialysate is similar to blood but without any toxins.

ANS: B Dialysis works using the passive transfer of toxins by diffusion. Diffusion is the movement of molecules from an area of higher concentration to an area of lower concentration. The other statements show a correct understanding about hemodialysis.

10. A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the clients anxiety. b. Give the client a back rub. c. Remind the client to turn. d. Teach about postoperative care.

ANS: B A back rub reduces anxiety and can be delegated to the UAP. Once teaching has been done, the UAP can remind the client to turn, but this is not related to relieving anxiety. Assessing anxiety and teaching are not within the scope of practice for the UAP.

8. A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first? a. Client being discharged later on a complicated analgesia regimen b. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale c. Postoperative client who received oral opioid analgesia 45 minutes ago d. Client who has returned from physical therapy and is resting in the recliner

ANS: B Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset abdominal pain needs to be seen first. The postoperative client needs 45 minutes to an hour for the oral medication to become effective and should be seen shortly to assess for effectiveness. The client going home requires teaching, which should be done after the first two clients have been seen and cared for, as this teaching will take some time. The client resting comfortably can be checked on quickly before spending time teaching the client who is going home.

7. After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client? a. Provide food to decrease nausea and aid in absorption. b. Instruct the client to ask for assistance when rising from bed. c. Collaborate with unlicensed assistive personnel to bathe the client. d. Monitor potassium levels and check for symptoms of hypokalemia.

ANS: B Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food. Collaboration with unlicensed assistive personnel to provide hygiene is not a priority. The client should be encouraged to complete activities of daily living as independently as possible. The nurse should monitor for hyperkalemia, not hypokalemia, especially if the client has renal insufficiency secondary to heart failure.

43.A nurse prepares to administer prescribed regular and NPH insulin. Place the nurses actions in the correct order to administer these medications. 1. Inspect bottles for expiration dates. 2. Gently roll the bottle of NPH between the hands. 3. Wash your hands. 4. Inject air into the regular insulin. 5. Withdraw the NPH insulin. 6. Withdraw the regular insulin. 7. Inject air into the NPH bottle. 8. Clean rubber stoppers with an alcohol swab. a. 1, 3, 8, 2, 4, 6, 7, 5 b. 3, 1, 2, 8, 7, 4, 6, 5 c. 8, 1, 3, 2, 4, 6, 7, 5 d. 2, 3, 1, 8, 7, 5, 4, 6

ANS: B After washing hands, it is important to inspect the bottles and then to roll the NPH to mix the insulin. Rubber stoppers should be cleaned with alcohol after rolling the NPH and before sticking a needle into either bottle. It is important to inject air into the NPH bottle before placing the needle in a regular insulin bottle to avoid mixing of regular and NPH insulin. The shorter-acting insulin is always drawn up first.

2. The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority? a. Allergies noted and allergy band on b. Consent for MIS procedure only c. No prior anesthesia exposure d. NPO status for the last 8 hours

ANS: B All MIS procedures have the potential for becoming open procedures depending on findings and complications. The clients consent should include this possibility. The nurse should report this finding to the surgeon prior to surgery taking place. Having allergies noted and an allergy band applied is standard procedure. Not having any prior surgical or anesthesia exposure is not the priority. Maintaining NPO status as prescribed is standard procedure

17. A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client? a. Document giving the drug. b. Raise the siderails on the bed. c. Record the clients vital signs. d. Teach relaxation techniques.

ANS: B All actions are appropriate for a preoperative client. However, for client safety, the nurse should raise the siderails on the bed because hydroxyzine can make the client sleepy.

25. A client is being discharged from the hospital after surgery on hydrocodone and acetaminophen (Lorcet). What discharge instruction is most important for this client? a. Call the doctor if the Lorcet does not relieve your pain. b. Check any over-the-counter medications for acetaminophen. c. Eat more fiber and drink more water to prevent constipation. d. Keep your follow-up appointment with the surgeon as scheduled.

ANS: B All instructions are appropriate for this client. However, advising the client to check over-the-counter medications for acetaminophen is an important safety measure. Acetaminophen is often found in common over-the-counter medications and should be limited to 3000 mg/day.

23.A nurse cares for a client who is diagnosed with acute rejection 2 months after receiving a simultaneous pancreas-kidney transplant. The client states, I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing. How should the nurse respond? a. Following the drug regimen more closely would have prevented this. b. One acute rejection episode does not mean that you will lose the new organs. c. Dialysis is a viable treatment option for you and may save your life. d. Since you are on the national registry, you can receive a second transplantation.

ANS: B An episode of acute rejection does not automatically mean that the client will lose the transplant. Pharmacologic manipulation of host immune responses at this time can limit damage to the organ and allow the graft to be maintained. The other statements either belittle the client or downplay his or her concerns. The client may not be a candidate for additional organ transplantation.

24. A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse? a. Warm the dialysate solution in a microwave before instillation. b. Take a sample of the effluent and send to the laboratory. c. Flush the tubing with normal saline to maintain patency of the catheter. d. Check the peritoneal catheter for kinking and curling.

ANS: B An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse. Checking the catheter for obstruction is a viable option but will not treat the peritonitis.

19. An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication would the nurse plan to educate the client? a. Desipramine (Norpramin) b. Duloxetine (Cymbalta) c. Morphine sulfate d. Nortriptyline (Pamelor).

ANS: B Antidepressants and anticonvulsants often are used for neuropathic pain relief. Morphine would not be used for this client. However, older adults do not tolerate tricyclic antidepressants very well, which eliminates desipramine and nortriptyline. Duloxetine would be the best choice for this older client

1.A nurse is teaching a client with diabetes mellitus who asks, Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL? How should the nurse respond? a. Glucose is the only fuel used by the body to produce the energy that it needs. b. Your brain needs a constant supply of glucose because it cannot store it. c. Without a minimum level of glucose, your body does not make red blood cells. d. Glucose in the blood prevents the formation of lactic acid and prevents acidosis.

ANS: B Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the bodys circulation is needed to meet the fuel demands of the central nervous system. The nurse would want to educate the client to prevent hypoglycemia. The body can use other sources of fuel, including fat and protein, and glucose is not involved in the production of red blood cells. Glucose in the blood will encourage glucose metabolism but is not directly responsible for lactic acid formation.

27. A client is recovering from a kidney transplant. The clients urine output was 1500 mL over the last 12-hour period since transplantation. What is the priority assessment by the nurse? a. Checking skin turgor b. Taking blood pressure c. Assessing lung sounds d. Weighing the client

ANS: B By taking blood pressure, the nurse is assessing for hypotension that could compromise perfusion to the new kidney. The nurse then should notify the provider immediately. Skin turgor, lung sounds, and weight could give information about the fluid status of the client, but they are not the priority assessment.

14. After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the clients understanding. Which client statement indicates a need for additional teaching? a. Ill be able to carry heavy loads after 6 months of rest. b. I will have my teeth cleaned by my dentist in 2 weeks. c. I must avoid eating foods high in vitamin K, like spinach. d. I must use an electric razor instead of a straight razor to shave.

ANS: B Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing a mitral valve replacement surgery, the client needs to be placed on anticoagulant therapy to prevent vegetation forming on the new valve. Clients on anticoagulant therapy should be instructed on bleeding precautions, including using an electric razor. If the client is prescribed warfarin, the client should avoid foods high in vitamin K. Clients recovering from open heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal.

36.After teaching a client with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I need to have an annual appointment even if my glucose levels are in good control. b. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick. c. I can still develop complications even though I do not have to take insulin at this time. d. If I have surgery or get very ill, I may have to receive insulin injections for a short time.

ANS: B Clients with diabetes need to be seen at least annually to monitor for long-term complications, including visual changes, microalbuminuria, and lipid analysis. The client may develop complications and may need insulin in the future.

28.A nurse reviews the medication list of a client with a 20-year history of diabetes mellitus. The client holds up the bottle of prescribed duloxetine (Cymbalta) and states, My cousin has depression and is taking this drug. Do you think Im depressed? How should the nurse respond? a. Many people with long-term diabetes become depressed after a while. b. Its for peripheral neuropathy. Do you have burning pain in your feet or hands? c. This antidepressant also has anti-inflammatory properties for diabetic pain. d. No. Many medications can be used for several different disorders.

ANS: B Damage along nerves causes peripheral neuropathy and leads to burning pain along the nerves. Many drugs, including duloxetine (Cymbalta), can be used to treat peripheral neuropathy. The nurse should assess the client for this condition and then should provide an explanation of why this drug is being used. This medication, although it is used for depression, is not being used for that reason in this case. Duloxetine does not have anti- inflammatory properties. Telling the client that many medications are used for different disorders does not provide the client with enough information to be useful.

3. A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to break scrub when going to the console and sitting down. What action by the nurse is best? a. Call a time-out to discuss sterile procedure and scrub technique. b. Document the time the robotic portion of the procedure begins. c. Inform the surgeon that the scrub preparation has been compromised. d. Report the surgeons actions to the charge nurse and unit manager.

ANS: B During a robotic operative procedure, the surgeon inserts the articulating arms into the client, then breaks scrub to sit at the viewing console to perform the operation. The nurse should document the time the robotic portion of the procedure began. There is no need for the other interventions.

5. A client is in stage 2 of general anesthesia. What action by the nurse is most important? a. Keeping the room quiet and calm b. Being prepared to suction the airway c. Positioning the client correctly d. Warming the client with blankets

ANS: B During stage 2 of general anesthesia (excitement, delirium), the client can vomit and aspirate. The nurse must be ready to react to this potential occurrence by being prepared to suction the clients airway. Keeping the room quiet and calm does help the client enter the anesthetic state, but is not the priority. Positioning the client usually occurs during stage 3 (operative anesthesia). Keeping the client warm is important throughout to prevent hypothermia.

12. A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the clients stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

ANS: B Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not relate to the progression of mitral valve stenosis.

12.A nurse cares for a client with diabetes mellitus who asks, Why do I need to administer more than one injection of insulin each day? How should the nurse respond? a. You need to start with multiple injections until you become more proficient at self-injection. b. A single dose of insulin each day would not match your blood insulin levels and your food intake patterns. c. A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates. d. A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock.

ANS: B Even when a single injection of insulin contains a combined dose of different-acting insulin types, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels. One dose of insulin would not be appropriate even if the client decreased carbohydrate intake. Additional injections are not required to allow the client practice with injections, nor will one dose increase the clients risk of insulin shock.

17. A hospitalized client has a history of depression for which sertraline (Zoloft) is prescribed. The client also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose? a. Hydrocodone and acetaminophen (Lorcet) b. Hydromorphone (Dilaudid) c. Meperidine (Demerol) d. Tramadol (Ultram)

ANS: B Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse should not choose Lorcet because it contains acetaminophen (Tylenol) and the client has a history of alcoholism. Tramadol should not be used due to the potential for interactions with the clients sertraline. Meperidine is rarely used and is often restricted.

6. An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the surgeon. c. Have the client sign the consent, then call the surgeon. d. Remind the client of what teaching the surgeon has done

ANS: B In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the surgeon. The nurse should notify the surgeon to come back and answer the clients questions before the client signs the consent form. The other actions are not appropriate.

9. A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important? a. Assist with administering muscle relaxants to the client. b. Place the client on a cardiac monitor and pulse oximeter. c. Prepare to administer intravenous antiemetics to the client. d. Prevent the client from experiencing postoperative shivering.

ANS: B Intravenous anesthetic agents have the potential to cause respiratory and circulatory depression. The nurse should ensure the client is on a cardiac monitor and pulse oximeter. Muscle relaxants are not indicated for this client at this time. Intravenous anesthetics have a lower rate of postoperative nausea and vomiting than other types. Shivering can occur in any client, but is more common after inhalation agents.

9. The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding? a. Woman with a blood pressure of 158/90 mm Hg b. Client with Kussmaul respirations c. Man with skin itching from head to toe d. Client with halitosis and stomatitis

ANS: B Kussmaul respirations indicate a worsening of chronic kidney disease (CKD). The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs. Hypertension is common in most clients with CKD, and skin itching increases with calcium-phosphate imbalances, another common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and stomatitis.

9.A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this clients teaching? a. Change positions slowly when you get out of bed. b. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs). c. If you miss a dose of this drug, you can double the next dose. d. Discontinue the medication if you develop a urinary infection.

ANS: B NSAIDs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.

35.A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time should the nurse assess the client for potential problems related to the NPH insulin? a. 0800 b. 1600 c. 2000 d. 2300

ANS: B Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 0800 would be too soon. Checking the client at 2000 and 2300 would be too late. The nurse should check the client at 1600.

23. A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the nurse is most important to ensure client safety? a. Assess and record vital signs every 2 hours. b. Have another nurse double-check the pump settings. c. Instruct the client to report any unrelieved pain. d. Monitor for numbness and tingling in the legs.

ANS: B PCA-delivered analgesia creates a potential risk for the client. Pump settings should always be double- checked. Assessing vital signs should be done per agency policy and nurse discretion, and may or may not need to be this frequent. Unrelieved pain should be reported but is not vital to client safety. Monitoring for numbness and tingling in the legs is an important function but will manifest after something has occurred to the client; monitoring does not prevent the event from occurring.

1. The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the clients recent history? a. Pyelonephritis b. Myocardial infarction c. Bladder cancer d. Kidney stones

ANS: B Pre-renal causes of AKI are related to a decrease in perfusion, such as with a myocardial infarction. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are post-renal causes of AKI related to urine flow obstruction.

12. A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first? a. Assess the clients blood pressure. b. Perform hand hygiene and apply gloves. c. Reinforce the dressing with a clean one. d. Remove the dressing to assess the wound.

ANS: B Prior to assessing or treating the drainage from the wound, the nurse performs hand hygiene and dons gloves to protect both the client and nurse from infection.

29.A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client? a. Urine specific gravity of 1.033 b. Presence of protein in the urine c. Elevated capillary blood glucose level d. Presence of ketone bodies in the urine

ANS: B Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal dysfunction. Specific gravity is elevated with dehydration. Elevated capillary blood glucose levels and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function.

30.A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the clients diet should the nurse decrease? a. Carbohydrates b. Proteins c. Fats d. Total calories

ANS: B Restriction of dietary protein to 0.8 g/kg of body weight per day is recommended for clients with microalbuminuria to delay progression to renal failure. The clients diet does not need to be decreased in carbohydrates, fats, or total calories

9. A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort? a. Assess the clients pain on a 0-to-10 scale. b. Assist the client into a position of comfort. c. Have the client sit up in a recliner. d. Tell the client when pain medication is due.

ANS: B Several nonpharmacologic comfort measures can help postoperative clients with their pain, including distraction, music, massage, guided imagery, and positioning. The nurse should help this client into a position of comfort considering the surgical procedure and position of any tubes or drains. Assessing the clients pain is important but does not improve comfort. The client may be more uncomfortable in a recliner. Letting the client know when pain medication can be given next is important but does not improve comfort.

3. A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. I sleep with four pillows at night. b. My shoes fit really tight lately. c. I wake up coughing every night. d. I have trouble catching my breath.

ANS: B Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.

8.A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this clients teaching to prevent bloodborne infections? a. Wash your hands after completing each test. b. Do not share your monitoring equipment. c. Blot excess blood from the strip with a cotton ball. d. Use gloves when monitoring your blood glucose.

ANS: B Small particles of blood can adhere to the monitoring device, and infection can be transported from one user to another. Hepatitis B in particular can survive in a dried state for about a week. The client should be taught to avoid sharing any equipment, including the lancet holder. The client should be taught to wash his or her hands before testing. The client would not need to blot excess blood away from the strip or wear gloves.

7. A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths. d. Tell the client a little pain is expected.

ANS: B Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client.

13. A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, Why will I need to take anticoagulants for the rest of my life? How should the nurse respond? a. The prosthetic valve places you at greater risk for a heart attack. b. Blood clots form more easily in artificial replacement valves. c. The vein taken from your leg reduces circulation in the leg. d. The surgery left a lot of small clots in your heart and lungs.

ANS: B Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.

18. A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The clients oxygen saturation is 87%. What action should the nurse perform first? a. Apply oxygen at 4 L/min. b. Attempt to arouse the client. c. Give naloxone (Narcan). d. Notify the Rapid Response Team.

ANS: B The Pasero Opioid-Induced Sedation Scale is used to assess for unwanted opioid-associated sedation. A Pasero Scale score of 3 is unacceptable but is managed by trying to arouse the client in order to take deep breaths and staying with the client until he or she is more alert. Administering oxygen will not help if the clients respiratory rate is 7 breaths/min. Giving naloxone and calling for a Rapid Response Team would be appropriate for a higher Pasero Scale score.

3. The nurse in the surgery clinic is discussing an upcoming surgical procedure with a client. What information provided by the nurse is most appropriate for the clients long-term outcome? a. At least you know that the pain after surgery will diminish quickly. b. Discuss acceptable pain control after your operation with the surgeon. c. Opioids often cause nausea but you wont have to take them for long. d. The nursing staff will give you pain medication when you ask them for it.

ANS: B The best outcome after a surgical procedure is timely and satisfactory pain control, which diminishes the likelihood of chronic pain afterward. The nurse suggests that the client advocate for himself and discuss acceptable pain control with the surgeon. Stating that pain after surgery is usually short lived does not provide the client with options to have personalized pain control. To prevent or reduce nausea and other side effects from opioids, a multimodal pain approach is desired. For acute pain after surgery, giving pain medications around the clock instead of waiting until the client requests it is a better approach.

44.A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: Vital Signs and Assessment Blood pressure: 90/62 mm Hg Pulse: 120 beats/min Respiratory rate: 28 breaths/min Urine output: 20 mL/hr via catheter Which action should the nurse take? Laboratory Results Serum potassium: 2.6 mEq/L Medications Potassium chloride 40 mEq IV bolus STAT Increase IV fluid to 100 mL/hr a. Administer the potassium and then consult with the provider about the fluid order. b. Increase the intravenous rate and then consult with the provider about the potassium prescription. c. Administer the potassium first before increasing the infusion flow rate. d. Increase the intravenous flow rate before administering the potassium.

ANS: B The client is acutely ill and is severely dehydrated and hypokalemic. The client requires more IV fluids and potassium. However, potassium should not be infused unless the urine output is at least 30 mL/hr. The nurse should first increase the IV rate and then consult with the provider about the potassium.

41.A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: Fasting blood glucose: 75 mg/dL Postprandial blood glucose: 200 mg/dL Hemoglobin A1c level: 5.5% How should the nurse interpret these laboratory findings? a. Increased risk for developing ketoacidosis b. Good control of blood glucose c. Increased risk for developing hyperglycemia d. Signs of insulin resistance

ANS: B The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the clients glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance.

16. A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regular gallop rhythm d. Coarse crackles in bilateral lung bases

ANS: B The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related.

8. A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate? a. After you wash the surgical site, shave that area with your own razor. b. Be sure to wash the area where you will have surgery very thoroughly. c. Use a washcloth to wash the surgical site; do not take a full shower or bath. d. Wash the surgical site first, then shampoo and wash the rest of your body.

ANS: B The entire proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. The client needs a full shower or bath (shower preferred). The client should wash the surgical site last; dirty water from shampooing will run over the cleansed site if the site is washed first.

14. A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding in the clients health history would lead the nurse to consult with the provider over the choice of medication? a. 25pack-year smoking history b. Drinking 3 to 5 beers a day c. Previous peptic ulcer d. Taking warfarin (Coumadin)

ANS: B The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen. The nurse should relay this information to the provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.

9. A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met? a. Drainage from the surgical site is 30 mL less than yesterday. b. There is no redness, warmth, or drainage at the insertion site. c. The client reports adequate pain control with medications. d. Urine is clear yellow and urine output is greater than 40 mL/hr.

ANS: B The priority client problem related to a surgical drain is the potential for infection. An insertion site that is free of redness, warmth, and drainage indicates that goals for this client problem are being met. The other assessments are normal, but not related to the drain.

11.A nurse cares for a client who is prescribed pioglitazone (Actos). After 6 months of therapy, the client reports that his urine has become darker since starting the medication. Which action should the nurse take? a. Assess for pain or burning with urination. b. Review the clients liver function study results. c. Instruct the client to increase water intake. d. Test a sample of urine for occult blood.

ANS: B Thiazolidinediones (including pioglitazone) can affect liver function; liver function should be assessed at the start of therapy and at regular intervals while the client continues to take these drugs. Dark urine is one indicator of liver impairment because bilirubin is increased in the blood and is excreted in the urine. The nurse should check the clients most recent liver function studies. The nurse does not need to assess for pain or burning with urination and does not need to check the urine for occult blood. The client does not need to be told to increase water intake.

4. A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this clients care? a. Edema and pain b. Electrolyte and fluid imbalance c. Cardiac and respiratory status d. Mental health status

ANS: B This client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance is essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the clients cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated

19. A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best? a. All preoperative clients get this medication. b. It helps prevent ulcers from the stress of the surgery. c. Since you dont have ulcers, I will have to ask. d. The physician prescribed this medication for you.

ANS: B Ulcer prophylaxis is common for clients undergoing long procedures or for whom high stress is likely. The nurse is not being truthful by saying all clients get this medication. If the nurse does not know the information, it is appropriate to find out, but this is a common medication for which the nurse should know the rationale prior to administering it. Simply stating that the physician prescribed the medication does not give the client any useful information.

6. A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? a. Allow the client to rest. b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast.

ANS: B Vomiting after surgery has several complications, including aspiration. The nurse should listen to the clients lung sounds. The client should be allowed to rest after an assessment. Documenting is important, but the nurse needs to be able to document fully, including an assessment. The client should not eat until nausea has subsided.

33.A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this clients teaching? a. When ill, avoid eating or drinking to reduce vomiting and diarrhea. b. Monitor your blood glucose levels at least every 4 hours while sick. c. If vomiting, do not use insulin or take your oral antidiabetic agent. d. Try to continue your prescribed exercise regimen even if you are sick.

ANS: B When ill, the client should monitor his or her blood glucose at least every 4 hours. The client should continue taking the medication regimen while ill. The client should continue to eat and drink as tolerated but should not exercise while sick.

19.A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO3 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28, HCO3 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO3 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.32, HCO3 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

ANS: B When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.

2. A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.) a. Blood glucose: 120 mg/dL b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L e. Sodium: 142 mEq/L

ANS: B, C, D Fluid and electrolyte balance are assessed carefully in the postoperative client because many imbalances can occur. The low hemoglobin may be from blood loss in surgery. The higher pH level indicates alkalosis, possibly from losses through the NG tube. The potassium is very low. The blood glucose is within normal limits for a postsurgical client who has been fasting. The sodium level is normal.

4. A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.) a. Client with a humerus fracture b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client

ANS: B, C, D, E All surgical clients should be assessed for VTE risk. Those considered at higher risk include those who are obese; are over 40; have cancer; have decreased mobility, immobility, or a spinal cord injury; have a history of any thrombotic event, varicose veins, or edema; take oral contraceptives or smoke; have decreased cardiac output; have a hip fracture; or are having total hip or knee surgery. Prolonged surgical time increases risk due to mobility and positioning needs.

5. A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.) a. I can continue to take antacids to relieve heartburn. b. I need to ask for an antibiotic when scheduling a dental appointment. c. Ill need to check my blood sugar often to prevent hypoglycemia. d. The dose of my pain medication may have to be adjusted. e. I should watch for bleeding when taking my anticoagulants.

ANS: B, C, D, E In discharge teaching, the nurse must emphasize that the client needs to have an antibiotic prophylactically before dental procedures to prevent infection. There may be a need for dose reduction in medications if the kidney is not excreting them properly (antacids with magnesium, antibiotics, antidiabetic drugs, insulin, opioids, and anticoagulants).

8. A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.) a. Allow small sips of plain water. b. Check that consent is on the chart. c. Ensure the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation.

ANS: B, C, D, E Providing for client safety is a priority function of the preoperative nurse. Checking for appropriately completed consent, verifying the clients identity, having the client assist in marking the surgical site if applicable, and allowing the client to use the toilet prior to sedating him or her are just some examples of important safety measures. The preoperative client should be NPO, so water should not be provided.

1. A faculty member explains to students the process by which pain is perceived by the client. Which processes does the faculty member include in the discussion? (Select all that apply.) a. Induction b. Modulation c. Sensory perception d. Transduction e. Transmission

ANS: B, C, D, E The four processes involved in making pain a conscious experience are modulation, sensory perception, transduction, and transmission.

1. A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.) a. Hemorrhage b. Infection c. Serious cardiac events d. Stroke e. Thromboembolism

ANS: B, C, E The SCIP project includes core measures to prevent infection, serious cardiac events, and thromboembolic events such as deep vein thrombosis.

6. A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.) a. Administering antibiotics for 72 hours b. Disposing of dressings properly c. Leaving draining wounds open to air d. Performing proper hand hygiene e. Removing and replacing wet dressings

ANS: B, D, E Interventions necessary to prevent surgical wound infection include proper disposal of soiled dressings, performing proper hand hygiene, and removing wet dressings as they can be a source of infection. Prophylactic antibiotics are given to clients at risk for infection, but are discontinued after 24 hours if no infection is apparent. Draining wounds should always be covered.

4. A client with a broken arm has had ice placed on it for 20 minutes. A short time after the ice was removed, the client reports that the effect has worn off and requests pain medication, which cannot be given yet. What actions by the nurse are most appropriate? (Select all that apply.) a. Ask for a physical therapy consult. b. Educate the client on cold therapy. c. Offer to provide a heating pad. d. Repeat the ice application. e. Teach the client relaxation techniques.

ANS: B, D, E Nonpharmacologic pain management can be very effective. These modalities include ice, heat, pressure, massage, vibration, and transcutaneous electrical stimulation. Since the client is unable to have more pain medication at this time, the nurse should focus on nonpharmacologic modalities. First the client must be educated; the effects of ice wear off quickly once it is removed, and the client may have had unrealistic expectations. The nurse can repeat the ice application and teach relaxation techniques if the client is open to them. A physical therapy consult will not help relieve acute pain. Heat would not be a good choice for this type of injury.

1. A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.) a. All phases require the client to be in the hospital. b. Phase I care may last for several days in some clients. c. Phase I requires intensive care unit monitoring. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III

ANS: B, D, E There are three phases of postoperative care. Phase I is the most intense, with clients coming right from surgery until they are completely awake and hemodynamically stable. This may take hours or days and can occur in the intensive care unit or the postoperative care unit. Phase II ends when the client is at a presurgical level of consciousness and baseline oxygen saturation, and vital signs are stable. Phase III involves the extended care environment and may continue at home or in an extended care facility if needed.

4. The nurse is teaching a client with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.) a. I need to decrease sodium, cholesterol, and protein in my diet. b. My weight should be maintained at a body mass index of 30. c. Smoking should be stopped as soon as I possibly can. d. I can continue to take an aspirin every 4 to 8 hours for my pain. e. I really only need to drink a couple of glasses of water each day.

ANS: B, D, E Weight should be maintained at a body mass index (BMI) of 22 to 25. A BMI of 30 indicates obesity. The use of nonsteroidal anti-inflammatory drugs such as aspirin should be limited to the lowest time at the lowest dose due to interference with kidney blood flow. The client should drink at least 2 liters of water daily. Diet adjustments should be made by restricting sodium, cholesterol, and protein. Smoking causes constriction of blood vessels and decreases kidney perfusion, so the client should stop smoking.

2. A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.) a. Hemicolectomy: diagnostic b. Liver biopsy: diagnostic c. Mastectomy: restorative d. Spinal cord decompression: palliative e. Total shoulder replacement: restorative

ANS: B, E A diagnostic procedure is used to determine cell type of cancer and to determine the cause of a problem. An example is a liver biopsy. A restorative procedure aims to improve functional ability. An example would be a total shoulder replacement or a spinal cord decompression (not palliative). A curative procedure either removes or repairs the causative problem. An example would be a mastectomy (not restorative) or a hemicolectomy (not diagnostic). A palliative procedure relieves symptoms but will not cure the disease. An example is an ileostomy. A cosmetic procedure is done to improve appearance. An example is rhinoplasty (a nose job).

10. The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub? a. Registered nurse who just floated from the surgical unit b. Registered nurse who just floated from the dialysis unit c. Registered nurse who was assigned the same client yesterday d. Licensed practical nurse with 5 years experience on this floor

ANS: C The client is exhibiting symptoms of pericarditis, which can occur with chronic kidney disease. Continuity of care is important to assess subtle differences in clients. Therefore, the registered nurse (RN) who was assigned to this client previously should again give care to this client. The float nurses would not be as knowledgeable about the unit and its clients. The licensed practical nurse may not have the education level of the RN to assess for pericarditis

5. A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the clients bed. The clients blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Lower the head of the bed. d. Nothing; this is expected.

ANS: C A client who had epidural or spinal anesthesia may become hypotensive when the head of the bed is raised. If this occurs, the nurse should lower the head of the bed to its original position. The Rapid Response Team is not needed, nor is an increase in IV rate.

5. A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL b. Hemoglobin: 14.8 mg/dL c. Potassium: 2.9 mEq/L d. Sodium: 134 mEq/L

ANS: C A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status. The nurse should communicate this laboratory value immediately. The creatinine is at the high end of normal, the hemoglobin is normal, and the sodium is only slightly low (normal low being 136 mEq/L), so these values do not need to be reported immediately.

34.A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? a. Serum potassium level has increased. b. Blood osmolarity has decreased. c. Glasgow Coma Scale score is unchanged. d. Urine remains negative for ketone bodies.

ANS: C A slow but steady improvement in central nervous system functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in the level of consciousness may indicate inadequate rates of fluid replacement. The Glasgow Coma Scale assesses the clients state of consciousness against criteria of a scale including best eye, verbal, and motor responses. An increase in serum potassium, decreased blood osmolality, and urine negative for ketone bodies do not indicate adequacy of treatment.

4. A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain assessment tool would the nurse choose for this assessment? a. Numeric rating scale b. Verbal Descriptor Scale c. FACES Pain Scale-Revised d. Wong-Baker FACES Pain Scale

ANS: C All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults.

12. A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best? a. Allow the client to walk to the bathroom. b. Delegate assisting the client to the nurses aide. c. Give the client a bedpan or urinal to use. d. Insert a urinary catheter now instead of waiting.

ANS: C Although possibly uncomfortable or embarrassing for the client, the client should not be allowed out of bed after receiving sedation. The nurse should get the client a bedpan or urinal. The client may or may not need a urinary catheter.

7. A nurse is monitoring a client after moderate sedation. The nurse documents the clients Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best? a. Assess the clients gag reflex. b. Begin providing discharge instructions. c. Document findings and continue to monitor. d. Increase oxygen and notify the provider.

ANS: C An RSS score of 3 means the client is able to respond quickly, but only to commands. The client has not had enough time to fully arouse. The nurse should document the findings and continue to monitor per agency policy. If the client had an oral endoscopy or was intubated, checking the gag reflex would be appropriate prior to permitting eating or drinking. The client is not yet awake enough for teaching. There is no need to increase oxygen and notify the provider.

2. A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left- sided heart failure? a. I have been drinking more water than usual. b. I am awakened by the need to urinate at night. c. I must stop halfway up the stairs to catch my breath. d. I have experienced blurred vision on several occasions.

ANS: C Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or catching their breath. This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.

4.A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first? a. Document the finding in the clients chart. b. Assess tactile sensation in the clients hands. c. Examine the clients feet for signs of injury. d. Notify the health care provider.

ANS: C Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse should inspect them for any signs of injury. After assessment, the nurse should document findings in the clients chart. Testing sensory perception in the hands may or may not be needed. The health care provider can be notified after assessment and documentation have been completed.

19. The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8 F (37.6 C). What is the most appropriate action by the nurse? a. Administer fluid to increase blood pressure. b. Check the white blood cell count. c. Monitor the clients temperature. d. Connect the client to an electrocardiographic (ECG) monitor.

ANS: C During hemodialysis, the dialysate is warmed to increase diffusion and prevent hypothermia. The clients temperature could reflect the temperature of the dialysate. There is no indication to check the white blood cell count or connect the client to an ECG monitor. The other vital signs are within normal limits.

25. The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching? a. I should leave the drainage bag above the level of my abdomen. b. I could flush the tubing with normal saline if the flow stops. c. I should take a stool softener every morning to avoid constipation. d. My diet should have low fiber in it to prevent any irritation.

ANS: C Inflow and outflow problems of the dialysate are best controlled by preventing constipation. A daily stool softener is the best option for the client. The drainage bag should be below the level of the abdomen. Flushing the tubing will not help with the flow. A diet high in fiber will also help with a constipation problem.

10. A student nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. What response by the registered nurse is best? a. A multimodal approach is the preferred method of control. b. Doctors are much more liberal with pain medications now. c. Pain is so complex it takes different approaches to control it. d. Clients are consumers and they demand lots of pain medicine.

ANS: C Pain is a complex phenomenon and often responds best to a regimen that uses different types of analgesia. This is called a multimodal approach. Using this terminology, however, may not be clear to the student if the terminology is not understood. Doctors may be more liberal with pain medications, but that is not the best reason for this approach. Saying that clients are consumers who demand medications sounds as if the nurse is discounting their pain experiences.

11. A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client? a. Hydroxyzine (Atarax) b. Lorazepam (Ativan) c. Metoclopramide (Reglan) d. Morphine sulfate

ANS: C Reglan increases gastric emptying, an important issue for this client who was eating just prior to the operation. The other drugs are appropriate for any surgical client

22. A nurse is caring for four clients receiving pain medication. After the hand-off report, which client should the nurse see first? a. Client who is crying and agitated b. Client with a heart rate of 104 beats/min c. Client with a Pasero Scale score of 4 d. Client with a verbal pain report of 9

ANS: C The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates unacceptable somnolence and is an emergency. The nurse should see this client first. The nurse can delegate visiting with the crying client to a nursing assistant; the client may be upset and might benefit from talking or a comforting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate this assessment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly above normal, and that client can be seen after the other two clients are cared for.

17. A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the clients fluid balance is stable at this time? a. Decreased calcium levels b. Increased phosphorus levels c. No adventitious sounds in the lungs d. Increased edema in the legs

ANS: C The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the clients body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance.

1. The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best? a. Call maintenance for repair. b. Check the machine before using. c. Get another piece of equipment. d. Notify the charge nurse.

ANS: C The circulating nurse is responsible for client safety. If an electrical cord is frayed, the risk of fire or sparking increases. The nurse should obtain a replacement. The nurse should also tag the original equipment for repair as per agency policy. Checking the equipment is not important as the nurse should not even attempt to use it. Calling maintenance or requesting maintenance per facility protocol is important, but first ensure client safety by having a properly working piece of equipment for the procedure about to take place. The charge nurse probably does need to know of the need for equipment repair, but ensuring client safety is the priority.

13. A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication patient-controlled analgesia (PCA). What action by the student requires the RN to intervene? a. Assesses the clients pain level per agency policy b. Monitors the clients respiratory rate and sedation c. Presses the button when the client cannot reach it d. Reinforces client teaching about using the PCA pump

ANS: C The client is the only person who should press the PCA button. If the client cannot reach it, the student should either reposition the client or the button, and should not press the button for the client. The RN should intervene at this point. The other actions are appropriate

28. A nurse reviews these laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium 136 mEq/L Potassium 5 mEq/L Blood urea nitrogen (BUN) 44 mg/dL Serum creatinine 2.5 mg/dL What initial intervention would the nurse anticipate? a. Start hemodialysis immediately. b. Discuss the need for peritoneal dialysis. c. Increase the dose of immunosuppression. d. Return the client to surgery for exploration.

ANS: C The client may need a higher dose of immunosuppressive medication as evidenced by the elevated BUN and serum creatinine levels. This increased dose may reverse the possible acute rejection of the transplanted kidney. The client does not need hemodialysis, peritoneal dialysis, or further surgery at this point.

40.After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I should increase my intake of vegetables with higher amounts of dietary fiber. b. My intake of saturated fats should be no more than 10% of my total calorie intake. c. I should decrease my intake of protein and eliminate carbohydrates from my diet. d. My intake of water is not restricted by my treatment plan or medication regimen.

ANS: C The client should not completely eliminate carbohydrates from the diet, and should reduce protein if microalbuminuria is present. The client should increase dietary intake of complex carbohydrates, including vegetables, and decrease intake of fat. Water does not need to be restricted unless kidney failure is present.

45.At 4:45 p.m., a nurse assesses a client with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the client is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below: Capillary Blood Glucose Testing (AC/HS) At 0630: 95 At 1130: 70 At 1630: 47 Dietary Intake Breakfast: 10% eaten client states she is not hungry Lunch: 5% eaten client is nauseous; vomits once After reviewing the clients assessment data, which action is appropriate at this time? a. Assess the clients oxygen saturation level and administer oxygen. b. Reorient the client and apply a cool washcloth to the clients forehead. c. Administer dextrose 50% intravenously and reassess the client. d. Provide a glass of orange juice and encourage the client to eat dinner.

ANS: C The clients symptoms are related to hypoglycemia. Since the client has not been tolerating food, the nurse should administer dextrose intravenously. The clients oxygen level could be checked, but based on the information provided, this is not the priority. The client will not be reoriented until the glucose level rises.

21. The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm

ANS: C The nurse should not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula should be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment.

3. A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care? a. Married young adult who is the primary caregiver for children b. Middle-aged client who is post knee replacement, needs physical therapy c. Older adult who lives at home despite some memory loss d. Young client who lives alone, has family and friends nearby

ANS: C The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The clients physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed. The other clients all have evidence of a support system and no known potential for serious safety issues.

2. The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96 F (35.6 C)

ANS: C The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression. The nurse should assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may be within that clients baseline. A pulse of 118 beats/min is slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96 F is slightly low and the client needs to be warmed. But none of these other vital signs take priority over the respiratory rate.

14. A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drains safety pin to the sheets d. Using sterile technique to empty the drain

ANS: C The safety pin that prevents the drain from slipping back into the clients body should be pinned to the clients gown, not the bedding. Pinning it to the sheets will cause it to pull out when the client turns. The other actions are appropriate.

25.A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the clients breath has a fruity odor. Which action should the nurse take? a. Encourage the client to use an incentive spirometer. b. Increase the clients intravenous fluid flow rate. c. Consult the provider to test for ketoacidosis. d. Perform meticulous pulmonary hygiene care.

ANS: C The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a fruity odor to the breath. Documentation should occur after all assessments have been completed. Using an incentive spirometer, increasing IV fluids, and performing pulmonary hygiene will not address this clients problem.

4. The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate? a. Ask the surgeon to change the sterile gown. b. Do nothing; this is acceptable sterile procedure. c. Inform the surgeon that the sterile field has been broken. d. Obtain a new pair of sterile gloves for the surgeon to put on.

ANS: C The surgical gown is considered sterile from the chest to the level of the surgical field. By placing the hands down by the hips, the surgeon has broken sterile field. The circulating nurse informs the surgeon of this breach. Changing only the gloves or only the gown does not restore the sterile sections of the gown. Doing nothing is unacceptable.

13. A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema? a. Maintaining oxygen saturation of 89% b. Minimal crackles and wheezes in lung sounds c. Maintaining a balanced intake and output d. Limited shortness of breath upon exertion

ANS: C With an optimal fluid balance, the client will be more able to eject blood from the left ventricle without increased pressure in the left ventricle and pulmonary vessels. Other ideal goals are oxygen saturations greater than 92%, no auscultated crackles or wheezes, and no demonstrated shortness of breath.

3. A postoperative client has an epidural infusion of morphine and bupivacaine (Marcaine). What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Ask the client to point out any areas of numbness or tingling. b. Determine how many people are needed to ambulate the client. c. Perform a bladder scan if the client is unable to void after 4 hours. d. Remind the client to use the incentive spirometer every hour. e. Take and record the clients vital signs per agency protocol.

ANS: C, D, E The UAP can assess and record vital signs, perform a bladder scan and report the results to the nurse, and remind the client to use the spirometer. The nurse is legally responsible for assessments and should ask the client about areas of numbness or tingling, and assess if the client is able to bear weight and walk.

27.A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this clients teaching to prevent injury? a. Examine your feet using a mirror every day. b. Rotate your insulin injection sites every week. c. Check your blood glucose level before each meal. d. Use a bath thermometer to test the water temperature.

ANS: D Clients with diminished sensory perception can easily experience a burn injury when bathwater is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and checking blood glucose levels will not prevent injury.

5. The nurse is assessing a clients pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. What question by the nurse would be best to ask the client for completing a comprehensive pain assessment? a. Are you worried about addiction to pain pills? b. Do you attach any spiritual meaning to pain? c. How high would you say your pain tolerance is? d. What pain rating would be acceptable to you?

ANS: D A comprehensive pain assessment includes the items listed in the question plus the clients opinion on a functional goal, such as what pain rating would be acceptable to him or her. Asking about addiction is not warranted in an initial pain assessment. Asking about spiritual meanings for pain may give the nurse important information, but getting the basics first is more important. Asking about pain tolerance may give the client the idea that pain tolerance is being judged.

14. A client has a long history of hypertension. Which category of medications would the nurse expect to be ordered to avoid chronic kidney disease (CKD)? a. Antibiotic b. Histamine blocker c. Bronchodilator d. Angiotensin-converting enzyme (ACE) inhibitor

ANS: D ACE inhibitors stop the conversion of angiotensin I to the vasoconstrictor angiotensin II. This category of medication also blocks bradykinin and prostaglandin, increases renin, and decreases aldosterone, which promotes vasodilation and perfusion to the kidney. Antibiotics fight infection, histamine blockers decrease inflammation, and bronchodilators increase the size of the bronchi; none of these medications helps slow the progression of CKD in clients with hypertension

4. Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best? a. Let me call the surgeon to see if you really need them. b. No, you have to use those for 24 hours after surgery. c. OK, we can remove them since you are stable now. d. To prevent blood clots you need them a few more hours.

ANS: D According to the Surgical Care Improvement Project (SCIP), any prophylactic measures to prevent thromboembolic events during surgery are continued for 24 hours afterward. The nurse should explain this to the client. Calling the surgeon is not warranted. Simply telling the client he or she has to wear the hose and compression devices does not educate the client. The nurse should not remove the devices.

13. A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next? a. Cognitive status b. Family stress c. Nutrition status d. Psychosocial status

ANS: D After ensuring the clients physiologic status is stable, these manifestations should lead the nurse to assess the clients psychosocial status. Anxiety especially can be demonstrated with elevations in vital signs. Cognitive and nutrition status are not related. Family stress is a component of psychosocial status.

10. A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? a. Be sure you keep all your postoperative appointments. b. Call your surgeon if you have any questions at home. c. Eat a diet high in protein, iron, zinc, and vitamin C. d. Wash your hands before touching the drain or dressing.

ANS: D All options are appropriate for the client being discharged after surgery. However, for this client who is changing a dressing and managing a drain, infection control is the priority. The nurse should instruct the client to wash hands often, including before and after touching the dressing or drain.

21. An older client who lives alone is being discharged on opioid analgesics. What action by the nurse is most important? a. Discuss the need for home health care. b. Give the client follow-up information. c. Provide written discharge instructions. d. Request a home safety assessment.

ANS: D All these activities are appropriate when discharging a client whose needs will continue after discharge. A home safety assessment would be most important to ensure the safety of this older client.

23. A nurse is caring for a client who is scheduled for a dose of cefazolin and vitamins at this time. Hemodialysis for this client is also scheduled in 60 minutes. Which action by the nurse is best? a. Administer cefazolin since the level of the antibiotic must be maintained. b. Hold the vitamins but administer the cefazolin. c. Hold the cefazolin but administer the vitamins. d. Hold all medications since both cefazolin and vitamins are dialyzable.

ANS: D Both the cefazolin and the vitamins should be held until after the hemodialysis is completed because they would otherwise be removed by the dialysis process.

10. A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this clients discharge teaching? a. Avoid drinking more than 3 quarts of liquids each day. b. Eat six small meals daily instead of three larger meals. c. When you feel short of breath, take an additional diuretic. d. Weigh yourself daily while wearing the same amount of clothing.

ANS: D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The client should be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.

12. A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient- controlled analgesia (PCA) pumps. Which client should the nurse see first? a. Client who appears to be sleeping soundly b. Client with no bolus request in 6 hours c. Client who is pressing the button every 10 minutes d. Client with a respiratory rate of 8 breaths/min

ANS: D Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse should first check this client. The client sleeping soundly could either be overly sedated or just comfortable and should be checked next. Pressing the button every 10 minutes indicates the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse should next assess that clients pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain.

37.When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, I will never be able to stick myself with a needle. How should the nurse respond? a. I can give your injections to you while you are here in the hospital. b. Everyone gets used to giving themselves injections. It really does not hurt. c. Your disease will not be managed properly if you refuse to administer the shots. d. Tell me what it is about the injections that are concerning you.

ANS: D Devote as much teaching time as possible to insulin injection and blood glucose monitoring. Clients with newly diagnosed diabetes are often fearful of giving themselves injections. If the client is worried about giving the injections, it is best to try to find out what specifically is causing the concern, so it can be addressed. Giving the injections for the client does not promote self-care ability. Telling the client that others give themselves injections may cause the client to feel bad. Stating that you dont know another way to manage the disease is dismissive of the clients concerns

7.A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? a. A 29-year-old Caucasian b. A 32-year-old African- American c. A 44-year-old Asian d. A 48-year-old American Indian

ANS: D Diabetes is a particular problem among African Americans, Hispanics, and American Indians. The incidence of diabetes increases in all races and ethnic groups with age. Being both an American Indian and middle-aged places this client at highest risk.

3.After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a. At my age, I should continue seeing the ophthalmologist as I usually do. b. I will see the eye doctor when I have a vision problem and yearly after age 40. c. My vision will change quickly. I should see the ophthalmologist twice a year. d. Diabetes can cause blindness, so I should see the ophthalmologist yearly.

ANS: D Diabetic retinopathy is a leading cause of blindness in North America. All clients with diabetes, regardless of age, should be examined by an ophthalmologist (rather than an optometrist or optician) at diagnosis and at least yearly thereafter.

15. A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Which assessment findings would lead the nurse to consult with the provider? a. Bilateral lung crackles b. Hypoactive bowel sounds c. Self-reported pain of 3/10 d. Urine output of 20 mL/2 hr

ANS: D Drugs in this category can affect renal function. Clients should be adequately hydrated and demonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse should consult with the provider about the choice of drug. Crackles and hypoactive bowel sounds are not related. A pain report of 3 does not warrant a call to the physician. The medication may be part of a round-the- clock regimen to prevent and control pain and would still need to be given. If the medication is PRN, the nurse can ask the client if he or she still wants it.

11. An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states She needs to get back to her old self! What response by the nurse is best? a. Everyone comes out of surgery differently. b. Lets just give her some more time, okay? c. She may have had a stroke during surgery. d. Sometimes older people take longer to wake up.

ANS: D Due to age-related changes, it may take longer for an older adult to metabolize anesthetic agents and pain medications, making it appear that they are taking too long to wake up and return to their normal baseline cognitive status. The nurse should educate the family on this possibility. While everyone does react differently, this does not give the family any objective information. Saying Lets just give her more time, okay? sounds patronizing and again does not provide information. While an intraoperative stroke is a possibility, the nurse should concentrate on the more common occurrence of older clients taking longer to fully arouse and awake.

17.After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I have so many complications; exercising is not recommended. b. I will exercise more frequently because I have so many complications. c. I used to run for exercise; I will start training for a marathon. d. I should look into swimming or water aerobics to get my exercise.

ANS: D Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury. The client should not exercise too vigorously

9. A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this clients teaching? a. Avoid taking aspirin or aspirin-containing products. b. Increase your intake of foods that are high in potassium. c. Hold this medication if your pulse rate is below 80 beats/min. d. Do not take this medication within 1 hour of taking an antacid.

ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption, nor do these statements decrease complications of digoxin therapy.

39.A nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication should alert the nurse to contact the provider and withhold the prescribed dose? a. Pioglitazone (Actos) b. Glimepiride (Amaryl) c. Glipizide (Glucotrol) d. Metformin (Glucophage)

ANS: D Glucophage should not be administered when the kidneys are attempting to excrete IV contrast from the body. This combination would place the client at high risk for kidney failure. The nurse should hold the metformin dose and contact the provider. The other medications are safe to administer after receiving IV contrast.

1. A client has arrived in the postoperative unit. What action by the circulating nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report

ANS: D Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority.

16.A nurse teaches a client who is prescribed an insulin pump. Which statement should the nurse include in this clients discharge education? a. Test your urine daily for ketones. b. Use only buffered insulin in your pump. c. Store the insulin in the freezer until you need it. d. Change the needle every 3 days.

ANS: D Having the same needle remain in place through the skin for longer than 3 days drastically increases the risk for infection in or through the delivery system. Having an insulin pump does not require the client to test for ketones in the urine. Insulin should not be frozen. Insulin is not buffered.

22. A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the clients nose and around the intravenous catheter. What action by the nurse is the priority? a. Hold pressure over the clients nose for 10 minutes. b. Take the clients pulse, blood pressure, and temperature. c. Assess for a bruit or thrill over the arteriovenous fistula. d. Prepare protamine sulfate for administration.

ANS: D Heparin is used with hemodialysis treatments. The bleeding alerts the nurse that too much anticoagulant is in the clients system and protamine sulfate should be administered. Pressure, taking vital signs, and assessing for a bruit or thrill are not as important as medication administration.

2.A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the clients polyuria? a. Serum sodium: 163 mEq/L b. Serum creatinine: 1.6 mg/dL c. Presence of urine ketone bodies d. Serum osmolarity: 375 mOsm/kg

ANS: D Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The clients serum osmolarity is high. The clients sodium would be expected to be high owing to dehydration. Serum creatinine and urine ketone bodies are not related to the polyuria.

32.A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately? a. Serum chloride level of 98 mmol/L b. Serum calcium level of 8.8 mg/dL c. Serum sodium level of 132 mmol/L d. Serum potassium level of 2.5 mmol/L

ANS: D Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.

1. A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best? a. Numeric pain scale b. Behavioral assessment c. Objective observation d. Clients self-report

ANS: D Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.

22.A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this clients teaching to decrease the clients insulin needs? a. Limit your fluid intake to 2 liters a day. b. Animal organ meat is high in insulin. c. Limit your carbohydrate intake to 80 grams a day. d. Walk at a moderate pace for 1 mile daily.

ANS: D Moderate exercise such as walking helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for clients with type 1 diabetes mellitus. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 grams of carbohydrates each day.

10.After teaching a client with type 2 diabetes mellitus who is prescribed nateglinide (Starlix), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the prescribed therapy? a. Ill take this medicine during each of my meals. b. I must take this medicine in the morning when I wake. c. I will take this medicine before I go to bed. d. I will take this medicine immediately before I eat.

ANS: D Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken immediately before each meal. The medication should not be taken without eating as it will decrease the clients blood glucose levels. The medication should be taken before meals instead of during meals.

11. A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. What intervention for pain management does the nurse include in the clients care plan? a. As-needed pain medication after therapy b. Client-controlled analgesia with a basal rate c. Pain medications prior to therapy only d. Round-the-clock analgesia with PRN analgesics

ANS: D Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specific procedures is managed with additional medication. An as-needed regimen will not control postoperative pain. A client-controlled analgesia pump might be a good idea but needs basal (continuous) and bolus (intermittent) settings to accomplish adequate pain control. Pain control needs to be continuous, not just administered prior to therapy

2. A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements

ANS: D Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. Lack of experience with surgery may increase anxiety and may require higher teaching needs, but is not the priority over client safety.

6. A nurse is assessing pain in an older adult. What action by the nurse is best? a. Ask only yes-or-no questions so the client doesnt get too tired. b. Give the client a picture of the pain scale and come back later. c. Question the client about new pain only, not normal pain from aging. d. Sit down, ask one question at a time, and allow the client to answer.

ANS: D Some older clients do not report pain because they think it is a normal part of aging or because they do not want to be a bother. Sitting down conveys time, interest, and availability. Ask only one question at a time and allow the client enough time to answer it. Yes-or-no questions are an example of poor communication technique. Giving the client a pain scale, then leaving, might give the impression that the nurse does not have time for the client. Plus the client may not know how to use it. There is no normal pain from aging.

7. A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse? a. Use the catheter for the next laboratory blood draw. b. Monitor the central venous pressure through this line. c. Access the line for the next intravenous medication. d. Place a heparin or heparin/saline dwell after hemodialysis.

ANS: D The central line should have a heparin or heparin/saline dwell after hemodialysis treatment. The central line catheter used for dialysis should not be used for blood sampling, monitoring central venous pressures, or giving drugs or fluids

38.A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. Which action should the nurse take? a. Apply ice to the site to reduce inflammation. b. Consult the provider for a new administration route. c. Assess the client for other signs of cellulitis. d. Instruct the client to rotate sites for insulin injection.

ANS: D The clients tissue has been damaged from continuous use of the same site. The client should be educated to rotate sites. The damaged tissue is not caused by cellulitis or any type infection, and applying ice may cause more damage to the tissue. Insulin can only be administered subcutaneously and intravenously. It would not be appropriate or practical to change the administration route.

11. A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best? a. Administer anxiolytics. b. Give the client warm blankets. c. Introduce the surgical staff. d. Remain with the client.

ANS: D The nurse can provide emotional support by remaining with the client until anesthesia has been provided. An extremely anxious client may need anxiolytics, but not all clients require this for emotional support. Physical comfort and introductions can also help decrease anxiety.

26. A client with chronic kidney disease states, I feel chained to the hemodialysis machine. What is the nurses best response to the clients statement? a. That feeling will gradually go away as you get used to the treatment. b. You probably need to see a psychiatrist to see if you are depressed. c. Do you need help from social services to discuss financial aid? d. Tell me more about your feelings regarding hemodialysis treatment.

ANS: D The nurse needs to explore the clients feelings in order to help the client cope and enter a phase of acceptance or resignation. It is common for clients to be discouraged because of the dependency of the treatment, especially during the first year. Referrals to a mental health provider or social services are possibilities, but only after exploring the clients feelings first. Telling the client his or her feelings will go away is dismissive of the clients concerns.

5. A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurses priority action? a. Calculate the mean arterial pressure (MAP). b. Ask for insertion of a pulmonary artery catheter. c. Take the clients pulse. d. Slow down the normal saline infusion.

ANS: D The nurse should assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the clients hemodynamic status, but this should not be the initial action by the nurse. Vital signs are also important after adjusting the intravenous infusion

16. A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. What action by the nurse is most important for client safety? a. Assess and record the clients pain every 4 hours. b. Ensure the client is eating a high-fiber diet. c. Monitor the clients bowel function every shift. d. Remove the old patch when applying the new one.

ANS: D The old fentanyl patch should be removed when applying a new patch so that accidental overdose does not occur. The other actions are appropriate, but not as important for safety.

20.A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? a. Administration of oxygen via face mask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin

ANS: D The rapid, deep respiratory efforts of Kussmaul respirations are the bodys attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The client who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the client glucose would be contraindicated. The client does not require seizure precautions.

8. A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take? a. Initiate oxygen therapy. b. Hold the next dose of Imdur. c. Instruct the client to drink water. d. Administer PRN acetaminophen.

ANS: D The vasodilating effects of isosorbide mononitrate frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. The clients headache is not related to hypoxia or dehydration; therefore, these interventions would not help. The client needs to take the medication as prescribed to prevent angina; the medication should not be held.

21.A nurse cares for a client who has type 1 diabetes mellitus. The client asks, Is it okay for me to have an occasional glass of wine? How should the nurse respond? a. Drinking any wine or alcohol will increase your insulin requirements. b. Because of poor kidney function, people with diabetes should avoid alcohol. c. You should not drink alcohol because it will make you hungry and overeat. d. One glass of wine is okay with a meal and is counted as two fat exchanges.

ANS: D Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when diabetes is well controlled. Because alcohol can induce hypoglycemia, it should be ingested with or shortly after a meal. One alcoholic beverage is substituted for two fat exchanges when caloric intake is calculated. Kidney function is not impacted by alcohol intake. Alcohol is not associated with increased hunger or overeating.