Med Surg- Final

The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation? "Walk to the point of pain, rest until the pain subsides, then resume ambulation." "If you feel pain during the walk, keep walking until the end of the hallway is reached." "As soon as you feel pain, we will go back and elevate your legs." "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room."

"Walk to the point of pain, rest until the pain subsides, then resume ambulation." The nurse instructs the patient to walk to the point of pain, rest until the pain subsides, and then resume walking so that endurance can be increased as collateral circulation develops. Pain can serve as a guide in determining the appropriate amount of exercise.

Which type of hematopoietic stem cell transplantation (HSCT) is characterized by cells from a donor other than the patient? Allogeneic Homogenic Autologous Syngeneic

Allogeneic If the source of donor cells is from a donor other than the patient, it is termed allogeneic. Autologous donor cells come from the patient. Syngeneic donor cells are from an identical twin. Homogenic is not a type of stem cell transplant.

You are caring for a client with CAD. What is an appropriate nursing action when evaluating a client with coronary artery disease (CAD)? Assess the client's mental and emotional status. Assess for any kind of drug abuse. Assess the skin of the client. Assess the characteristics of chest pain.

Assess the characteristics of chest pain. The nurse should assess the characteristics of chest pain for a client with CAD. Assessing the client's mental, emotional status, the skin of the client, or for drug abuse will not assist the nurse in evaluating the client for CAD.

A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms?

Raynaud's disease

As the moment of death approaches, which of the following does the nurse encourage the family to do? Speak to the client in a calm and soothing voice. Have the family sit in front of the client so they can be seen. Rub the client's hand and arm to comfort the client. Lie next to the client and hold the client.

Speak to the client in a calm and soothing voice. Sight and touch diminish as the client approaches death; however, hearing tends to remain intact. Speaking to the client calmly is most appropriate.

What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? Ulcers and infection in the edematous area Cyanosis Loose and wrinkled skin Evident scarring

Ulcers and infection in the edematous area In a client with lymphedema, the tissue nutrition is impaired because of the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area. Later, the skin also appears thickened, rough, and discolored. Scarring does not occur in clients with lymphedema. Cyanosis is a bluish discoloration of the skin and mucous membranes.

A client is undergoing photochemotherapy involving a combination of a photosensitizing chemical and ultraviolet light. What health problem does this client most likely have? undesired tattoo dandruff psoriasis plantar warts

psoriasis Photochemotherapy is used to treat psoriasis.

A client with a brain tumor recently stopped radiation and chemotherapy for treatment of the cancer. The client recently reported dry mouth. Which intervention by the hospice nurse demonstrates that the nurse understands treatment measures for dry mouth? Gently suction the client's mouth and buccal cavity. Begin 9% normal saline IV at 125 mL/hr. Place two drops of atropine ophthalmic 1% solution sublingually. Provide gentle oral care after each meal.

Provide gentle oral care after each meal. Dry mouth can generally be managed through nursing measures such as mouth care. The use of artificial hydration (IV fluids) carries considerable risks and does not contribute to comfort at the end of life. Atropine ophthalmic 1% drops administered sublingually help to reduce oral secretions. Gentle oral suctioning reduces the production of secretions.

A client with severe mitral valve insufficiency has been admitted to your unit. The client is in heart failure and has developed pulmonary edema. What would be the best course of treatment for this client? Cardiac glycosides Beta blockers Surgery Palliative care

Surgery If the cause of heart failure and pulmonary edema can be corrected surgically (e.g., a mitral valve disorder), the client is supported medically while being prepared for surgery. Options A, B, and D do not have the potential to reverse or stabilize this client's disease process, so they would not be the best treatment option.

A pt diagnosed 2 weeks ago with acute pharyngitis comes to the clinic stating that the sore throat got better for a couple of days and is now back along with an earache. What complications should the nurse be aware of related to acute pharyngitis?(Select all that apply.) a. Mastoiditis b. Otitis media c. Peritonsillar abscess d. Pericarditis e. Encephalitis

a. Mastoiditis b. Otitis media c. Peritonsillar abscess

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?

impaired gas exchange

The classification of Stage II of COPD is defined as moderate COPD. at risk for COPD. very severe COPD. severe COPD. mild COPD.

moderate COPD. Stage II is moderate COPD. Stage 0 is at risk for COPD. Stage I is mild COPD. Stage III is severe COPD. Stage IV is very severe COPD.

A nurse practitioner prescribes a therapeutic bath for a patient with an exacerbation of psoriasis. She tells the patient to make sure the bath area is well ventilated. Which of the following is the therapeutic bath solution prescribed by the nurse?

Medicated tars

The nurse is assigned to care for a patient with COPD with hypoxemia and hypercapnia. When planning care for this patient, what does the nurse understand is the main goal of treatment? Providing sufficient oxygen to improve oxygenation Avoiding the use of oxygen to decrease the hypoxic drive Monitoring the pulse oximetry to assess need for early intervention when PCO2 levels rise Increasing pH

Providing sufficient oxygen to improve oxygenation The main objective in treating patients with hypoxemia and hypercapnia is to give sufficient oxygen to improve oxygenation.

The nurse, caring for a patient with emphysema, understands that airflow limitations are not reversible. The end result of deterioration is: Respiratory acidosis. Hypoxemia secondary to impaired oxygen diffusion. Hypercapnia resulting from decreased carbon dioxide elimination. Diminished alveolar surface area.

Respiratory acidosis. Decreased carbon dioxide elimination results in increased carbon dioxide tension (hypercapnia), which leads to respiratory acidosis and chronic respiratory failure.

Which infecting agent causes scabies?

itch mite

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client? Wear antiembolic stockings daily to assist with blood return to the heart. Keep your feet elevated above your heart. Stop smoking. Do not cross your legs for more than 30 minutes at a time.

Stop smoking. Nicotine from tobacco products causes vasospasm and can thereby dramatically reduce circulation to the extremities. When the client elevates the feet above the heart level, the heart must work against gravity to supply blood to the feet. Antiembolic stocking are helpful for venous return to the heart, but constriction is not helpful for lack of arterial blood flow. Crossing the legs for more than a few minutes at a time compresses arteries and decreases blood supply to the legs and feet.

A patient in the emergency department who presented with shortness of breath has been informed by her health care provider that her chest X-ray is suggestive of a pleural effusion. The health care provider recently outlined the proposed course of treatment, but the patient has just asked the nurse, "Can you tell me exactly what's wrong with me?" What response would be most accurate? "The small air sacs that make up your lungs have become infected." "Bacteria have entered the fluid surrounding your lungs and these bacteria must be eliminated." "Fluid has built up between your lungs and the lining that surrounds your lungs." "A large amount of fluid has accumulated in your lungs and made it difficult to breathe."

"Fluid has built up between your lungs and the lining that surrounds your lungs." A pleural effusion is characterized by an accumulation of fluid in the pleural space. This excess fluid is not located in the lung tissue itself or in the alveoli. A pleural effusion is not normally infectious in etiology.

A terminally ill patient in pain asks the nurse to administer enough pain medication to end the suffering forever. What is the best response by the nurse? "I will see if the physician will order enough for that to occur." "I will notify the physician that the current dose of medication is not relieving your pain." "I can't do that, I will go to jail." "I am surprised that you would ask me to do something like that."

"I will notify the physician that the current dose of medication is not relieving your pain." Palliative sedation is distinguished from euthanasia and physician-assisted suicide in that the intent of palliative sedation is to relieve symptoms, not to hasten death. Palliative sedation is most commonly used when the patient exhibits intractable pain, dyspnea, seizures, or delirium, and it is generally considered appropriate in only the most difficult situations.

A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which client statement indicates an accurate understanding of appropriate ways to deal with this deficit? "I'll play card games with my friends." "I'll take a long trip to visit my aunt." "I'll eat lunch in a restaurant every day." "I'll bowl with my team after discharge."

"I'll play card games with my friends." During chemotherapy, playing cards is an appropriate diversional activity because it doesn't require a great deal of energy. To conserve energy, the client should avoid such activities as taking long trips, bowling, and eating in restaurants every day. However, the client may take occasional short trips and dine out on special occasions.

The admitting nurse is assessing a client with COPD. The nurse auscultates diminished breath sounds, which signify changes in the airway. These changes indicate to the nurse to monitor the patient for what? 1. Clubbing of the fingers and cyanosis 2. Hypoxemia and clubbing of the fingers 3. Bronchospasm and clubbing of the fingers 4. Dyspnea and hypoxemia

4. Dyspnea and hypoxemia These changes in the airway require that the nurse monitor the patient for dyspnea and hypoxemia. Cyanosis is a sign of hypoxemia.

A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will not continue treatment after leaving the clinic. Which of the following measures is the highest priority? Provide the client with oral penicillin that will last for 5 days. Provide emphatic oral instructions for the client. Administer one intramuscular injection of penicillin. Ask an accompanying homeless friend to monitor the client's follow-up.

Administer one intramuscular injection of penicillin. If a nurse is concerned that a client may not perform follow-up treatment for streptococcal pharyngitis, the highest priority is to administer penicillin as a one-time injection dose. Oral penicillin is as effective and less painful, but the client needs to take the full course of treatment to prevent antibiotic-resistant germs from developing. The nurse should provide oral and written instructions for the client, but this is not as high a priority as administering the penicillin. Having a homeless friend monitor the client's care does not ensure that the client will follow therapy.

A nursing student is discussing a patient with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for patients with viral pharyngitis? A) Teaching focuses on safe and effective use of antibiotics. B) The patient should be preliminarily screened for surgery. C) Symptom management is the main focus of medical and nursing care. D) The focus of care is resting the voice to prevent chronic hoarseness.

C) Symptom management is the main focus of medical and nursing care. Nursing care for patients with viral pharyngitis focuses on symptomatic management. Antibiotics are not prescribed for viral etiologies. Surgery is not indicated in the treatment of viral pharyngitis. Chronic hoarseness is not a common sequela of viral pharyngitis, so teaching ways to prevent it would be of no use in this instance

Which of the following is the most effective treatment for obstructive sleep apnea (OSA)? Bilevel positive airway pressure (BiPAP) Oxygen by nasal cannula Continuous positive airway pressure (CPAP) Mechanical ventilation

Continuous positive airway pressure (CPAP) CPAP is the most effective treatment for OSA because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. To use CPAP, the patient must be breathing independently. BiPAP ventilation offers independent control of inspiratory and expiratory pressure while providing pressure support ventilation. Mechanical ventilation is not the most effective treatment for OSA. Administration of low-flow nasal oxygen at night can help relieve hypoxemia in some patients but has little effect on the frequency or severity of apnea.

Which of the following is an appropriate method of assessing the dying client? Focus on the client's basic needs. Stimulate the client every 30 minutes. Sedate the client before completing range-of-motion exercises. Repeat assessments as necessary.

Focus on the client's basic needs Initially, nurses focus assessment on the client's basic physical needs, such as pain, breathing, nutrition, hydration, and elimination. The other options are inappropriate in the assessment of the dying client.

A nurse is caring for a client after cardiac surgery. Upon assessment, the client appears restless and reports nausea and weakness. The client's ECG reveals peaked T waves. The nurse reviews the client's serum electrolytes, anticipating which abnormality? Hypomagnesemia Hyponatremia Hyperkalemia Hypercalcemia

Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia would likely be demonstrated by asystole. Hypomagnesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. Hyponatremia would likely be indicated by weakness, fatigue, and confusion, without changes in T-wave formation.

With repeated reactions of contact dermatitis, which of the following can occur?

Secondary bacterial infection

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?

Measure abdominal girth according to a set routine. If the abdomen appears enlarged, the nurse measures it according to a set routine. The nurse reports any change in mental status or signs of gastrointestinal bleeding immediately. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis.

While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply? Povidone-iodine-soaked gauze Sterile petroleum gauze Dry sterile dressing Moist sterile saline gauze

Moist sterile saline gauze Moist sterile saline dressings support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent but because it can irritate epithelial cells, it shouldn't be left on an open wound.

When measuring the blood pressure in each arm of a healthy adult client, the nurse recognizes that which statement is true? Pressures must be equal in both arms. Pressures may vary 10 mm Hg or more between arms. Pressures may vary, with the higher pressure found in the left arm. Pressures should not differ more than 5 mm Hg between arms.

Pressures should not differ more than 5 mm Hg between arms. Normally, in the absence of any disease of the vasculature, arm pressures differ by no more than 5 mm Hg. The pressures in each arm do not have to be equal to be considered normal. Pressures that vary more than 10 mm Hg between arms are an abnormal finding. The left arm pressure is not anticipated to be higher than the right as a normal anatomic variant.

A patient visits a clinic for assessment of an inflammatory skin disorder. The nurse diagnoses the condition as psoriasis based on the appearance of the skin. Which of the following describes the dermatoses?

Red, raised patches of skin covered with silvery scales

An extended care facility has been the site of a breakout of scabies in recent days. The staff at the facility recognize the need for an expedited, coordinated response to this outbreak. This response should include which of the following measures? Select all that apply. a. Providing warm, soapy baths to affected residents b. Providing prophylactic antibiotics to unaffected residents c. Applying a topical scabicide to the skin of affected residents d. Providing a course of oral antiviral medication to all residents e. Vaccinating all staff and residents against scabies as soon as possible

a. Providing warm, soapy baths to affected residents c. Applying a topical scabicide to the skin of affected residents

A nurse is monitoring the vital signs and blood results of a client who is receiving anticoagulation therapy. What does nurse identify as a major indication of concern? heart rate of 87 bpm hematocrit of 30% hemoglobin of 16 g/dL blood pressure of 129/72 mm Hg

hematocrit of 30% Hematocrit is a measurement of the proportion of blood volume that is occupied by red blood cells. A lower hematocrit can imply internal bleeding. Blood pressure of 129/72 and heart rate of 87 bpm are normal. A hemoglobin count of 16 g/dL is also normal.

According to the TNM classification system, T0 means there is no distant metastasis. no evidence of primary tumor. no regional lymph node metastasis. distant metastasis.

no evidence of primary tumor. T0 means that there is no evidence of primary tumor. N0 means that there is no regional lymph node metastasis. M0 means that there is no distant metastasis. M1 means that there is distant metastasis.

A client is being treated for acne vulgaris. What contributes to follicular irritation? potato chips chocolate stress overproduction of sebum

overproduction of sebum The overproduction of sebum provides an ideal environment for bacterial growth within the irritated follicle. The follicle becomes further distended and irritated, causing a raised papule in the skin.

A patient states that her family has had several colds during this winter and spring despite their commitment to handwashing. The high communicability of the common cold is attributable to whatfactor?

The virus is shed for 2 days prior to the emergence of symptoms.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

ambu

A client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include

hoarseness.

When a patient has been diagnosed with scabies, if the infection has spread, family members may complain of pruritus within which time frame?

1 month

When obtaining a health history from a patient at the clinic with suspected community acquired pneumonia, the nurse expects the patient to report?

An abrupt onset of fever and chills

Photochemotherapy has been used as a treatment for which of the following skin disorders? Allergic dermatitis Shingles Rosacea Psoriasis

Psoriasis Photochemotherapy is used for severe, disabling psoriasis that does not respond to other methods of treatments.

Which of the following would be inconsistent with a hypertensive urgency? Epistaxis Intracranial hemorrhage Anxiety Severe headache

Intracranial hemorrhage Elevated blood pressure in hypertensive urgency is associated with severe headache, epistaxis, and anxiety. An example of a hypertensive emergency is a myocardial infarction, intracranial hemorrhage, or dissecting aortic aneurysm.

A nurse is assisting with with checking blood pressures at a local health care fair. To which client would the nurse pay particular attention? A 40-year-old African-American man A 16-year-old girl A 50-year-old Caucasian woman An Asian adult man

A 40-year-old African-American man Prevalence of hypertension varies by ethnicity, with African Americans having the highest prevalence.

A patient is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the patients nutrition during treatment?

A liquid or soft diet

Which is the strongest predisposing factor for asthma? Air pollution Allergy Congenital malformations Male gender

Allergy Allergy is the strongest predisposing factor for asthma.

The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated in patients with which diagnosis?

COPD

The nurse is providing instruction to a client with acne. The nurse promotes avoidance of which food(s)? Select all that apply. Bananas Chocolate Ice cream Onions

Chocolate Ice cream The nurse should promote avoidance of foods associated with flare-up of acne, particularly those high in refined sugars, including chocolate, cola, and ice cream.

Which drug is second-line pharmacotherapy for smoking abstinence?

Clonidine Second-line pharmacotherapy includes the antihypertensive agent clonidine. However, its use is limited by its side effects. First-line therapy includes nicotine gum, nortriptyline, and buproprion SR.

Which of the following is the primary cause of skin cancer?

Exposure to UV radiation in sunlight

Which of the following skin conditions is caused by staphylococci, streptococci, or multiple bacteria?

Impetigo

For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death? Increased eating Increased urinary output Increased wakefulness Increased restlessness

Increased restlessness As the oxygen supply to the brain decreases, the client may become restless. As the body weakens, the client will sleep more and begin to detach from the environment. For many clients, refusal of food is an indication that they are ready to die. Based on decreased intake, urinary output generally decreases in amount and frequency.

Why is immediate treatment needed for peritonsillar abscess?

Interferes with swallowing saliva and can also cause airway obstruction

A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?

International normalized ratio (INR) is 2.5. Oral anticoagulants such as warfarin are monitored by PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)

You are a clinic nurse doing patient education for clinic patients. A patient visits the clinic and is diagnosed with acute laryngitis. What should you instruct the patient to do?

Limit speech

Which is a risk factor for venous disorders of the lower extremities?

Obesity

Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)?

Obesity

The nurse is caring for a client admitted with a diagnosis of bacterial pharyngitis. The nurse anticipates the client will be ordered which medication?

Penicillin

A night-shift nurse receives a call from the emergency department about a client with herpes zoster who is going to be admitted to the floor. Based on this diagnosis, where should the nurse assign the client?

Private room

A client with hepatitis C develops liver failure and GI hemorrhage. The blood products that most likely bring about hemostasis in the client are:

cryoprecipitate and fresh frozen plasma.

When caring for a client with severe impetigo, the nurse should include which intervention in the care plan?

Administering systemic antibiotics as ordered

A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction best prevents skin damage? "Apply sunscreen even on overcast days." "Minimize sun exposure from 1 to 4 p.m., when the sun is strongest." "Use a sunscreen with a sun protection factor of 6 or higher." "When at the beach, sit in the shade to prevent sunburn."

"Apply sunscreen even on overcast days." Sunscreen should be applied even on overcast days, because the sun's rays are as damaging then as on sunny days. The sun is strongest from 10 a.m. to 3 p.m. (11 a.m. to 4 p.m. daylight saving time) — not from 1 to 4 p.m. Sun exposure should be minimized during these hours. The nurse should recommend sunscreen with a sun protection factor of at least 15. Sitting in the shade when at the beach doesn't guarantee protection against sunburn because sand, concrete, and water can reflect more than half the sun's rays onto the skin.

Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis? "I will come back in 1 week to have the test read." "I will avoid contact with my family until I am done with the test." "If the test area turns red that means I have tuberculosis." "Because I had a previous reaction to the test, this time I need to get a chest X-ray."

"Because I had a previous reaction to the test, this time I need to get a chest X-ray." A client who previously had a positive PPD test (a reaction to the antigen) can't receive a repeat PPD test and must have a chest X-ray done instead. The test should be read 48 to 72 hours after administration. Redness at the test area doesn't indicate a positive test; an induration of greater than 10 mm indicates a positive test. The client doesn't need to avoid contact with people during the test period.

The clinic nurse is caring for a client who has just been diagnosed with a tumor. The client says to the nurse "The doctor says my tumor is benign. What does that mean?" What is the nurse's best response? "Benign tumors don't usually cause death." "Benign tumors grow very rapidly." "Benign tumors invade surrounding tissue." "Benign tumors can spread from one place to another."

"Benign tumors don't usually cause death." Benign tumors remain at their site of development. They may grow large, but their growth rate is slower than that of malignant tumors. They usually do not cause death unless their location impairs the function of a vital organ, such as the brain.

A client with high blood pressure is receiving an antihypertensive drug. When developing a client teaching plan to minimize orthostatic hypotension, which instruction should the nurse include? "Avoid drinking alcohol and straining at stool, and eat a low-protein snack at night." "Rest between demanding activities, eat plenty of fruits and vegetables, and drink 6 to 8 cups of fluid daily." "Flex your calf muscles, avoid alcohol, and change positions slowly." "Wear elastic stockings, change positions quickly, and hold onto a stationary object when rising."

"Flex your calf muscles, avoid alcohol, and change positions slowly." Measures that minimize orthostatic hypotension include flexing the calf muscles to boost blood return to the heart, avoiding alcohol and straining at stool, changing positions slowly, eating a high-protein snack at night, wearing elastic stockings, and holding onto a stationary object when rising. Although the client should rest between demanding activities and consume plenty of fluids and fiber (contained in fruits and vegetables) to maintain a balanced diet, these measures don't directly relieve orthostatic hypotension.

A 66-year-old client presents to the emergency department reporting severe headache and mild nausea for the past 6 hours. Upon assessment, the client's BP is 210/120 mm Hg. The client has a history of hypertension and takes 1.0 mg clonidine twice daily. Which question is most important for the nurse to ask the client next? "Do you have a dry mouth or nasal congestion?" "Have you taken your prescribed clonidine today?" "Did you take any medication for your headache?" "Are you having chest pain or shortness of breath?"

"Have you taken your prescribed clonidine today?" The nurse must ask whether the client has taken his prescribed clonidine. Clients need to be informed that rebound hypertension can occur if antihypertensive medications are suddenly stopped. Specifically, a side effect of clonidine is rebound or withdrawal hypertension. Although the other questions may be asked, it is most important to inquire whether the client has taken the prescribed hypertension medication given the client's severely elevated BP.

A client with chronic obstructive pulmonary disease (COPD) expresses a desire to quit smoking. The first appropriate response from the nurse is: "I can refer you to the American Lung Association." "Have you tried to quit smoking before?" "Many options are available for you." "Nicotine patches would be appropriate for you."

"Have you tried to quit smoking before?" All the options are appropriate statements; however, the nurse needs to assess the client's statement further. Assessment data include information about previous attempts to quit smoking.

The nurse is preparing to interview a client with cirrhosis. Based on an understanding of this disorder, which question would be most important to include?

"How often do you drink alcohol?" The most common type of cirrhosis results from chronic alcohol intake and is frequently associated with poor nutrition. Although it can follow chronic poisoning with chemicals or ingestion of hepatotoxic drugs such as acetaminophen, asking about alcohol intake would be most important. Asking about an infection or exposure to hepatotoxins or industrial chemicals would be important if the client had postnecrotic cirrhosis.

A client is placed on a low-sodium (500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective? "I chose broiled chicken with a baked potato for dinner." "I chose a tossed salad with sardines and oil and vinegar dressing for lunch." "I can still eat a ham-and-cheese sandwich with potato chips for lunch." "I'm glad I can still have chicken bouillon."

"I chose broiled chicken with a baked potato for dinner." The client's choice of a baked potato with broiled chicken indicates effective nutrition teaching because potatoes and chicken are relatively low in sodium. Ham, sardines, and bouillon are extremely high in sodium and shouldn't be included in a low-sodium diet.

A nurse has just completed teaching with a client who has been prescribed a meter-dosed inhaler for the first time. Which statement if made by the client would indicate to the nurse that further teaching and follow-up care is necessary? "After I breathe in, I will hold my breath for 10 seconds." "I do not need to rinse my mouth with this type of inhaler." "I will make sure to take a slow, deep breath as I push on my inhaler." "If I use the spacer, I know I am only supposed to push on the inhaler once."

"I do not need to rinse my mouth with this type of inhaler." Mouth-washing and spitting are effective in reducing the amount of drug swallowed and absorbed systemically. Actuation during a slow (30 L/min or 3 to 5 seconds) and deep inhalation should be followed by 10 seconds of holding the breath. The client should actuate only once. Simple tubes do not obviate the spacer/VHC per inhalation.

A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching? "I take a stool softener every morning." "I floss my teeth every morning." "I removed all the throw rugs from the house." "I use an electric razor to shave."

"I floss my teeth every morning." A client with a platelet count of 30,000/mm3 is at risk for bleeding and shouldn't floss his teeth. Flossing may increase the risk of bleeding in a client with a platelet count less than 40,000/mm3. Using an electric razor is appropriate because doing so helps minimize the risk of cutting when shaving. Taking a stool softener helps decrease potential trauma to the GI tract that may cause bleeding. Removing throw rugs from the house helps prevent falls, which could lead to uncontrolled bleeding.

A client is recovering from a craniotomy with tumor debulking. Which comment by the client indicates to the nurse a correct understanding of what the surgery entailed? "I will be glad to finally be done with treatments for this thing." "Thank goodness the tumor is contained and curable." "I guess the doctor could not remove the entire tumor." "I am so glad the doctor was able to remove the entire tumor."

"I guess the doctor could not remove the entire tumor." Debulking is a reference made when a tumor cannot be completely removed, often due to its extension far into healthy tissue. Without complete removal, this is not a cure and, the cancer cells will continue to replicate and require adjuvant therapies to prevent further invasion. The physician, not the nurse, will need to clarify the details of the surgery.

A nurse is assessing a terminally ill female client. Which client statement indicates that the client is in the bargaining stage of dying? "I just want to see my daughter graduate from college. That's all." "Why is this happening to me. I've led a good life. Why is God punishing me?" "I can't believe this. I'm going to get a second opinion." "I don't know how my husband is going to manage things when I'm gone."

"I just want to see my daughter graduate from college. That's all." Bargaining is manifested by pleading for more time to reach an important goal. This is reflected in the client's statement about wanting to see her daughter's college graduation. The statement about going to get a second opinion reflects denial. The statement about why reflects anger. The statement about not knowing how the husband will manage reflects the depression stage.

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says: "I should eat a high-protein diet." "I should become involved in a weight loss program." "I need to keep my inhaler at the bedside." "I should sleep on my side all night long."

"I should become involved in a weight loss program." Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea.

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? "My pants don't fit around my waist." "My feet are bigger than normal." "I sleep on three pillows each night." "I don't have the same appetite I used to."

"I sleep on three pillows each night." Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? "I have environmental allergies." "I was chewing ice chips all day long." "I used my voice in excess over the weekend." "I smoke a pack of cigarettes a day."

"I was chewing ice chips all day long." Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies, smoking, and excessive use of the voice causing straining are frequent causes.

A community health nurse teaches a group of older adults about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which statement? "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." "The older I get the higher my risk for peripheral arterial disease gets." "Because my family is from Italy, I have a higher risk of developing peripheral arterial disease." "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels."

"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." The use of tobacco products may be one of the most important risk factors in the development of atherosclerotic lesions. Nicotine in tobacco decreases blood flow to the extremities and increases heart rate and blood pressure by stimulating the sympathetic nervous system. This causes vasoconstriction, thereby decreasing arterial blood flow. It also increases the risk of clot formation by increasing the aggregation of platelets.

The clinic nurse is caring for a client who has just been diagnosed with chronic obstructive pulmonary disease (COPD). The client asks the nurse what COPD means. What would be the nurse's best response? "It means that the lungs have been damaged in such a way that there is limited airflow in and out of the lungs." "It means your lungs can't expand and contract like they are supposed to which makes it hard for you to breathe." "It is an umbrella term for diseases like acute bronchitis." "It is a term that covers so many lung diseases I can't list them all."

"It means that the lungs have been damaged in such a way that there is limited airflow in and out of the lungs." Chronic obstructive pulmonary disease (COPD) is an umbrella term for chronic lung diseases that have limited airflow in and out of the lungs.

A mother of three young children has been diagnosed with stage III breast cancer and is distraught. Which statement best communicates a spirit of hopefulness to this client? "You should seek a second medical opinion about your diagnosis." "I know another client with the same diagnosis who has been in remission for 10 years." "Let's take this one day at a time; remember you have your daughter's dance recital next month." "I believe that you will fight hard to beat this and see your babies grow up."

"Let's take this one day at a time; remember you have your daughter's dance recital next month." Helping a client to find reasons to live and look forward to events promotes positive attitudes and ability to live for the moment, which in turn communicates a spirit of hopefulness. The statement about a second opinion is inappropriate because it gives the client false hope that her current diagnosis is inaccurate. Although he client may choose another medical opinion, she needs to come to that decision without the nurse's advice. Reponses should not convey false hope to the client. Nurses and clients should not confuse hope with unrealistic optimism.

Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension? "Limiting my salt intake to 2 grams per day will improve my blood pressure." "A glass of red wine each day will lower my blood pressure." "If I include less fat in my diet, I'll lower my blood pressure." "I should eliminate caffeine from my diet to lower my blood pressure."

"Limiting my salt intake to 2 grams per day will improve my blood pressure." To lower blood pressure, a client should limit daily salt intake to 2 g or less. Alcohol intake is associated with a higher incidence of hypertension, poor compliance with treatment, and refractory hypertension. Chronic, moderate caffeine intake and fat intake don't affect blood pressure

The nurse is caring for a client diagnosed with herpes zoster. Which statement by the client needs further clarification by the nurse? a. "Even though this is from a childhood disease, I am still contagious." b. "Herpes zoster is caused by a viral infection." c. "Herpes zoster is a reactivation of the varicella virus." d. "Once I get the infection, I cannot get it again."

"Once I get the infection, I cannot get it again."

A client newly diagnosed with COPD tells the nurse, "I can't believe I have COPD; I only had a cough. Are there other symptoms I should know about"? Which is the best response by the nurse? "You can also expect to experience a progressive weight gain." "Other symptoms you may develop are shortness of breath upon exertion and sputum production." "As your COPD worsens, you will frequently develop respiratory infections." "There are no other symptoms; however, your cough may get worse as the disease progresses."

"Other symptoms you may develop are shortness of breath upon exertion and sputum production." COPD is characterized by three primary symptoms: cough, sputum production, and dyspnea upon exertion. Clients with COPD are at risk for respiratory insufficiency and respiratory infections, which in turn increase the risk of acute and chronic respiratory failure. Weight loss is common with COPD.

A nurse is teaching a client with newly diagnosed hypertension who asks if there is any harm in stopping antihypertensive medication. What is the nurse's best response? "Postural hypotension can occur." "Rebound hypertension can occur." "Rebound hypotension can occur." "Postural hypertension can occur."

"Rebound hypertension can occur." Clients need to be informed that rebound hypertension can occur if they stop antihypertensive medications suddenly. This can be extremely dangerous and have serious consequences. Hypotension would not be a problem with discontinuation of antihypertensive medications.

A nurse is educating a client about monitoring blood pressure readings at home. What will the nurse be sure to emphasize? "Sit quietly for 5 minutes prior to taking blood pressure." "Avoid smoking cigarettes for 8 hours prior to taking blood pressure." "Sit with legs crossed when taking your blood pressure." "Be sure the forearm is well supported above heart level while taking blood pressure."

"Sit quietly for 5 minutes prior to taking blood pressure." Instructions for the client regarding measuring the blood pressure at home include the following: (1) Avoid smoking cigarettes or drinking caffeine for 30 minutes before measuring blood pressure. (2) Sit quietly for 5 minutes before the measurement. (3) Have the forearm supported at heart level, with both feet on the ground during the measurement of the blood pressure.

A terminally ill patient is admitted to the hospital. The patient grabs the nurse's hand and asks, "Am I dying?" What response would be best for the nurse to give? "Tell me more about what's on your mind." "Why do you think that?" "I am not at liberty to disclose that information." "Did someone tell you that you are dying?"

"Tell me more about what's on your mind." In response to the question "Am I dying?" the nurse could establish eye contact and follow with a statement acknowledging the patient's fears ("This must be very difficult for you") and an open-ended statement or question ("Tell me more about what is on your mind"). The nurse then needs to listen intently, ask additional questions for clarification, and provide reassurance only when it is realistic.

Which statements made by the nurse demonstrates that the nurse is providing spiritually sensitive care? "Tell me who or what gives you strength." "A key component of hospice care is following your family for up to a year after your death." "Denial, sadness, anger, fear, and anxiety are normal grief reactions." "Mourning may be demonstrated by emotional feelings of sadness, anger, guilt, and numbness."

"Tell me who or what gives you strength." Spirituality is a personal belief system that focuses on a search for meaning and purpose of life. Assessment of people or things that provide strength to a terminally ill client is one way the nurse provides spiritually sensitive patient care. Grief is defined as the personal feelings that accompany an anticipated or actual loss. Bereavement is a period during which mourning for a loss take place. Mourning is an expression of grief and associated behaviors.

A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate?

"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect."

The nurse is caring for a client who is scheduled for chemotherapy. Which is the best statement the nurse can make about the client experiencing chemotherapy-induced alopecia? "The hair loss is usually temporary." "New hair growth will return without any change to color or texture." "Wigs can be used after the chemotherapy is completed." "Clients with alopecia will have delay in grey hair."

"The hair loss is usually temporary." Alopecia associated with chemotherapy is usually temporary and will return after the therapy is completed. New hair growth may return unchanged, but there is no guarantee and color, texture, and quality of hair may be changed. There is no correlation between chemotherapy and delay in greying of hair. Use of wigs, scarves, and head coverings can be used by clients at any time during treatment plan.

The family of a terminally ill client tells the nurse that the client has been breathing irregularly and, at times, it appears that he is not breathing at all. The client's daughter states, "He moans when he breathes. Is he in pain?" Which response by the nurse would be most appropriate? "He is getting less oxygen to the brain, so the moaning means he is dreaming." "The moaning you hear is from air moving over very relaxed vocal cords." "He has secretions that are collecting at the back of the throat." "His moaning does indicate pain, so we'll increase his pain medication."

"The moaning you hear is from air moving over very relaxed vocal cords." As a client approaches death, certain signs appear. The family is reporting irregular breathing with periods of apnea. The moaning that they hear reflects the sound of air passing over very relaxed vocal cords. It does not signify pain or distress. Therefore, no additional pain medication would be needed. Secretions collecting at the back of the throat are noted by a rattling or gurgling sound. Decreased oxygen to the brain would lead to confusion, which may be reported by the client as strange dreams or visions.

The clinic nurse is caring for a patient who has just been diagnosed with COPD. The patient asks the nurse what he could have done to minimize the risk of contracting the disease. What would be the nurse's best answer?

"The most important risk factor for COPD is cigarette smoking"

When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris? "The pain resolved after I ate a sandwich." "The pain lasted about 45 minutes." "The pain occurred while I was mowing the lawn." "The pain got worse when I took a deep breath."

"The pain occurred while I was mowing the lawn." Decreased oxygen supply to the myocardium causes angina pectoris. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and may precipitate this chest pain. Anginal pain typically is self-limiting, lasting 5 to 15 minutes. Food consumption doesn't reduce angina pain, although it may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.

A 52-year-old mother of three has just been diagnosed with lung cancer. The health care provider discusses treatment options and makes recommendations to this patient. After the health care provider leaves the room, the patient asks the nurse how the treatment is decided on. What would be the nurse's best response? "The type of treatment depends on the patient's age and health status." "The type of treatment depends on what the patient wants when given the options." "The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status." "The type of treatment depends on the discussion between the patient and the health care provider over which treatment is best."

"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status." The objective of management is to provide a cure, if possible. Treatment depends on the cell type, the stage of the disease, and the patient's physiologic status (particularly cardiac and pulmonary status). Treatment does not depend primarily on the patient's age, or the patient's preference between the different treatment modes. The decision surrounding treatment does not depend solely on a discussion between the patient and the health care provider over which treatment is best, although patient preferences are an important consideration.

A client is receiving anticoagulant therapy. What question will the nurse ask the client to detect any signs of bleeding? "Is your skin drier than normal?" "What color is your urine?" "How is your appetite?" "Do you have any breathing problems?"

"What color is your urine?" The patient receiving anticoagulation therapy should be monitored for signs and symptoms of bleeding, such as changes in the color of the stool or urine. Anticoagulation therapy should not cause dry skin. The anticoagulation therapy should not change the client's breathing or appetite.

A college student presents to the health clinical with signs and symptoms of viral rhinitis (common cold). The patient states, "I've felt terrible all week; what can I do to feel better?" Which of the following is the best response the nurse can give?

"You should rest, increase your fluids, and take Ibuprofen."

A young female client has received chemotherapeutic medications and asks about any effects the treatments will have related to her sexual health. The most appropriate statement by the nurse is "You will continue having your menses every month." "You will experience menopause now." "You will need to practice birth control measures." "You will be unable to have children."

"You will need to practice birth control measures." Following chemotherapy female clients may experience normal ovulation, early menopause, or permanent sterility. Clients are advised to use reliable methods of birth control until reproductivity is known.

Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse's concern? Select all that apply. Ascites Wheezes Jugular vein distention Decreased airflow Compromised gas exchange

-Compromised gas exchange -Decreased airflow -Wheezes Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may cause dyspnea, static secretions, and infection. Bronchospasm can sometimes be detected on auscultation with a stethoscope when wheezing or diminished breath sounds are heard. Increased mucus production, along with decreased mucociliary action, contributes to further reduction in the caliber of the bronchi and results in decreased airflow and decreased gas exchange. This is further aggravated by the loss of lung elasticity that occurs with COPD (GOLD, 2015).

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? a) The client exhibits bronchial breath sounds over the affected area .b) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. c) The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. d) The client exhibits restlessness and confusion.

.b) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.

A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication? 7 to 8 mm 9 mm 5 to 6 mm 0 to 4 mm

0 to 4 mm The Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The size of the induration determines the significance of the reaction. A reaction of 0 to 4 mm is considered not significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk.

The nurse is caring for a client with COPD. It is time to do discharge teaching with this client. The nurse teaches the client about breathing exercises. What should the nurse include in the teaching? 1. Use diaphragmatic breathing 2. Make inhalation longer than exhalation 3. Exhale through an open mouth 4. Use chest breathing

1. Use diaphragmatic breathing Inspiratory muscle training and breathing retraining may help improve breathing patterns. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and, sometimes, helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and controls the rate and depth of respiration. It also promotes relaxation, which allows patients to gain control of dyspnea and reduce feelings of panic. Diaphragmatic breathing, not chest breathing, increases lung expansion.

An obese male is being evaluated for OSA. The nurse asks the patient's wife to document the number and frequency of incidences of apnea while her husband is asleep. The nurse tells the wife that a characteristic indicator of OSA is a breathing cycle characterized by periods of breathing cessation for: 6 seconds with 3 episodes/hour. 10 seconds with 5 episodes/hour. 4 seconds with 2 episodes/hour. 8 seconds with 4 episodes/hour.

10 seconds with 5 episodes/hour. OSA is characterized by frequent and loud snoring, with breathing cessation for 10 seconds or longer, for at least five episodes per hour, followed by abrupt awakening with a loud snort as the blood oxygen level drops. Symptoms typically progress with weight gain, aging, and during the transition to menopause for women.

The nurse is reviewing the results of a total cholesterol level for a client who has been taking simvastatin. What results display the effectiveness of the medication? 280-300 mg/dL 160-190 mg/dL 250-275 mg/dL 210-240 mg/dL

160-190 mg/dL Simvastatin is a statin frequently given as initial therapy for significantly elevated cholesterol and low-density lipoprotein levels. Normal total cholesterol is less than 200 mg/dL.

A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient's ejection fraction to be? 55% 65% 30% 5%

30% The ejection fraction is normal in diastolic heart failure, but severely reduced in systolic heart failure. The normal EF is 55%-65%. An EF of 5% is not life sustaining and an EF of 30% is about half the normal percentage.

The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What statement by the nurse is correct related to risk for cancer in smokers? 1. "The risk for cancer never decreases, so you will need annual chest x-rays." 2. "The risk for cancer increases annually and there is nothing you can do about that." 3. "The risk is determined by pack-year history and the age you started smoking." 4. "Risk is determined by the pack-year, the age of initiation of smoking, the depth of inhalation, and the tar and nicotine levels in the cigarettes smoked."

4. "Risk is determined by the pack-year, the age of initiation of smoking, the depth of inhalation, and the tar and nicotine levels in the cigarettes smoked." Risk is determined by the pack-year history (number of packs of cigarettes used each day, multiplied by the number of years smoked), the age of initiation of smoking, the depth of inhalation, and the tar and nicotine levels in the cigarettes smoked. The younger a person is when he or she starts smoking, the greater the risk of developing lung cancer. Options B and D are incorrect; they give the person asking the question inaccurate information. Option C is incorrect as it is incomplete.

You are caring for a 24-year-old patient with an antitrypsin deficiency. The patient states he has never smoked in his life. An antitrypsin deficiency predisposes the patient to what? 1. Pulmonary edema 2. Cystic fibrosis 3. Empyema 4. Development of lobular emphysema

4. Development of lobular emphysema' A host risk factor for COPD is a deficiency of alpha1-antitrypsin, an enzyme inhibitor that protects the lung parenchyma from injury. This deficiency predisposes young patients to rapid development of lobular emphysema even in the absence of smoking.

A critical-care nurse is caring for a 68-year-old patient diagnosed with mycoplasmal pneumonia after a surgical procedure. The nurse documents that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do? 1. Lie in a low Fowler's position 2. Increase activity 3. Call the nurse for deep suctioning 4. Increase oral fluids unless contraindicated

4. Increase oral fluids unless contraindicated The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Deep suctioning may cause trauma to the mucosa. The patient should have the head of the bed increased, and rest should be promoted to avoid exacerbation of symptoms.

Approximately what percentage of the arterial lumen must be obstructed before intermittent claudication is experienced? 20 30 40 50

50 Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced.

A client has had an echocardiogram to measure ejection fraction. The nurse explains that ejection fraction is the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects? 50% 40% 55% 45%

55% Normally, a healthy heart ejects 55% or more of the blood that fills the left ventricle during diastole.

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? 2 to 4 months 6 to 12 months 1 to 3 weeks 3 to 5 days

6 to 12 months Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.

The goal for oxygen therapy in COPD is to support tissue oxygenation, decrease the work of the cardiopulmonary system, and maintain the resting partial arterial pressure of oxygen (PaO2) of at least ______ mm Hg and an arterial oxygen saturation (SaO2) of at least ___%. 58 mm Hg; 88% 60 mm Hg; 90% 56 mm Hg; 86% 54 mm Hg; 84%

60 mm Hg; 90% The goal is a PaO2 of at least 60 mm Hg and an SaO2 of 90%.

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? A client who ambulates in the hallway every 4 hours A client who is receiving acetaminophen (Tylenol) for pain A client with a nasogastric tube A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago

A client with a nasogastric tube Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

A nurse is discussing with a nursing student how to accurately measure blood pressure. What statement by the student indicates an understanding of the education? A cuff that is too small will give a false low blood pressure. A cuff that is too large will give a false high blood pressure. A cuff that is too small will give a false high blood pressure. The size of the cuff does not matter as long as it fits snugly around the arm.

A cuff that is too small will give a false high blood pressure. Using a cuff that is too small will give a false high blood pressure measurement, while using a cuff that is too large results in a false low blood pressure measurement.

Which statement describes emphysema? A disease that results in reversible airflow obstruction, a common clinical outcome Presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years A disease of the airways characterized by destruction of the walls of overdistended alveoli Chronic dilatation of a bronchus or bronchi

A disease of the airways characterized by destruction of the walls of overdistended alveoli Emphysema is a category of chronic obstructive pulmonary disease (COPD). In emphysema, impaired oxygen and carbon dioxide exchange results from destruction of the walls of overdistended alveoli. Emphysema is a pathologic term that describes an abnormal distention of the airspaces beyond the terminal bronchioles and destruction of the walls of alveoli; a chronic inflammatory response may induce disruption of the parenchymal tissues. Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years. Bronchiectasis is a condition of chronic dilatation of a bronchus or bronchi.

A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis?

A liver biopsy A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding.

The oncology nurse is giving chemotherapy to a client in a short stay area. The client confides that they are very depressed. The nurse recognizes depression as which of the following? A side effect of the neoplastic drugs. A psychiatric diagnosis everyone has at one time or another. A normal reaction to the diagnosis of cancer. An aberrant psychologic reaction to the chemotherapy.

A normal reaction to the diagnosis of cancer. Clients have many reactions, ranging from anxiety, fear, and depression to feelings of guilt related to viewing cancer as a punishment for past actions or failure to practice a healthy life-style. They also may express anger related to the diagnosis and their inability to be in control. While depression is a psychiatric diagnosis not everyone has the diagnosis sometime in their life; depression is not a side effect of the neoplastic drugs nor is it an aberrant psychologic reaction to the chemotherapy.

Which would be least likely to contribute to a case of hospital-acquired pneumonia? A highly virulent organism is present. A nurse washes her hands before beginning client care. Inoculum of organisms reaches the lower respiratory tract and overwhelms the host's defenses. Host defenses are impaired.

A nurse washes her hands before beginning client care. HAP occurs when at least one of three conditions exists: host defenses are impaired, inoculums of organisms reach the lower respiratory tract and overwhelm the host's defenses, or a highly virulent organism is present.

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true? A negative reaction always excludes the diagnosis of TB. The PPD can be read within 12 hours after the injection. A positive reaction indicates that the client has active tuberculosis (TB). A positive reaction indicates that the client has been exposed to the disease.

A positive reaction indicates that the client has been exposed to the disease. A positive reaction means the client has been exposed to TB; it isn't conclusive for the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease.

Which of the following is accurate regarding status asthmaticus? Usually does not progress to severe obstruction A severe asthma episode that is refractory to initial therapy Usually occurs with warning Patients have a productive cough.

A severe asthma episode that is refractory to initial therapy Status asthmaticus is a severe asthma episode that is refractory to initial therapy. It is a medical emergency. Patients report rapid progressive chest tightness, wheezing, dry cough, and shortness of breath. It may occur with little or no warning.

The nurse is caring for a patient who needs education on his medication therapy for allergic rhinitis. The patient is to take cromolyn (Nasalcrom) daily. In providing education for this patient, how should the nurse describe the action of the medication? A) It inhibits the release of histamine and other chemicals. B) It inhibits the action of proton pumps. C) It inhibits the action of the sodium-potassium pump in the nasal epithelium. D) It causes bronchodilation and relaxes smooth muscle in the bronchi.

A) It inhibits the release of histamine and other chemicals. Cromolyn (Nasalcrom) inhibits the release of histamine and other chemicals. It is prescribed to treat allergic rhinitis. Beta-adrenergic agents lead to bronchodilation and stimulate beta-2 adrenergic receptors in the smooth muscle of the bronchi and bronchioles. It does not affect proton pump action or the sodium-potassium pump in the nasal cells.)

A nurse practitioner has provided care for three different patients with chronic pharyngitis over the past several months. Which patients are at greatest risk for developing chronic pharyngitis? A) Patients who are habitual users of alcohol and tobacco B) Patients who are habitual users of caffeine and other stimulants C) Patients who eat a diet high in spicy foods D) Patients who have gastrointestinal reflux disease (GERD)

A) Patients who are habitual users of alcohol and tobacco Chronic pharyngitis is common in adults who live and work in dusty surroundings, use the voice to excess, suffer from chronic chough, and habitually use alcohol and tobacco. Caffeine and spicy foods have not been linked to chronic pharyngitis. GERD is not a noted risk factor.

The nurse is providing patient teaching to a patient diagnosed with acute rhinosinusitis. For what possible complication should the nurse teach the patient to seek immediate follow-up? A) Periorbital edema B) Headache unrelieved by OTC medications C) Clear drainage from nose D) Blood-tinged mucus when blowing the nose

A) Periorbital edema Patient teaching is an important aspect of nursing care for the patient with acute rhinosinusitis. The nurse instructs the patient about symptoms of complications that require immediate follow-up. Referral to a physician is indicated if periorbital edema and severe pain on palpation occur. Clear drainage and blood-tinged mucus do not require follow-up if the patient has acute rhinosinusitis. A persistent headache does not necessarily warrant immediate follow-up

A patient has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to what complication? A) Sinus infections B) Esophageal strictures C) Pharyngitis D) Laryngitis

A) Sinus infections Patients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections. Thus, accurate assessment of patients with these tubes is critical. Use of a nasogastric tube is not associated with the development of the other listed pathologies

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following? Tracheobronchitis Acute respiratory distress syndrome Lung cancer Bronchitis

Acute respiratory distress Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis.

Following surgery for adenocarcinoma, the client learns the tumor stage is T3,N1,M0. What treatment mode should the nurse anticipate? Palliative care is likely. No further treatment is indicated. Repeat biopsy is needed before treatment begins. Adjuvant therapy is likely.

Adjuvant therapy is likely. T3 indicates a large tumor size, with N1 indicating regional lymph node involvement so treatment is needed. A T3 tumor must have its size reduced with adjuncts like chemotherapy and radiation. Although M0 suggest no metastasis, following with adjuvant (chemotherapy or radiation therapy) treatment is indicated to prevent the spread of cancer outside the lymph to other organs. The tumor stage IV wound be indicative of palliative care. A repeated biopsy is not needed until after treatment is completed.

A patient with a diagnosis of renal cell carcinoma is being treated with chemotherapy. During a previous round of chemotherapy, the patient's tumor responded well to treatment but the chemotherapy caused intense nausea and vomiting. How should the patient's potential nausea and vomiting be addressed during this current round of treatment? Administer antiemetics if the patient vomits or believes he will soon vomit. Prioritize nonpharmacological treatments over medications. Provide the patient with antiemetics at his first complaint of nausea. Administer antiemetics in anticipation of the patient's nausea.

Administer antiemetics in anticipation of the patient's nausea. The prevention of chemotherapy-induced nausea and vomiting is a priority. It is inappropriate to reject pharmacological treatments or to wait until the patient experiences nausea and/or vomiting before providing medication.

A client in the emergency room is in cardiac arrest and exhibiting pulseless electrical activity (PEA) on the cardiac monitor. What will be the nurse's next action? Change oxygen delivery to a mask. Stop all emergency measures. Analyze the arterial blood gas. Administer epinephrine.

Administer epinephrine PEA can be caused by hypovolemia, hypoxia, hypothermia, hyperkalemia, massive pulmonary embolism, myocardial infarction, and medication overdose (beta blockers, calcium channel blockers). PEA is treated with epinephrine according to advanced life support protocol. Applying oxygen or analyzing an arterial blood gas will not change the client's heart rhythm. PEA is treated until there is no change in the client's rhythm after treatments.

A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. The client also complains of nausea, diaphoresis, and shortness of breath. What is the nurse's priority action? Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the health care provider. Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team. Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and take vital signs.

Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the health care provider before completing the initial assessment is premature.

After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention? Serving small portions of bland food Administering metoclopramide and dexamethasone as ordered Encouraging rhythmic breathing exercises Withholding fluids for the first 4 to 6 hours after chemotherapy administration

Administering metoclopramide and dexamethasone as ordered The nurse should assign highest priority to administering an antiemetic, such as metoclopramide, and an anti-inflammatory agent, such as dexamethasone, because it may reduce the severity of chemotherapy-induced nausea and vomiting. This intervention, in turn, helps prevent dehydration, a common complication of chemotherapy. Serving small portions of bland food, encouraging rhythmic breathing exercises, and withholding fluids for the first 4 to 6 hours are less likely to achieve this outcome.

A patient's severe and widespread psoriasis has prompted her care provider to prescribe potent topical corticosteroids. When teaching this patient about her new medication regimen, the nurse should recognize that topical corticosteroids that are applied to large skin surfaces create a risk of: Disseminated intravascular coagulation (DIC) Hypothyroidism Adrenal suppression Kaposi's sarcoma

Adrenal suppression When psoriasis involves large areas of the body, topical corticosteroid treatment can be expensive and involve some systemic risk. The more potent corticosteroids, when applied to large areas of the body, have the potential to cause adrenal suppression through percutaneous absorption of the medication. This treatment is not associated with a risk of DIC, Kaposi's sarcoma, or hypothyroidism.

A client with newly diagnosed hypertension asks what to do to decrease the risk for related cardiovascular problems. Which risk factor is not modifiable by the client? Dyslipidemia Age Inactivity Obesity

Age Age and family history for cardiovascular disease are risk factors that cannot be changed. Obesity, inactivity, and dyslipidemia are risk factors that can be improved by the client through dietary changes, exercise, and other healthy lifestyle choices.

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal?

Albumin Albumin is an abnormal finding in a routine urine specimen. Ascites present in liver failure contain albumin; therefore, if the bladder ruptured, ascites containing albumin would drain from the indwelling urinary catheter because the catheter is no longer contained in the bladder. Creatinine, urobilinogen, and chloride are normally found in urine.

A client with asthma is prescribed a short acting beta-adrenergic (SABA) for quick relief. Which of the following is the most likely drug to be prescribed? Fluticasone propionate Ipratropium bromide and albuterol sulfate Ipratropium bromide Albuterol

Albuterol Albuterol (Proventil), a SABA, is given to asthmatic patients for quick relief of symptoms. Ipratropium bromide (Atrovent) is an anticholinergic. Ipratropium bromide and albuterol sulfate (Combivent) is a combination SABA/anticholinergic, and Fluticasone propionate (Flonase) is a corticosteroid.

During a teaching session, a parent asks the nurse which inhaler to use for quick relief if the child has an asthma attack. What teaching should the nurse review with the parent? Theophylline is a tablet, so it will take a while to work. Albuterol is a short-acting inhalant and will relax muscles quickly. Salmeterol is a long-acting inhalant and will not provide relief for an asthma attack. Cromolyn sodium is an inhalant used for asthma.

Albuterol is a short-acting inhalant and will relax muscles quickly. Short-acting beta2-adrenergic agonists, such as albuterol (AccuNeb, Proventil, Ventolin), levalbuterol (Xopenex HFA), and pirbuterol (Maxair), are the inhalant medications of choice for relief of acute symptoms and prevention of exercise-induced asthma. Cromolyn sodium (Crolom, NasalCrom) and nedocromil (Alocril, Tilade) are mild to moderate anti-inflammatory agents that stabilize mast cells, and are contraindicated in acute asthma exacerbations. Long-acting beta2-adrenergic agonists, such as theophylline (Slo-Bid, Theo- Dur) and salmeterol (Serevent Diskus), are not indicated for immediate relief of symptoms.

All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason? Allows for the nurse to understand when the grieving process should be concluded Allows the nurse to express his or her feelings Allows for the nurse to facilitate the grieving process Allows for the nurse to take the client through in the appropriate order

Allows for the nurse to facilitate the grieving process Grieving is a painful yet normal reaction that helps clients cope with loss and leads to emotional healing. The nurse is responsible for facilitating the grieving process and helping the client and family deal with their emotions

A nurse is reevaluating a client receiving IV fibrinolytic therapy. Which finding requires immediate intervention by the nurse? Minimal oozing of blood from the IV site Presence of reperfusion dysrhythmias Altered level of consciousness Chest pain 2 of 10 (on a 1-to-10 pain scale)

Altered level of consciousness A client receiving fibrinolytic therapy is at risk for complications associated with bleeding. Altered level of consciousness may indicate hypoxia and intracranial bleeding, and the infusion should be discontinued immediately. Minimal bleeding requires manual pressure. Reperfusion dysrhythmias are an expected finding. A chest pain score of 2 is low and indicates the client's chest pain is subsiding, an expected outcome of this therapy.

Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)? Ceftin Keflex Amoxicillin Levofloxacin

Amoxicillin Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid is the antibiotic of choice. For clients who are allergic to penicillin, doxycycline or respiratory quinolones, such as levofloxacin or moxifloxacin, can be used. Other antibiotics previously prescribed to treat ABRS, including cephalosporins such as cephalexin and cefuroxime, are no longer recommended because they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.

A client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the client about? Cefuroxime Clarithromycin Cephalexin Amoxicillin-clavulanic acid

Amoxicillin-clavulanic acid Treatment of acute rhinosinusitis depends on the cause; a 5- to 7-day course of antibiotics is prescribed for bacterial cases. Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid ( Augmentin) is the antibiotic of choice. Other antibiotics prescribed previously to treat ABRS, including cephalosporins such as cephalexin (Keflex), cefuroxime (Ceftin), cefaclor (Ceclor), and cefixime (Suprax), trimethoprim-sulfamethoxazole (Bactrim, Septra), and macrolides such as clarithromycin (Biaxin) and azithromycin (Zithromax), are no longer recommended because they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.

The nurse is caring for a client who has had a nuclear scan to aid in the diagnosis of possible cancer. The scan showed a "hot spot". What does this mean? An area of increased concentrations of the tracer used in the scan. Distinguishes areas of tissue that are normal. An area of decreased concentrations of the tracer used in the scan. Distinguishes abnormal areas of tumor

An area of increased concentrations of the tracer used in the scan. Nuclear Scans: Clients ingest or receive intravenous (IV) radioisotopes (also known as tracers). After specific time intervals, images are taken of tissues that are affected by cancer or other diseases; the images distinguish tissues or portions of tissues that absorb more or less of the tracer. "Hot spots" show on an image of a tumor that has increased concentrations of the tracer, whereas "cold spots" can be the image of a tumor that has decreased concentration of the tracer. Options B, C, and D are incorrect information about hot spots.

The nurse is conducting a screening for familial predisposition to cancer. Which element should the nurse note as a possible indication of hereditary cancer syndrome? Onset of cancer after age 50 in family member A second cousin diagnosed with cancer A first cousin diagnosed with cancer An aunt and uncle diagnosed with cancer

An aunt and uncle diagnosed with cancer The hallmarks of hereditary cancer syndrome include cancer in two or more first-degree or second-degree relatives, early onset of cancer in family members younger than age 50, the same type of cancer in several family members, individual family members with more than one type of cancer, and a rare cancer in one or more family members.

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross? Acceptance Anger Bargaining Denial

Anger Anger is the second stage and is exhibited by statement similar to "Why me?" Denial occurs when the person refuses to believe certain information. Bargaining is an attempt to postpone death. During the acceptance stage, the dying clients accept their fate and make peace spiritually and with those to whom they are close.

What is the most commonly prescribed treatment for the common cold? Decongestants Antihistamines Expectorants Antitussives

Antihistamines Antihistamines are the first group of medications recommended for treating sneezing, pruritus, rhinorrhea, and nasal congestion associated with the common cold.

Which class of antineoplastic agents is cell cycle-specific? Antimetabolites (5-FU) Alkylating agents (cisplatin) Antitumor antibiotics (bleomycin) Nitrosoureas (carmustine)

Antimetabolites (5-FU) Antimetabolites are cell cycle-specific (S phase). Antitumor antibiotics, alkylating agents, and nitrosoureas are cell cycle-nonspecific.

A client has been diagnosed with shingles. Which of the following medication classifications will reduce the severity and prevent development of new lesions? Antipyretics Corticosteroids Analgesics Antiviral

Antiviral Oral acyclovir (Zovirax), when taken within 48 hours of the appearance of symptoms, reduces their severity, and prevents the development of additional lesions. Corticosteroids, analgesics,, and antipyretics are not used for this purpose.

The nurse understands it is important to promote adequate tissue perfusion following cardiac surgery. Which measures should the nurse complete to prevent the development of deep venous thrombosis (DVT) and possible pulmonary embolism (PE)? Select all that apply. Initiate passive exercises. Place pillows in the popliteal space. Apply antiembolism stockings. Encourage the client to cross their legs. Avoid elevating the knees on the bed.

Apply antiembolism stockings. Avoid elevating the knees on the bed. Initiate passive exercises. Preventive measures used to prevent venous stasis include application of sequential pneumatic compression devices; discouraging crossing of legs; avoiding elevating the knees on the bed; omitting pillows in the popliteal space; and beginning passive exercises followed by active exercises to promote circulation and prevent venous stasis.

The nurse is caring for a geriatric client with thin, chapped, itchy skin. Which nursing intervention should the nurse alter in the plan of care?

Applying lanolin ointment

While providing care to a terminally ill client, the client's niece asks the nurse about the client's condition and prognosis. Which of the following would be most appropriate? Refer the niece to the client's physician for information. Check with the client's immediate family members about sharing information. Provide the niece with the information that she is requesting. Ask the client's consent before sharing any information with the niece.

Ask the client's consent before sharing any information with the niece. Before disclosing any health information about a client to family members, nurses should follow the agency's policy for obtaining consent from the client in accordance with the Health Insurance Portability and Accountability Act (HIPAA) rules. Information is shared only with the client's consent.

Which of the following is a potential complication of a low pressure in the endotracheal cuff? Tracheal bleeding Aspiration pneumonia Tracheal ischemia Pressure necrosis

Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

An older adult is postoperative day one, following a coronary artery bypass graft (CABG). The client's family members express concern to the nurse that the client is uncharacteristically confused. After reporting this change in status to the health care provider, what additional action should the nurse take? Educate the family about how confusion is expected in older adults postoperatively. Assess for factors that may be causing the client's delirium. Reorient the client to place and time. Document the early signs of dementia and ensure the client's safety.

Assess for factors that may be causing the client's delirium. Uncharacteristic changes in cognition following cardiac surgery are suggestive of delirium. Dementia has a gradual onset with organic brain changes and is not an acute response to surgery. Assessment is a higher priority than reorientation, which may or may not be beneficial. Even though delirium is not rare, it is not considered to be an expected part of recovery.

Assessment of a client on a medical surgical unit finds a regular heart rate of 120 beats per minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 mL over the past hour. What is the reason the nurse anticipates transferring the client to the intensive care unit? The client shows signs of aneurysm rupture. The client is in the early stage of right-sided heart failure. The client is experiencing heart failure. The client is going into cardiogenic shock.

The client is going into cardiogenic shock. This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as poor blood flow causes lactic acid to accumulate and prevents waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as?

Asterixis Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy (Fig. 49-13).

You are caring for a client with obstructive pulmonary disease. Your nursing care includes diagnoses, outcomes, and interventions for what? Pain Impaired physical mobility Atelectasis Side effects of medication therapy

Atelectasis For a client with obstructive pulmonary disease, atelectasis is one of the conditions for which nursing actions are identified to detect, manage, and minimize the unexpected outcomes.

A client has recently undergone a coronary artery bypass graft (CABG). The nurse should be alert to which respiratory complication? Elevated blood glucose level Urinary tract infection (UTI) Atelectasis Hyperkalemia

Atelectasis Respiratory complications that may occur include atelectasis. An incentive spirometer and the use of deep breathing exercises are necessary to prevent atelectasis and pneumonia. Elevated blood sugar levels, hyperkalemia, UTI, and are complications that can occur but are unrelated to the respiratory system.

You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult? Aneurysm Coronary thrombosis Atherosclerosis Raynaud's disease

Atherosclerosis Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. Therefore, options A, B, and D are incorrect.

The nurse administers propranolol hydrochloride to a patient with a heart rate of 64 beats per minute (bpm). One hour later, the nurse observes the heart rate on the monitor to be 36 bpm. What medication should the nurse prepare to administer that is an antidote for the propranolol? Atropine Protamine sulfate Digoxin Sodium nitroprusside

Atropine Sheath removal and the application of pressure on the vessel insertion site may cause the heart rate to slow and the blood pressure to decrease (vasovagal response). A dose of IV atropine is usually given to treat this response.

A client in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete? Assess for unilateral swelling and tenderness of either leg. Ask about any changes in skin color that occur in response to cold. Attempt to palpate the dorsalis pedis and posterior tibial pulses. Check for the presence of tortuous veins bilaterally on the legs.

Attempt to palpate the dorsalis pedis and posterior tibial pulses. Intermittent claudication is a sign of peripheral arterial insufficiency. The nurse should assess for other clinical manifestations of peripheral arterial disease in a client who describes intermittent claudication. A thorough assessment of the client's skin color and temperature and the character of the peripheral pulses are important in the diagnosis of arterial disorders.

Which type of vaccine uses the client's own cancer cells, which are killed and prepared for injection back into the client? Prophylactic Allogeneic Autologous Therapeutic

Autologous Autologous vaccines are made from the client's own cancer cells, which are obtained during diagnostic biopsy or surgery. Prophylactic vaccines, such as the polio vaccine, are given to prevent people from developing a disease. Therapeutic vaccines are given to kill existing cancer cells and to provide long-lasting immunity against further cancer development. Allogeneic vaccines are made from cancer cells that are obtained from other people who have a specific type of cancer.

Which of the following uses the body's own digestive enzymes to break down necrotic tissues? Enzymatic debridement Wet dressings Wet to dry dressings Autolytic debridement

Autolytic debridement Autolytic debridement is a process that uses the body's own digestive enzymes to break down necrotic tissue. Application of enzymatic debriding agents speeds the rate at which necrotic tissues is removed. A form of mechanical debridement is a wet to dry dressing, which removes necrotic tissue and absorbs small to large amounts of exudates.

The nurse caring for a client with repeated episodes of contact dermatitis is providing instruction to prevent future episodes. Which information should the nurse include?

Avoid cosmetics with fragrance.

Which of the following advice does the nurse offer clients who are undergoing unsealed radiation therapy to reduce exposure? Avoid applying skin moisturizers. Avoid kissing and sexual contact. Avoid drinking plenty of fluids. Avoid eating for 3 hours after therapy.

Avoid kissing and sexual contact. Clients who are undergoing unsealed radiation therapy are advised to avoid kissing and sexual contact. Clients are encouraged to drink plenty of fluids to help flush radioactive substances. Client may be asked to apply mild moisturizers and are not asked not to eat after the therapy.

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack? Avoid fatty foods and exercise. Take over-the-counter decongestants. Avoid situations that contribute to ischemic episodes. Report changes in the usual pattern of chest pain.

Avoid situations that contribute to ischemic episodes. Teaching for clients with Raynaud's disease and their family members is important. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.

The nurse is caring for a client with Raynaud's disease. What is an important instruction for a client who is diagnosed with this disease to prevent an attack? Avoid situations that contribute to ischemic episodes. Take over-the-counter decongestants. Avoid fatty foods and exercise. Report changes in the usual pattern of chest pain.

Avoid situations that contribute to ischemic episodes. Teaching for clients with Raynaud's disease and their family members is important. They need to understand what contributes to an attack. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.

Which intervention should a nurse perform during the grieving period when caring for a dying client? Spending time with client Providing palliative care Allowing a period of privacy Avoiding criticizing or giving advice

Avoiding criticizing or giving advice The nurse should listen in a nonjudgmental manner and should avoid criticizing or giving advice during the grieving period when caring for dying clients. Allowing a period of privacy is necessary to help family members cope with the death of a client and is not necessary during the grieving period. Spending time with the client and providing palliative care are not required nursing interventions during the grieving period. Palliative care is provided to a dying client when the client is unable to live independently.

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan? Applying talcum powder to the irradiated areas daily after bathing Avoiding using soap on the irradiated areas Wearing a lead apron during direct contact with the client Removing thoracic skin markings after each radiation treatment

Avoiding using soap on the irradiated areas Because external radiation commonly causes skin irritation, the nurse should wash the irradiated area with water only and leave the area open to air. No soaps, deodorants, lotions, or powders should be applied. A lead apron is unnecessary because no radiation source is present in the client's body or room. Skin in the area to be irradiated is marked to position the radiation beam as precisely as possible; skin markings must not be removed.

The nurse is performing the health interview of a patient with chronic rhinosinusitis who experiences frequent nose bleeds. The nurse asks the patient about her current medication regimen. Which medication would put the patient at a higher risk for recurrent epistaxis? A) Afrin B) Beconase C) Sinustop Pro D) Singulair

B) Beconase Beconase should be avoided in patients with recurrent epistaxis, glaucoma, and cataracts. Sinustop Pro and Afrin are pseudoephedrine and do not have a side effect of epistaxis. Singulair is a bronchodilator and does not have epistaxis as a side effect.

The perioperative nurse has admitted a patient who has just underwent a tonsillectomy. The nurse's postoperative assessment should prioritize which of the following potential complications of this surgery? A) Difficulty ambulating B) Hemorrhage C) Infrequent swallowing D) Bradycardia

B) Hemorrhage Hemorrhage is a potential complication of a tonsillectomy. Increased pulse, fever, and restlessness may indicate a postoperative hemorrhage. Difficulty ambulating and bradycardia are not common complications in a patient after a tonsillectomy. Infrequent swallowing does not indicate hemorrhage; frequent swallowing does.

The nurse is caring for a patient who has just been diagnosed with chronic rhinosinusitis. While being admitted to the clinic, the patient asks, "Will this chronic infection hurt my new kidney?" What should the nurse know about chronic rhinosinusitis in patients who have had a transplant? A) The patient will have exaggerated symptoms of rhinosinusitis due to immunosuppression. B) Taking immunosuppressive drugs can contribute to chronic rhinosinusitis. C) Chronic rhinosinusitis can damage the transplanted organ. D) Immunosuppressive drugs can cause organ rejection.

B) Taking immunosuppressive drugs can contribute to chronic rhinosinusitis. URIs, specifically chronic rhinosinusitis and recurrent acute rhinosinusitis, may be linked to primary or secondary immune deficiency or treatment with immunosuppressive therapy (i.e., for cancer or organ transplantation). Typical symptoms may be blunted or absent due to immunosuppression. No evidence indicates damage to the transplanted organ due to chronic rhinosinusitis. Immunosuppressive drugs do not cause organ rejection

The nurse recognizing a female patient's susceptibility to infection due to her history of chronic obstructive pulmonary disease (COPD). When teaching this patient to reduce her risk of infection in the community, what measure should the nurse emphasize to the patient? A. Remaining indoors when possible during allergy season B. Washing her hands frequently and thoroughly C. Avoiding abrupt transitions from cold air to hot air D. Avoiding contact with individuals who have not received an influenza vaccination

B. Washing her hands frequently and thoroughly Patients with COPD should be encouraged to avoid sick individuals and to receive an annual flu vaccination. However, the most important infection-control measure is vigilant handwashing. Temperature transitions do not lead to infections. Allergens can exacerbate COPD, but they do not play a major role in the development of infection.

A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client? Intubation of the airway Hourly administration of a fluid bolus BP and pulse measurements every 15 to 30 minutes Insertion of a central venous catheter

BP and pulse measurements every 15 to 30 minutes Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP, and pulse measurements approximately every 15 to 30 minutes.

Which of the following assessment results is considered a major risk factor for PAD? Triglyceride level of 150 mg/dL LDL of 100 mg/dL BP of 160/110 mm Hg Cholesterol of 200 mg/dL

BP of 160/110 mm Hg Hypertension is considered a major risk factor for PAD. Blood pressure should be less than 130/90 mm Hg. The other laboratory results are within the recommended range of normal to high normal.

A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring? Heart rate of 72 beats/minute Blood pressure 80/46 mm Hg Respiratory rate of 20 breaths/minute Oxygen saturation 94%

Blood pressure 80/46 mm Hg The body can compensate for changes in heart function that occur over time. When cardiac output falls, the body uses certain compensatory mechanisms designed to increase stroke volume and maintain blood pressure. These compensatory mechanisms can temporarily improve the client's cardiac output but ultimately fail when contractility is further compromised. A heart rate of 72 beats/minute is within normal range as well as the blood pressure and oxygen saturation.

Which observation regarding ulcer formation on the client's lower extremity indicates that the ulcer is a result of venous insufficiency? Is deep, involving the joint space Border of the ulcer is irregular Though superficial, it is very painful Base is pale to black

Border of the ulcer is irregular The border of an ulcer caused by arterial insufficiency is circular. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows a beefy red to fibrinous yellow color. Venous insufficiency ulcers are usually superficial.

Which statement is true about both lung transplant and bullectomy? Both procedures cure COPD. Both procedures treat end-stage emphysema. Both procedures improve the overall quality of life of a client with COPD. Both procedures treat patients with bullous emphysema.

Both procedures improve the overall quality of life of a client with COPD. Treatments for COPD are aimed more at treating the symptoms and preventing complications, thereby improving the overall quality of life of a client with COPD. In fact, there is no cure for COPD. Lung transplant is aimed at treating end-stage emphysema and bullectomy is used to treat clients with bullous emphysema.

The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure? Blood urea nitrogen (BUN) Complete blood count (CBC) Brain natriuretic peptide (BNP) Creatinine

Brain natriuretic peptide (BNP) BNP is the key diagnostic indicator of heart failure. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. A BUN, creatinine, and CBC are included in the initial workup.

Which of the following is a leading cause of chronic obstructive pulmonary disease (COPD) exacerbation? Asthma Pneumonia Bronchitis Common cold

Bronchitis A wide range of viral, bacterial, and mycoplasmal infections can produce acute episodes of bronchitis, a leading cause of exacerbations. Pneumonia, the common cold, and asthma are not leading causes of exacerbations.

A patient is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the patient's nutrition during treatment? A) A 1.5 L/day fluid restriction B) A high-potassium, low-sodium diet C) A liquid or soft diet D) A high-protein diet

C) A liquid or soft diet A liquid or soft diet is provided during the acute stage of the disease, depending on the patient's appetite and the degree of discomfort that occurs with swallowing. The patient is encouraged to drink as much fluid as possible (at least 2 to 3 L/day). There is no need for increased potassium or protein intake

The nurse is creating a plan of care for a patient diagnosed with acute laryngitis. What intervention should be included in the patient's plan of care? A) Place warm cloths on the patient's throat, as needed. B) Have the patient inhale warm steam three times daily. C) Encourage the patient to limit speech whenever possible. D) Limit the patient's fluid intake to 1.5 L/day.

C) Encourage the patient to limit speech whenever possible. Management of acute laryngitis includes resting the voice, avoiding irritants (including smoking), resting, and inhaling cool steam or an aerosol. Fluid intake should be increased. Warm clothes on the throat will not help relieve the symptoms of acute laryngitis.)

The nurse is teaching a patient with allergic rhinitis about the safe and effective use of his medications. What would be the most essential information to give this patient about preventing possible drug interactions? A) Prescription medications can be safely supplemented with OTC medications. B) Use only one pharmacy so the pharmacist can check drug interactions. C) Read drug labels carefully before taking OTC medications. D) Consult the Internet before selecting an OTC medication.

C) Read drug labels carefully before taking OTC medications. Patient education is essential when assisting the patient in the use of all medications. To prevent possible drug interactions, the patient is cautioned to read drug labels before taking any OTC medications. Some Web sites are reliable and valid information sources, but this is not always the case. Patients do not necessarily need to limit themselves to one pharmacy, though checking for potential interactions is important. Not all OTC medications are safe additions to prescription medication regimens.)

It is cold season and the school nurse been asked to provide an educational event for the parent teacher organization of the local elementary school. What should the nurse include in teaching about the treatment of pharyngitis? A) Pharyngitis is more common in children whose immunizations are not up to date. B) There are no effective, evidence-based treatments for pharyngitis. C) Use of warm saline gargles or throat irrigations can relieve symptoms. D) Heat may increase the spasms in pharyngeal muscles.

C) Use of warm saline gargles or throat irrigations can relieve symptoms. Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. The benefits of this treatment depend on the degree of heat that is applied. The nurse teaches about these procedures and about the recommended temperature of the solution: high enough to be effective and as warm as the patient can tolerate, usually 105ºF to 110ºF (40.6ºC to 43.3ºC). Irrigating the throat may reduce spasm in the pharyngeal muscles and relieve soreness of the throat. You would not tell the parent teacher organization that there is no real treatment of pharyngitis

A 72-year-old patient is status post right knee replacement, and the nurse recognizes the patient's risk of hospital-acquired pneumonia (HAP). What is a priority nursing measure for the prevention of HAP? A. Providing emotional support B. Providing extra nutrition for the elderly patient C. Providing anticipatory interventions D. Giving antibiotics as ordered

C. Providing anticipatory interventions Important nursing measures for prevention of HAP include providing anticipatory interventions and preventive care. This scenario is asking about prevention of HAP, not what to do after it occurs, so emotional support and antibiotics are incorrect. Providing extra nutrition is not a preventive measure for HAP.

A family of a dying client reports that their loved one is experiencing more shortness of breath. Which nursing intervention is most appropriate at this time? Call the health care provider to obtain an oxygen order Get the client out of bed to the chair. Offer the bedpan to urinate or defecate Offer the client sips to drink.

Call the health care provider to obtain an oxygen order Obtaining an oxygen order can reduce the client's shortness of breath and help the family feel more comfortable. It is difficult for families to see the client with shortness of breath. The dying client and family need support, and the bedpan, sitting in a chair, or offering sips to drink do not address the feelings of shortness of breath.

A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: Tis, N0, M0. What does this classification mean? Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Can't assess tumor or regional lymph nodes and no evidence of metastasis

Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Tis, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can't be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately?

Change in the client's handwriting and/or cognitive performance The earliest symptoms of hepatic encephalopathy include mental status changes and motor disturbances. The client will appear confused and unkempt and have altered mood and sleep patterns. Neurologic status should be assessed frequently. Mental status is monitored by the nurse keeping the client's daily record of handwriting and arithmetic performance. The nurse should report any change in mental status immediately. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis.

A middle-aged client presents to the ED reporting severe chest discomfort. Which finding is most indicative of a possible myocardial infarction (MI)? Chest discomfort not relieved by rest or nitroglycerin Cool, clammy skin and a diaphoretic, pale appearance Intermittent nausea and emesis for 3 days Anxiousness, restlessness, and lightheadedness

Chest discomfort not relieved by rest or nitroglycerin Chest pain or discomfort not relieved by rest or nitroglycerin is associated with an acute MI. The other findings, although associated with acute coronary syndrome or MI, may also occur with angina and, alone, are not indicative of an MI.

Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is: Cigarette smoking. Obesity. Stress. Lack of exercise.

Cigarette smoking. Nicotine decreases blood flow, increases heart rate and blood pressure, and increases the risk for clot formation by increasing platelet aggregation. Smokers have a four-fold higher risk of developing pain from arterial disease than nonsmokers. Carbon monoxide, produced by burning tobacco, combines with hemoglobin more readily than oxygen, thus depriving tissues of oxygen.

A client with chronic heart failure is able to continue with his regular physical activity and does not have any limitations as to what he can do. According to the New York Heart Association (NYHA), what classification of chronic heart failure does this client have? Class II (Mild) Class IV (Severe) Class I (Mild) Class III (Moderate)

Class I (Mild) Class I is when ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.

Pentoxifylline (Trental) is a medication used for which of the following conditions? Elevated triglycerides Claudication Hypertension Thromboemboli

Claudication Trental and Pletal are the only medications specifically indicated for the treatment of claudication. Thromboemboli, hypertension, and elevated triglycerides are not indications for using Trental

A nurse is providing care to a client experiencing symptoms associated with terminal illness. Which of the following would be most appropriate to use as a means for managing the client's symptoms? Length of required treatment Physician's orders Client's goals Invasiveness of the treatment

Client's goals When managing the symptoms of a client with a terminal illness, the client's goals take precedence over the clinician's goals to relieve all symptoms at all costs. Although the length and invasiveness of the treatment may influence decision making, ultimately it is the client's goals that determine what will be done.

A client admitted with pneumonia has a history of lung cancer and heart failure. A nurse caring for this client recognizes that he should maintain adequate fluid intake to keep secretions thin for ease in expectoration. The amount of fluid intake this client should maintain is:

Clients need to keep their secretions thin by drinking 2 to 3 L of clear liquids per day. In clients with heart failure, fluid intake shouldn't exceed 1.5 L daily.

Which medication is given to clients who are diagnosed with angina but are allergic to aspirin? Amlodipine Clopidogrel Diltiazem Felodipine

Clopidogrel Clopidogrel or ticlopidine is given to clients who are allergic to aspirin or are given in addition to aspirin to clients who are at high risk for MI. Amlodipine, diltiazem, and felodipine are calcium channel blockers.

A client diagnosed with acute myelocytic leukemia has been receiving chemotherapy. During the last 2 cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple platelet transfusions. The client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia? Closely observe the client's skin for petechiae and bruising. Perform a cardiovascular assessment every 4 hours. Check the client's history for a congenital link to thrombocytopenia. Monitor daily platelet counts.

Closely observe the client's skin for petechiae and bruising. The nurse should closely observe the client's skin for petechiae and bruising. Daily laboratory testing may not reflect the client's condition as quickly as subtle changes in the client's skin. Performing a cardiovascular assessment every 4 hours and checking the clients history for a congenital link to thrombocytopenia don't help detect early signs and symptoms of thrombocytopenia.

When caring for a client with COPD, the nurse knows it is important to monitor what?

Cognitive changes

A 72-year-old patient who was admitted to the hospital for a total hip arthroplasty has developed increasing dyspnea and leukocytosis over the past 48 hours and has been diagnosed with hospital-acquired pneumonia (HAP). The choice of antibiotic therapy for this patient will be primarily based on which of the nurse's assessments? Auscultation and percussion of the patient's thorax Analysis of the patient's leukocytosis and the white blood cell (WBC) differential Collection of a sputum sample for submission to the hospital laboratory Assessment of the patient's activities of daily living

Collection of a sputum sample for submission to the hospital laboratory Choice of antibiotic therapy is based primarily on the patient's history and the results of sputum cultures. Blood work and chest auscultation confirm the diagnosis of pneumonia but do not typically inform the choice of antibiotic.

The nurse is working with community groups. At which of the following locations would the nurse anticipate a possible scabies outbreak? Gymnasium College dormitory Swimming pool Shopping mall

College dormitory The nurse is correct to anticipate a potential scabies outbreak in a college dormitory. Outbreaks are common where large groups of people are confined or housed. Spread of scabies is from skin-to-skin contact. Although there are groups of people at the shopping mall, swimming pool, and gymnasium, typically, there is no personal contact.

A nurse is providing hospice care in Portland, Oregon to a client with terminal liver cancer. The client confides to the nurse, "I'm in agony all the time. I want this to be over now—please help me." Which interventions should the nurse implement? Select all that apply. Control the client's pain with prescribed medication. Advise the client's health care provider of the client's condition. Encourage the client to explain his or her wishes. Recommend that the client consider physician-assisted suicide. Comfort the client by saying it will all be over soon.

Control the client's pain with prescribed medication. Advise the client's health care provider of the client's condition. Encourage the client to explain his or her wishes. This client lives in Oregon, one of five states that have decriminalized physician-assisted suicide, the practice of providing a means by which a client can end his or her own life. This practice is controversial, with proponents arguing the client has a right to self-determination and a relief from suffering when there is no other means of palliation. Opponents, on the other hand, find it contrary to the Hippocratic Oath. In this scenario, the nurse should determine exactly what the client is asking and then support his or her wishes. It is not the nurse's role to suggest physician-assisted suicide voluntarily, however.

A client comes to the Emergency Department (ED) complaining of precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would you suspect in this client? Cardiogenic shock Raynaud's disease Coronary artery disease Venous occlusive disease

Coronary artery disease The classic symptom of CAD is chest pain (angina) or discomfort during activity or stress. Such pain or discomfort typically is manifested as sudden pain or pressure that may be centered over the heart (precordial) or under the sternum (substernal). Raynaud's disease in the hands presents with symptoms of hands that are cold, blanched, and wet with perspiration. Cardiogenic shock is a complication of an MI. Venous occlusive disease occurs in the veins, not the arteries.

The nurse is conducting an admission history and physical examination of a client with a history of contact dermatitis. The nurse assesses whether the client uses which medication classification?

Corticosteroids

Which medication classification may be used for contact dermatitis? Corticosteroids Antifungals Antivirals Saline irrigations

Corticosteroids Corticosteroids are used for contact dermatitis. Antifungals, antivirals, and saline irrigations are not used in the treatment of contact dermatitis.

A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer? Cough or change in chronic cough Shortness of breath Pain on inspiration Obvious trauma

Cough or change in chronic cough A cough or change in chronic cough is the most frequent symptom of lung cancer. Symptoms of fractured ribs consist primarily of severe pain on inspiration and expiration, obvious trauma, and shortness of breath. These symptoms may also be caused by other disorders, but they are not considered to be indicative of lung cancer.

The nurse is to administer morphine sulfate to a client with chest pain. What initial nursing action is required prior to administration? Measure the blood pressure for hypertension. Count the respiratory rate for bradypnea. Measure urinary output for dehydration. Check the radial pulse for dysrhythmias.

Count the respiratory rate for bradypnea. The nurse should always check the respiratory rate prior to administering morphine sulfate. The drug should be withheld, and the health care provider notified, if the respiratory rate is below 16 breaths/minute.

The nurse has completed a head-to-toe assessment of a patient who was admitted for the treatment of heart failure (HF). Which of the following assessment findings should signal to the nurse a possible exacerbation of the patient's condition? Blood glucose testing reveals a glucose level of 158 mg/dL. The patient has put out 600 mL of dilute urine over the past 8 hours. Crackles are audible on chest auscultation. The patient's blood pressure (BP) is 144/99.

Crackles are audible on chest auscultation. Patients with HF often exhibit crackles, which are produced by the sudden opening of edematous small airways and alveoli that have adhered together by exudate. These may be heard at the end of inspiration and are not cleared with coughing. A widened pulse pressure, increased BP, and production of dilute urine are not characteristic of HF. Changes in blood glucose levels are not normally symptomatic of HF.

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? Sibilant wheezes Low-pitched rhonchi during expiration Crackles in the lung bases Pleural friction rub

Crackles in the lung bases When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.

The nurse is planning the care of a complex elderly patient who has been admitted to the medical ward for the treatment of cellulitis. The nurse notes that the patient has a longstanding history of chronic obstructive pulmonary disease (COPD). What assessment finding would most clearly indicate the need for oxygen therapy? A. Presence of bilateral fine crackles to lower lung fields on auscultation B. Respiratory rate (RR) of 25 breaths per minute at rest C. Presence of an occasional productive cough D. SaO2 of 86% on room air

D. SaO2 of 86% on room airCrackles, coughing, and increased RR are all consistent with COPD. However, the decision on whether to apply oxygen therapy is most commonly made on the basis of oxygen levels as determined by pulse oximetry.

A student nurse is developing a teaching plan for a patient with chronic obstructive pulmonary disease (COPD). What should the student include as a priority area of teaching? A. Avoiding emotional disturbances and stressful situations that might trigger a coughing episode B. Avoiding extremes of heat and cold C. Adopting a lifestyle of moderate activity, ideally in a climate with minimal shifts in temperature and humidity D. Setting and accepting realistic short-term and long-range goals

D. Setting and accepting realistic short-term and long-range goals A major area of teaching involves setting and accepting realistic short-term and long-range goals. The other options should also be included in the teaching plan, but they are not areas that are as significant as setting and accepting realistic goals.

A home health nurse sees a client with end-stage chronic obstructive pulmonary disease. An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met? Decreased oxygen requirements Decreased activity tolerance Normothermia Increased sputum production

Decreased oxygen requirements A client who is free from infection will most likely have decreased oxygen requirements. A client with infection will display increased sputum production, fever, shortness of breath, decreased activity tolerance, and increased oxygen requirements.

A nurse is caring for a client who experienced an MI. The client is ordered to received metoprolol. The nurse understands that this medication has which therapeutic effect? Increases cardiac output Decreases cholesterol level Decreases resting heart rate Decreases platelet aggregation

Decreases resting heart rate The therapeutic effects of beta-adrenergic blocking agents such as metoprolol are to reduce myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced heart rate, slowed conduction of impulses through the conduction system, decreased blood pressure, and reduced myocardial contractility to balance the myocardial oxygen needs and amount of oxygen available. This helps to control chest pain and delays the onset of ischemia during work or exercise. This classification of medication also reduces the incidence of recurrent angina, infarction, and cardiac mortality. In general, the dosage of medication is titrated to achieve a resting heart rate of 50-60 bpm. Metoprolol is not administered to decrease cholesterol levels, increase cardiac output, or decrease platelet aggregation.

The nurse is administering a calcium channel blocker to a patient who has symptomatic sinus tachycardia at a rate of 132 bpm. What is the anticipated action of the drug for this patient? Creates a positive inotropic effect Increases the heart rate Decreases the sinoatrial node automaticity Increases the atrioventricular node conduction

Decreases the sinoatrial node automaticity Calcium channel blockers have a variety of effects on the ischemic myocardium. These agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of myocardial contraction (negative inotropic effect).

The nurse is assessing a client's skin when the client points out a mole. The nurse brings the mole to the physician's attention when which characteristic is noted? Uniform light brown color Diameter exceeding 6 mm Symmetrical appearance Distinct borders

Diameter exceeding 6 mm The nurse brings the mole to the physician's attention when characteristics of melanoma are detected, such as a diameter exceeding 6 mm. Other characteristics of melanoma include asymmetric appearance; irregular, indistinct borders; and red, white, or blue coloration.

Which is a characteristic of arterial insufficiency? Superficial ulcer Pulses are present but may be difficult to palpate Diminished or absent pulses Aching, cramping pain

Diminished or absent pulses A diminished or absent pulse is a characteristic of arterial insufficiency. Venous characteristics include superficial ulcer formation, an aching and cramping pain, and presence of pulses.

The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)? Nocturia Tachycardia Ascites Dizziness

Dizziness Cerebrovascular manifestations of heart failure stemming from decreased brain perfusion include dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow.

A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg? Dorsiflex the foot while the leg is elevated to check for calf pain. Elevate the patient's legs for 20 minutes and then lower them slowly while checking for areas of inadequate blood return. Extend the leg, plantar flex the foot, and check for the patency of the dorsalis pedis pulse. Lower the patient's legs and massage the calf muscles to note any areas of tenderness.

Dorsiflex the foot while the leg is elevated to check for calf pain. Homan's sign is indicated by pain in the calf after the foot is sharply dorsiflexed.

A client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using? Living will declaration End-of-life treatment directive Medical directive by proxy Durable power of attorney for health care

Durable power of attorney for health care A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. It allows another individual to make medical decisions on the client's behalf. The other options are incorrect.

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? Sore throat and abdominal pain Hemoptysis and dysuria Nonproductive cough and normal temperature Dyspnea and wheezing

Dyspnea and wheezing In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.

A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients? Maintenance of SpO2 levels ≥90% using supplementary oxygen Passive range of motion exercises for the upper and lower extremities Early ambulation and the use of compression stockings Incentive spirometry and deep breathing and coughing exercises

Early ambulation and the use of compression stockings For patients at risk for PE, the most effective approach for prevention is to prevent deep venous thrombosis (DVT). Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression or intermittent pneumatic compression stockings are general preventive measures. Range of motion exercises, supplementary oxygen, incentive spirometry, and deep breathing exercises are not measures that directly reduce a patient's risk of DVT and consequent PE.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? Serum electrolytes Electrocardiogram (ECG) Blood urea nitrogen (BUN) Echocardiogram

Echocardiogram An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed during the initial workup.

The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump? A chest radiograph Electrocardiogram Echocardiogram A pulmonary arteriography

Echocardiogram The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. A pulmonary arteriography is used to confirm cor pulmonale. A chest radiograph can reveal the enlargement of the heart. An electrocardiogram is used to determine the activity of the heart's conduction system.

Which diagnostic method is recommended to determine whether left ventricular hypertrophy has occurred? Blood urea nitrogen Blood chemistry Electrocardiography Echocardiography

Echocardiography An echocardiogram is recommended method of determining whether hypertrophy has occurred. Electrocardiography and blood chemistry are part of the routine workup. Renal damage may be suggested by elevations in blood urea nitrogen and creatinine concentrations.

A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency? Elevate the legs periodically for at least an hour. Elevate the legs periodically for at least 15 to 20 minutes. Avoid foods with iodine. Refrain from sexual activity for a week.

Elevate the legs periodically for at least 15 to 20 minutes. The nurse should advise the client to periodically elevate the legs for at least 15 to 20 minutes. Avoiding foods with iodine or refraining from sexual activity for a week does not relate to venous insufficiency.

When caring for a patient with leg ulcers, the positioning of the legs depends on whether the patient's ulcer is arterial or venous in origin. How should the nurse position a patient who has leg ulcers that are venous in origin? Keep the patient's knees at a 45-degree angle. Elevate the patient's lower extremities. Hang the patient's legs over the side of the bed Keep the patient's legs flat without the knees raised.

Elevate the patient's lower extremities. Positioning of the legs depends on whether the ulcer is of arterial or venous origin. If there is venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Bending the knees, keeping the legs flat, and dangling the patient's legs may exacerbate the condition.

An oncology nurse is caring for a client who relates that certain tastes have changed. The client states that "meat tastes bad." What nursing intervention can be used to increase protein intake for a client with taste changes? Encourage maximum fluid intake. Stay away from protein beverages. Encourage eating cheese, eggs, and legumes Suck on hard candy during treatment.

Encourage eating cheese, eggs, and legumes The nurse encourages the clients with taste changes to eat cheese, eggs, and legumes. Encouraging the client to take in the maximum amount of fluids does not increase protein intake. The nurse advises the client to drink protein beverages. Sucking on hard candies during treatment does not increase protein intake.

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? Offer nutritious snacks 2 times a day. Give antibiotics as ordered. Place client on bed rest. Encourage increased fluid intake.

Encourage increased fluid intake. The nurse places the client in semi-Fowler's position to aid breathing and increase the amount of air taken with each breath. Increased fluid intake is important to encourage because it helps to loosen secretions and replace fluids lost through fever and increased respiratory rate. The nurse monitors fluid intake and output, skin turgor, vital signs, and serum electrolytes. He or she administers antipyretics as indicated and ordered. Antibiotics are not given for viral pneumonia. The client's activity level is ordered by the physician, not decided by the nurse.

he family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which intervention should a nurse perform in such a situation? Encourage the family members to express their feelings and listen to them in their frank communication Encourage the client's family members to spend time with the client Encourage conversations about the impending death of the client Be a silent observer and allow the client to communicate with the family members

Encourage the family members to express their feelings and listen to them in their frank communication Family members usually find it difficult to communicate frankly with a dying person. When a nurse encourages family members to express their feelings and listens to them as they frankly communicate, family members may feel more prepared to carry on a similarly honest dialogue with the dying client. It is not advisable for the nurse to encourage conversations about the impending death of the client. Being a silent observer or encouraging the family members to spend time with the dying client may not help the family members express their feelings.

The nurse is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply. Applying a sequential compression device Instructing the client to move the legs in a "pumping" exercise Encouraging a liberal fluid intake Instructing the client to dangle the legs over the side of the bed for 30 minutes, four times a day Using elastic stockings, especially when decreased mobility would promote venous stasis

Encouraging a liberal fluid intake Instructing the client to move the legs in a "pumping" exercise Using elastic stockings, especially when decreased mobility would promote venous stasis Applying a sequential compression device The use of anti-embolism stockings or intermittent pneumatic leg compression devices reduces venous stasis. These measures compress the superficial veins and increase the velocity of blood in the deep veins by redirecting the blood through the deep veins. Having the client move the legs in a "pumping" exercise helps increase venous flow. Legs should not be dangled or feet placed in a dependent position while the client sits on the edge of the bed; instead, feet should rest on the floor or on a chair.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? Maintaining a cool room temperature Turning the client every 2 hours Encouraging increased fluid intake Elevating the head of the bed 30 degrees

Encouraging increased fluid intake Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2 hours would help prevent atelectasis, but will not adequately mobilize thick secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing, but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.

A 60-year-old man has been diagnosed with obstructive sleep apnea (OSA) based on his clinical symptoms and polysomnographic findings. What intervention should the nurse perform to assist this patient in the management of his health problem? Encouraging the patient to adopt a later bedtime and earlier rising hour Teaching the patient deep breathing and coughing exercises to perform before going to bed Encouraging the patient to avoid alcohol and hypnotic medications Teaching the patient strategies for waking himself up when he experiences an apneic spell

Encouraging the patient to avoid alcohol and hypnotic medications Treatments for OSA are varied but include weight loss and avoidance of alcohol and hypnotic medications initially. Patients are not normally able to awaken themselves during apneic periods. Deep breathing exercises and changes to sleeping times are not known to improve the signs and symptoms of OSA.

A nurse is teaching about lifestyle modifications to a group of clients with known hypertension. Which statement would the nurse include in the education session? Maintain a body mass index between 30 and 35. Engage in aerobic activity at least 30 minutes/day most days of the week. Maintain a waist circumference of 45 inches (114 cm) (men) and 40 inches (102 cm) (women) or less. Limit alcohol consumption to no more that 3 drinks per day.

Engage in aerobic activity at least 30 minutes/day most days of the week. Recommended lifestyle modifications to prevent and manage hypertension include maintaining a normal body mass index (about 24; greater than 25 is considered overweight), maintaining a waist circumference of less than 40 inches for men and 35 inches for women, limiting alcohol intake to no more than 2 drinks for men and 1 drink for women per day, and engaging in aerobic activity at least 30 minutes per day most days of the week.

The nurse is teaching a client about lifestyle modifications after a heart failure diagnosis. What will be included in the teaching? Drink 3 liters of fluid per day. Avoid any alcohol. Restrict dietary potassium. Engage in exercise daily.

Engage in exercise daily. Lifestyle recommendations after heart failure include restriction of dietary sodium; avoidance of excessive fluid intake, excessive alcohol intake, and smoking; weight reduction when indicated; and regular exercise. The restriction of potassium is not required. Drinking 3 liters of fluid per day would be excessive for a client with heart failure.

A client is being seen at the clinic for a routine physical when the nurse notes the client's blood pressure is 150/97. The client is considered to be a healthy, well-nourished young adult. What type of hypertension does this client have? Essential (primary) Malignant Pathologic Secondary

Essential (primary) Essential or primary hypertension, about 95% of cases, is sustained elevated BP with no known cause. This client does not have secondary, pathologic, or malignant hypertension.

A client has a significant history of congestive heart failure. What should the nurse specifically assess during the client's semiannual cardiology examination? Select all that apply. Examine the client's eyes for excess tears. Examine the client's joints for crepitus. Monitor the client for signs of lethargy or confusion. Examine the client's neck for distended veins.

Examine the client's neck for distended veins. Monitor the client for signs of lethargy or confusion. During a head-to-toe assessment of a client with congestive heart failure, the nurse checks for dyspnea, auscultates apical heart rate and counts radial heart rate, measures BP, and documents any signs of peripheral edema, lethargy, or confusion. Excess tears are not part of the checklist.

A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence? The parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction. Fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction. The pericardial space is eliminated with scar tissue and thickened pericardium. Excess pericardial fluid compresses the heart and prevents adequate diastolic filling.

Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. The cardinal signs of cardiac tamponade are falling systolic blood pressure, narrowing pulse pressure, rising venous pressure (increased JVD), and distant (muffled) heart sounds. Increased pericardial pressure, reduced venous return to the heart, and decreased carbon dioxide result in cardiac tamponade (e.g., compression of the heart).

A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema? The client says he has been hungry in the evening. The client says his rings have become tight and are difficult to remove. The client says he is short of breath when ambulating. The client says that he has been urinating less frequently at night.

The client says his rings have become tight and are difficult to remove. Clients may observe that rings, shoes, or clothing have become tight. The client would most likely be urinating more frequently in the evening. Accumulation of blood in abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger. Shortness of breath with ambulation would occur most often in left-sided heart failure.

A patient with uterine cancer is being treated with internal radiation therapy. What would the nurse's priority responsibility be for this patient? Explain to the patient that she will continue to emit radiation while the implant is in place. Maintain as much distance as possible from the patient while in the room. Alert family members that they should restrict their visiting to 5 minutes at any one time. Wear a lead apron when providing direct patient care.

Explain to the patient that she will continue to emit radiation while the implant is in place. When the patient has a radioactive implant in place, the nurse and other health care providers need to protect themselves, as well as the patient, from the effects of radiation. Patients receiving internal radiation emit radiation while the implant is in place; therefore, contact with the health care team is guided by principles of time, distance, and shielding to minimize exposure of personnel to radiation. Safety precautions used in caring for a patient receiving brachytherapy include assigning the patient to a private room, posting appropriate notices about radiation safety precautions, having staff members wear dosimeter badges, making sure that pregnant staff members are not assigned to the patient's care, prohibiting visits by children or pregnant visitors, limiting visits from others to 30 minutes daily, and seeing that visitors maintain a 6-foot distance from the radiation source.

The nurse is caring for a pediatric client who is dying. The best way to provide care and comfort to dying clients and their families is to first do which of the following? Use evidence-based practice in daily care regimen. Explore own feelings on mortality and death and dying. A workshop on caring for the dying client Participate in a support group to learn clients' feeling on care.

Explore own feelings on mortality and death and dying. To care for others in the dying process, the nurse must explore his or her own feelings about mortality and death and dying. Understanding self provides a perspective to cope with and then support clients and families experiencing pain and grief. The other options are helpful in determining appropriate nursing care but not the first step.

Which exposure acts as a risk factor for and accounts for the majority of cases of chronic obstructive pulmonary disease (COPD)? Exposure to tobacco smoke Passive smoking Ambient air pollution Occupational exposure

Exposure to tobacco smoke Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases. Occupational exposure, passive smoking, and ambient air pollution are risk factors but do not account for the majority.

A nurse is conducting a spiritual assessment of a terminally ill client using the four step FICA process and asks the question, "What gives your life meaning?" The nurse is assessing which of the following? Address in care Community Importance and influence Faith and belief

Faith and belief The question about what gives life meaning provides information about the client's faith and belief. Importance and influence are addressed by questions focusing on the role faith plays in the client's life and how his or her beliefs affect the way the client cares for self and illness. Community is addressed by questions focusing on the client's participation in a spiritual or religious community and the support obtained from it. Address in care focuses on how the nurse would integrate the issues involving spirituality in the client's care.

You are the nurse caring for a client with cancer. The client complains of pain and nausea. When assessed, you note that the client appears fearful. What other factor must you consider when a client with cancer indicates signs of pain, nausea, and fear? Fatigue Ulceration Infection High cholesterol levels

Fatigue Clients with cancer experience fatigue, which is a side effect of cancer treatments that rest fails to relieve. The nurse must assess the client for other stressors that contribute to fatigue such as pain, nausea, fear, and lack of adequate support. The nurse works with other healthcare team members to treat the client's fatigue. The above indications do not contribute to infections, ulcerations, or high cholesterol levels.

A client presents to the emergency room with characteristics of atherosclerosis. What characteristics would the client display? Cholesterol plugs in the lumen of veins Fatty deposits in the lumen of arteries Emboli in the veins Blood clots in the arteries

Fatty deposits in the lumen of arteries Atherosclerosis is a condition in which the lumen of arteries fill with fatty deposits called plaque. Therefore, the other options are incorrect.

Which of the following nonsedating antihistamines is appropriate for daytime pruritus? Lorazepam (Ativan) Fexofenadine (Allegra) Hydroxyzine (Atarax) Diphenhydramine (Benadryl)

Fexofenadine (Allegra) Nonsedating antihistamine medications such as Allegra are more appropriate to relieve daytime pruritus. Benadryl or Atarax, when prescribed in a sedative dose at bedtime, may be beneficial in producing a restful and comfortable sleep. Ativan has sedating properties and is used as an antianxiety medication.

As a clinic nurse, you are caring for a patient who has been prescribed an antibiotic for tonsillitis and hasbeen instructed to take the antibiotic for 10 days. When you do a follow-up call with this patient, you areinformed that the patient is feeling better and is stopping the medication after taking it for 4 days. Whatinformation should you provide to this patient?

Finish all the antibiotics to eliminate the organism completely

Which term refers most precisely to a localized skin infection of a single hair follicle? Comedone Carbuncle Furuncle Cheilitis

Furuncle Furuncles occur anywhere on the body but are most prevalent in areas subjected to irritation, pressure, friction, and excessive perspiration, such as the back of the neck, the axillae, or the buttocks. A carbuncle is a localized skin infection involving several hair follicles. Cheilitis refers to dry cracking at the corners of the mouth. Comedones are the primary lesions of acne, caused by sebum blockage in the hair follicle.

Which of the following nursing interventions will a nurse perform to transfer heat and improve circulation in a dying client? Administer warm intravenous fluids. Gently massage the arms and legs. Change the position frequently. Administer intramuscular injections.

Gently massage the arms and legs. A nurse should gently massage the client's arms and legs to transfer heat and improve circulation in a dying client. Changing the position frequently helps protect the client's skin from breakdown. Administering warm intravenous fluids and intramuscular injections will not help transfer heat and improve circulation in a dying client.

You are speaking at a local PTO meeting about upper respiratory infections. Which preventive factor for rhinitis should you teach the attendees? Avoid carbonated fluids. Get adequate rest and sleep. Use a straw to drink fluids. Avoid clearing the throat.

Get adequate rest and sleep. Teaching clients about upper respiratory infections helps prevent them and reduce potential complications. The best prevention for rhinitis is to maintain a healthy life-style with adequate rest and sleep, proper diet, and moderate exercise. The nurse instructs clients who have undergone tonsillectomy and adenoidectomy to drink fluids without a straw, avoid clearing the throat, and avoid carbonated fluids. These instructions are not relevant for clients with rhinitis.

Which term is used to describe the personal feelings that accompany an anticipated or actual loss? Bereavement Spirituality Grief Mourning

Grief Grief is defined as the personal feelings that accompany an anticipated or actual loss. Bereavement is a period during which mourning for a loss take place. Mourning is an expression of grief and associated behaviors. Spirituality is a personal belief system that focuses on a search for meaning and purpose of life.

A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?

Group A, beta-hemolytic streptococci

A patient comes to the clinic and is diagnosed with tonsillitis and adenoiditis. What bacterial pathogen does the nurse know is commonly associated with tonsillitis and adenoiditis?

Group A, beta-hemolytic streptococcus

What foods should the nurse suggest that the patient consume less of in order to reduce nitrate intake because of the possibility of carcinogenic action? Fish and poultry Eggs and milk Green, leafy vegetables Ham and bacon

Ham and bacon Dietary substances that appear to increase the risk of cancer include fats, alcohol, salt-cured or smoked meats, nitrate and nitrite-containing foods, and red and processed meats. Nitrates are added to cured meats, such as ham and bacon.

The nurse is performing an assessment on a patient to determine the effects of hypertension on the heart and blood vessels. What specific assessment data will assist in determining this complication? (Select all that apply.) Heart rhythm Heart rate Character of apical and peripheral pulses Respiratory rate Lung sounds

Heart rate Heart rhythm Character of apical and peripheral pulses During the physical examination, the nurse must also pay specific attention to the rate, rhythm, and character of the apical and peripheral pulses to detect the effects of hypertension on the heart and blood vessels.

A nurse is working with a family of a deceased client and assisting them in working through their grief and mourning. Which of the following would be the priority to promote healthy accommodation of the loss by the family? Encouraging the family to remember the relationship they had with the client Helping the family recognize the loss has occurred Assisting the family in expressing their feelings of loss Urging them to give up their old attachments to the client

Helping the family recognize the loss has occurred The priority in assisting the family to accommodate the loss of the client in a healthy way is to help them recognize the loss. Once this occurs, then the family can react to, experience, and express the feeling the of the pain of the loss; recollect and re-experience the deceased, the relationship, and associated feelings; and relinquish old attachments to the deceased.

An asthma educator is teaching a new patient with asthma and his family about the use of a peak flow meter. What does a peak flow meter measure? Highest airflow during a normal expiration Highest airflow during a normal inspiration Highest airflow during a forced inspiration Highest airflow during a forced expiration

Highest airflow during a forced expiration A peak flow meter is a small hand-held device that measures the fastest flow the patient can generate after taking a deep breath in and blowing out as hard and fast as possible.

Development of malignant melanoma is associated with which risk factor? Residence in the Northeast African American heritage History of severe sunburn Skin that tans easily

History of severe sunburn Ultraviolet rays are strongly suspected as the etiology of malignant melanoma. Fair-skinned, blue-eyed, light-haired people of Celtic or Scandinavian origin are at higher risk for developing malignant melanoma. People who burn and do not tan are at risk for developing malignant melanoma. Elderly individuals who retire to the southwestern United States seem to have a higher incidence of developing malignant melanoma.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? Hyperoxemia, hypocapnia, and hyperventilation Hyperventilation, hypertension, and hypocapnia Hypercapnia, hypoventilation, and hypoxemia Hypotension, hyperoxemia, and hypercapnia

Hypercapnia, hypoventilation, and hypoxemia The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.

A client is taking 50 mg of oral spironolactone twice a day to assist with blood pressure control. While the nurse is performing the morning assessment, the client reports nausea, general muscle cramps, and weakness. The ECG strip shows a peaked, narrow T-wave, which is a change. What electrolyte imbalance does the nurse suspect? Hyperkalemia Hyponatremia Hypernatremia Hypokalemia

Hyperkalemia Potassium-sparing diuretics, such as spironolactone, can cause hyperkalemia, especially if given with an ACE inhibitor. Signs of hyperkalemia are nausea, diarrhea, abdominal cramps, and peaked narrow T-waves.

A client is already being treated for hypertension. The doctor is concerned about the potential for heart failure, and has the client return for regular check-ups. What does hypertension have to do with heart failure? Hypertension causes the heart's chambers to shrink. Heart failure occurs when blood pressures drops. Hypertension causes the heart's chambers to enlarge and weaken. Hypertension in older males regularly leads to heart failure.

Hypertension causes the heart's chambers to enlarge and weaken. Hypertension causes the heart's chambers to enlarge and weaken, making it impossible for the ventricles to eject all the blood they receive.

What should the nurse tell a client who is about to begin chemotherapy and is anxious about hair loss? The client should consider getting a wig or cap prior to beginning treatment. The hair will grow back the same as it was before treatment. Alopecia related to chemotherapy is relatively uncommon. The hair will grow back within 2 months post therapy.

The client should consider getting a wig or cap prior to beginning treatment. If hair loss is anticipated and causing the client anxiety, a wig, cap, or scarf should be purchased before therapy begins. Alopecia develops because chemotherapy affects the rapidly growing cells of the hair follicles. Hair usually begins to grow again within 4 to 6 months after therapy. Clients should know that new growth may have a slightly different color and texture.

The staff educator is talking to a group of new emergency department nurses about hypertensive crises. The nurse educator is aware that hypertensive urgency differs from hypertensive emergency in what way? Close hemodynamic monitoring is required during treatment of hypertensive emergencies. Hypertensive emergencies are associated with evidence of target organ damage. The patient's blood pressure (BP) is always higher in a hypertensive emergency. Hypertensive urgency is treated with rest and tranquilizers to lower BP.

Hypertensive emergencies are associated with evidence of target organ damage. Hypertensive emergencies are acute, life-threatening blood pressure elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. Blood pressures are extremely elevated in both urgency and emergency; however, there is no evidence of target organ damage in hypertensive urgency. Extremely close hemodynamic monitoring of the patient's blood pressure is required in both. The medications of choice in hypertensive emergencies are those with an immediate effect, such as IV vasodilators. Oral doses of fast-acting agents such as beta-adrenergic blocking agents, angiotensin-converting enzyme inhibitors, or alpha agonists are recommended for the treatment of hypertensive urgencies.

Which describes a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage? Hypertensive urgency Secondary hypertension Hypertensive emergency Primary hypertension

Hypertensive emergency A hypertensive emergency is a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage. Hypertensive urgency is a situation in which blood pressure is severely elevated but there is no evidence of actual or probable target organ damage. Secondary hypertension is high blood pressure from an identified cause, such as renal disease. Primary hypertension denotes high blood pressure from an unidentified source.

In which grade of COPD is the forced expiratory volume (FEV) less than 30%? I II III IV

IV Clients with grade III COPD demonstrate an FEV1 less than 30-50% predicted, with respiratory failure or clinical signs of right heart failure. Grade I is mild COPD, with an FEV1 ≥80% predicted. Clients with grade II COPD demonstrate an FEV1 of 50-80% predicted. Grade IV is characterized by FEV1 less 30% predicted.

A client admitted to the coronary care unit (CCU) diagnosed with a STEMI is anxious and fearful. Which medication will the nurse administer to relieve the client's anxiety and decrease cardiac workload? IV morphine IV nitroglycerin Amlodipine Atenolol

IV morphine IV morphine is the analgesic of choice for the treatment of an acute MI. It is given to reduce pain and treat anxiety. It also reduces preload and afterload, which decreases the workload of the heart. IV nitroglycerin is given to alleviate chest pain. Administration of atenolol and amlodipine are not indicated in this situation.

What can the nurse do to meet the challenges in caring for a patient with cancer? Set the same goals for all patients with cancer. Identify own perception of cancer and set realistic goals. Tell the patient about the things the patient has done to cause cancer. Ensure that the patient has the financial means to afford their care.

Identify own perception of cancer and set realistic goals. Nurses need to identify their own perception of cancer and set realistic goals to meet the challenges inherent in caring for patients with cancer. In addition, nurses caring for patients with cancer must be prepared to support patients and families through a wide range of physical, emotional, social, cultural, financial, and spiritual challenges. Cancer is a diverse set of diseases, so the nurse would not make the same goals for all patients with cancer. The causes of many types of cancer are still unknown, so the nurse should not attempt to tell the patient what he or she has done to cause the cancer. The nurse need not ensure that the patient has the financial means to afford the care.

A mother calls the clinic asking for a prescription for Amoxicillin for her 2-year-old son who has whatthe nurse suspects to be viral rhinitis. What should the nurse explain to this mother?

Ill certainly inform the doctor, but if it is a cold, antibiotics wont be used because they do not affectthe virus.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? Ineffective tissue perfusion (cardiopulmonary) Anxiety Decreased cardiac output Impaired gas exchange

Impaired gas exchange For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.

The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin? Within 12 hours Within the first 24 hours In 3 to 5 days In 2 days

In 3 to 5 days Oral anticoagulants, such as warfarin, are monitored by the PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0) (Holbrook et al., 2012).

When the nurse notes that, after cardiac surgery, the client demonstrates low urine output (less than 25 mL/h) with high specific gravity (greater than 1.025), the nurse suspects which condition? Overhydration Anuria Normal glomerular filtration Inadequate fluid volume

Inadequate fluid volume Urine output less than 0.5 mL/kg/h may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine, which occurs with inadequate fluid volume. Indices of normal glomerular filtration are output of 0.5 mL/kg/h or more and specific gravity between 1.010 and 1.025. Overhydration is manifested by high urine output with low specific gravity. The anuric client does not produce urine.

Which measure may increase complications for a client with COPD? Administration of antitussive agents Administration of antibiotics Decreased oxygen supply Increased oxygen supply

Increased oxygen supply Administering too much oxygen can result in the retention of carbon dioxide. Clients with alveolar hypoventilation cannot increase ventilation to adjust for this increased load, and hypercapnia occurs. All the other measures aim to prevent complications.

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 38°C The client states this is the third episode this season. The highest priority nursing diagnosis is Deficient knowledge related to prevention of upper respiratory infections Ineffective airway clearance related to excess mucus production Acute pain related to upper airway irritation Deficient fluid volume related to increased fluid needs

Ineffective airway clearance related to excess mucus production All the listed nursing diagnoses are appropriate for this client. Following Maslow's hierarchy of needs, physiological needs are addressed first and, within physiological needs, airway, breathing, and circulation are the most immediate. Thus, ineffective airway clearance is the priority nursing diagnosis.

Select the nursing diagnosis that would warrant immediate health care provider notification. Deficient fluid volume related to decreased fluid intake and increased fluid loss secondary to diaphoresis associated with a fever Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation Deficient knowledge regarding prevention of upper airway infections, treatment regimens, the surgical procedure, or postoperative care Acute pain related to upper airway irritation secondary to an infection

Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation Ineffective airway clearance can lead to respiratory depression, which necessitates immediate intervention.

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: Ineffective breathing pattern. Ineffective airway clearance. Impaired tissue integrity. Risk for falls.

Ineffective airway clearance. Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? Impaired gas exchange related to increased blood flow Ineffective peripheral tissue perfusion related to venous congestion Risk for injury related to edema Excess fluid volume related to peripheral vascular disease

Ineffective peripheral tissue perfusion related to venous congestion Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.

A patient comes to the clinic with a cold and wants something to help relieve the symptoms. What should the nurse include in educating the patient about the uncomplicated common cold? (Select all that apply.) Inform the patient that the virus is contagious for 2 days before symptoms appear and during the first part of the symptomatic phase. Suggest that the patient take adequate fluids and get plenty of rest. Inform the patient that taking an antihistamine will help to decrease the duration of the cold. Tell the patient to take prescribed antibiotics to decrease the severity of symptoms. Inform the patient about the symptoms of secondary infection.

Inform the patient that the virus is contagious for 2 days before symptoms appear and during the first part of the symptomatic phase. Suggest that the patient take adequate fluids and get plenty of rest. Inform the patient about the symptoms of secondary infection. Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. Management consists of symptomatic therapy that includes adequate fluid intake, rest, prevention of chilling, and the use of expectorants as needed. The nurse instructs the patient about methods to treat symptoms of the common cold and provides both verbal and written information to assist in the prevention and management of URIs.

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? Administer a heparin bolus and begin an infusion at 500 units/hour. Initiate oxygen therapy. Perform nasopharyngeal suctioning. Administer analgesics as ordered.

Initiate oxygen therapy. The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.

For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan? Providing for frequent rest periods Administering aspirin if the temperature exceeds 102° F (38.8° C) Inspecting the skin for petechiae once every shift Placing the client in strict isolation

Inspecting the skin for petechiae once every shift Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.

A client experiences orthostatic hypotension while receiving furosemide to treat hypertension. How will the nurse intervene? Administer I.V. fluids as ordered. Instruct the client to sit for several minutes before standing. Insert an indwelling urinary catheter as ordered. Administer an isosorbide as ordered.

Instruct the client to sit for several minutes before standing. To minimize the effects of orthostatic hypotension, the nurse should instruct the client to rise slowly, such as by sitting for several minutes before standing. Administering I.V. fluids would be inappropriate (unless the client were dehydrated) because doing so would counteract the effects of furosemide and could cause fluid imbalance. Administering a vasodilator, isosorbide, would further reduce the client's blood pressure, worsening orthostatic hypotension. Inserting an indwelling urinary catheter would make it easier to monitor urine output, but wouldn't minimize the effects of orthostatic hypotension.

A nurse is teaching a client newly diagnosed with arterial insufficiency. Which term should the nurse use to refer to leg pain that occurs when the client is walking? Orthopnea Intermittent claudication Dyspnea Thromboangiitis obliterans

Intermittent claudication Intermittent claudication is leg pain that is brought on by exercise and relieved by rest. Dyspnea is difficulty breathing and is subjective. Orthopnea is the inability to breathe except in the upright (sitting) position. Thromboangiitis obliterans is a peripheral vascular disease also known as Buerger disease.

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? Acute limb ischemia Dizziness Vertigo Intermittent claudication

Intermittent claudication The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease.

Which drug is an oral retinoid used to treat acne? Benzoyl peroxide Tetracycline Estrogen Isotretinoin

Isotretinoin Isotretinoin, an oral retinoid, is used in clients diagnosed with nodular cystic acne that does not respond to conventional therapy. Estrogen, tetracycline, and benzoyl peroxide are not oral retinoids.

When caring for a client in a prenatal clinic who has history of acne vulgaris, which client medication would the nurse advise against? Tazarotene Tretinoin Isotretinoin Benzoyl peroxide

Isotretinoin The nurse is correct to screen for the acne medication, isotretinoin (Accutane). It is contraindicated for pregnant females or those who may become pregnant due to the potential of first trimester miscarriages and congenital malformations.

A nurse is educating about lifestyle modifications for a group of clients with newly diagnosed hypertension. While discussing dietary changes, which point would the nurse emphasize? It takes 2 to 3 months for the taste buds to adapt to decreased salt intake. A person with hypertension should never consume alcohol. The taste buds never adapt to decreased salt intake. There is usually no need to change alcohol consumption for clients with hypertension.

It takes 2 to 3 months for the taste buds to adapt to decreased salt intake. It takes 2 to 3 months for the taste buds to adapt to changes in salt intake. Knowing this may help the client adjust to reduced salt intake. The client should be advised to limit alcohol intake.

A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician? JVD is noted 4 cm above the sternal angle. No JVD is present. JVD is noted at the level of the sternal angle. JVD is noted 2 cm above the sternal angle.

JVD is noted 4 cm above the sternal angle. JVD is assessed with the client sitting at a 45° angle. Jugular vein distention greater than 4 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure.

Which is a characteristic of right-sided heart failure? Jugular vein distention Pulmonary crackles Dyspnea Cough

Jugular vein distention Jugular vein distention is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure.

The nurse assesses the client and observes reddish-purple to dark blue macules, plaques, and nodules. The nurse recognizes that these manifestations are associated with which condition? Kaposi sarcoma Platelet disorders Syphilis Allergic reactions

Kaposi sarcoma Kaposi sarcoma is a frequent comorbidity of clients with AIDS. With platelet disorders, the nurse observes ecchymosis (bruising) and purpura (bleeding into the skin). Urticaria (wheals or hives) is the manifestation of allergic reactions. A painless chancre or ulcerated lesion is a typical finding in clients with syphilis.

Which of the following nursing interventions should a nurse perform to promote the dignity and self-esteem of a dying client? Share emotional pain. Help the client live according to his or her wishes. Communicate hopefulness. Keep the client clean and well groomed.

Keep the client clean and well groomed. A nurse should keep the client clean, well groomed, and free of unpleasant odors to promote his or her dignity and self-esteem. Although sharing emotional pain is an essential component of care for dying clients, it will not promote their dignity and self-esteem. Communicating hopefulness helps sustain hope in dying clients. Helping the client live according to his or her wishes is a feature of hospice care.

The nurse is administering medications to a client that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent?

Lactulose Lactulose is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients. Potassium-sparing diuretics such as spironolactone are used to treat ascites. Cholestyramine is a bile acid sequestrant and reduces pruritus. Kanamycin decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.

The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following? Right ventricular function Left ventricular function Left atrial function Right atrial function

Left ventricular function The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The degree of shock is proportional to the extent of left ventricular dysfunction.

A decrease in circulating white blood cells (WBCs) is referred to as Leukopenia Granulocytopenia Neutropenia Thrombocytopenia

Leukopenia A decrease in circulating WBCs is referred to as leukopenia. Granulocytopenia is a decrease in neutrophils. Thrombocytopenia is a decrease in the number of platelets. Neutropenia is an abnormally low absolute neutrophil count.

Which feature is the hallmark of systolic heart failure? Pulmonary congestion Basilar crackles Limited activities of daily living (ADLs) Low ejection fraction (EF)

Low ejection fraction (EF) A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the client's symptoms.

You are presenting a class on cancer for a local community group. You inform the attendees that chemical agents in the environment are believed to account for 75% of all cancers. Which organs are most susceptible to cancer caused by these chemical agents? Eyes, breast, and prostrate Lungs, liver, and kidneys Bone, breast, and thyroid Prostate, colon, and breast

Lungs, liver, and kidneys The lungs, liver, and kidneys are affected mostly because they are involved with biotransformation and excretion of chemicals.

A client hospitalized for treatment of hypertension is being prepared for discharge. Which teaching topic should the nurse be sure to cover? Maintaining a low-sodium diet Receiving I.V. antihypertensive medications Skipping a medication dose if dizziness occurs Maintaining a low-potassium diet

Maintaining a low-sodium diet The nurse must teach the hypertensive client how to modify his diet to restrict sodium and saturated fats. In addition to teaching about adverse effects of ordered antihypertensives, she must discuss the actions and dosages of these drugs. A client receiving antihypertensives may also take a diuretic as part of the drug regimen and thus may require dietary potassium supplements and high-potassium foods to avoid electrolyte disturbances. Instead of skipping medication if dizziness occurs, the client should notify the physician of this symptom. The client receiving antihypertensives at home takes them by mouth, not I.V.

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal?

Maintaining the airway Explanation:Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway can be compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.

During a routine checkup, a client refers to a recent change in the color of the skin. Which of the following should the nurse suggest to the client? Start chemotherapy. Consider skin grafting. Get a biopsy done as soon as possible. Make an appointment for a medical examination as soon as possible.

Make an appointment for a medical examination as soon as possible. The nurse should encourage all those with any type of skin change to seek medical attention because it may be a sign of skin cancer. Diagnosis is made by visual inspection and confirmed by a biopsy, but it is not the recommended suggestion. The treatment of melanoma involves a radical excision of the tumor and the adjacent tissues followed by chemotherapy. In some instances, skin grafting may be necessary to replace large areas of defect when a wide excision of the tumor is necessary. Chemotherapy and skin grafting should be done only after the confirmation of skin cancer and as a treatment for skin cancer.

Which is a growth-based classification of tumors? Malignancy Carcinoma Sarcoma Leukemia

Malignancy Tumors classified on the basis of growth are described as benign or malignant. Tumors that are classified on the basis of the cell or tissue of origin are carcinomas, sarcomas, lymphomas, and leukemias.

What is histamine, a mediator that supports the inflammatory process in asthma, secreted by? Eosinophils Lymphocytes Mast cells Neutrophils

Mast cells Mast cells, neutrophils, eosinophils, and lymphocytes play key roles in the inflammation associated with asthma. When activated, mast cells release several chemicals called mediators. One of these chemicals is called histamine.

A hospice nurse should be aware that the most effective pain medication used at the end of life that also relieves dyspnea and anxiety is which of the following? Percodan Morphine Codeine Demerol

Morphine Morphine is a potent narcotic that relieves pain and diminishes anxiety, thus managing respirations. Concentrated morphine solution can be very effectively delivered by the sublingual route, because the small liquid volume is well tolerated even if swallowing is not possible.

A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with physician orders that will relieve anxiety and slow respiratory rate? Dopamine Nitroglycerin Furosemide Morphine sulfate

Morphine sulfate Morphine seems to help relieve respiratory symptoms by depressing higher cerebral centers, thus relieving anxiety and slowing respiratory rate. Morphine also promotes muscle relaxation and reduces the work of breathing. Furosemide is a loop diuretic and will decrease fluid accumulation but will not reduce anxiety. Nitroglycerin will promote smooth muscle relaxation in the vessel walls and will relieve pain but not reduce anxiety. Dopamine is an inotrope that will increase the force of ventricular contraction but will not alleviate anxiety.

A nurse reading a chart notes that the client had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result? Borderline Positive Uncertain Negative

Negative The size of the induration determines the significance of the reaction. A reaction 0-4 mm is not considered significant. A reaction ≥5 mm may be significant in people who are considered to be at risk. An induration ≥10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity.

A client presents to the ED reporting anxiety and chest pain after shoveling heavy snow that morning. The client says that nitroglycerin has not been taken for months but upon experiencing this chest pain did take three nitroglycerin tablets. Although the pain has lessened, the client states, "They did not work all that well." The client shows the nurse the nitroglycerin bottle; the prescription was filled 12 months ago. The nurse anticipates which order by the physician? Ativan 1 mg orally Nitroglycerin SL Chest x-ray Serum electrolytes

Nitroglycerin SL Nitroglycerin is volatile and is inactivated by heat, moisture, air, light, and time. Nitroglycerin should be renewed every 6 months to ensure full potency. The client's tablets were expired, and the nurse should anticipate administering nitroglycerin to assess whether the chest pain subsides. The other choices may be ordered at a later time, but the priority is to relieve the client's chest pain.

The nurse is caring for a client with questionable lice infestation. The nurse is using a bright light focused on an area of the head to confirm the presence of lice. In which manner is it easiest to differentiate nits from dandruff? Dandruff is throughout the hair. Nits are located near the scalp. Dandruff looks white and flakey. Nits are difficult to move from hair shafts.

Nits are difficult to move from hair shafts. The nurse is correct to use the difference of the nits being securely attached to the hair shaft as a guide to confirmation of lice infestation. Dandruff is fine, white particles of dead, dry scalp cells that can be easily picked from the hair.

A patient is diagnosed with malignant melanoma that directly invades the adjacent dermis (vertical growth). The nurse knows that this type of melanoma has a poor prognosis. Which of the following is most likely the type of melanoma described in this scenario? Superficial spreading Lentigo-maligna Nodular melanoma Acral-lentiginous

Nodular melanoma A nodular melanoma is a spherical, blueberry-like nodule with a relatively smooth surface and a relatively uniform, blue-black color. A nodular melanoma invades directly into adjacent dermis (i.e., vertical growth) and therefore has a poorer prognosis.

The nurse is caring for a patient who returned from the tropics 2 weeks ago. The patient has been diagnosed with lymphangitis and is experiencing lymphedema. You are aware that the lymphedema may be due to what? Obstructed lymph vessels Sensitivity to antibiotics Excessive lymph is the vascular space Improper anticoagulant use

Obstructed lymph vessels Lymphedema is caused by accumulation of lymph in the tissues and may be a result of obstructed lymph vessels. It is not caused by sensitivity to antibiotics, vascular accumulation of lymph, or improper anticoagulant use.

Which type of sleep apnea is characterized by lack of airflow due to pharyngeal occlusion? a) Central b) Obstructive c) Mixed d) Simple

Obstructive Obstructive sleep apnea occurs usually in men, and especially in men who are older and overweight. Types of sleep apnea do not include a simple characterization. Mixed sleep apnea is a combination of central and obstructive apnea with one apneic episode. In central sleep apnea, the patient demonstrates simultaneous cessation of both airflow and respiratory movements.

A nurse is teaching a community class about how to decrease the risk of cancer. Which food should the nurse recommend? Low-fat hot dogs Smoked ham Oranges Medium-rare steak

Oranges A diet high in vitamin C and citrus may help reduce the risk of certain cancers, such as stomach and esophageal cancers. Hot dogs and smoked and cured foods are high in nitrates, which may be linked to esophageal and gastric cancers. Steak is a high-fat food that may increase the risk of breast, colon, and prostate cancers.

Which describes difficulty breathing when a client is lying flat? Bradypnea Orthopnea Tachypnea Paroxysmal nocturnal dyspnea (PND)

Orthopnea Orthopnea occurs when the client is having difficulty breathing when lying flat. Sudden attacks of dyspnea at night are known as paroxysmal nocturnal dyspnea. Tachypnea is a rapid breathing rate and bradypnea is a slow breathing rate.

Which type of surgery is used in an attempt to relieve complications of cancer? Salvage Prophylactic Palliative Reconstructive

Palliative Palliative surgery is performed to relieve complications of cancer. Prophylactic surgery involves removing nonvital tissues or organs that are likely to develop cancer. Reconstructive surgery may follow curative or radical surgery and is carried out in an attempt to improve function or to obtain a more desirable cosmetic effect. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach.

A 50-year-old client is an alcoholic. The client has been diagnosed with pancreatic cancer and underwent surgery to remove the tumor. Despite the tumor being removed, the physician informs the client that chemotherapy needs to be started immediately. Using evidence-based practice, which intervention might the nurse expect the physician to include, with the goal of improving quality of life, mood, and median survival. Angiogenesis Respite care Palliative care Radiation

Palliative care In a study of referral to palliative care for clients newly diagnosed with a disease with very poor prognosis, researchers found that those clients receiving palliative care plus standard oncology demonstrated improved quality of life and mood and had longer median survival. Radiation is primarily used when a cancer spreads to other organs, and it has not been proven to affect mood. Angiogenesis is the growth of new capillaries from the tissue of origin. This process helps malignant cells obtain needed nutrients and oxygen to promote growth. Respite care is provided on an occasional basis to relieve the family caregivers.

The family of a client in hospice decides to place their loved one in a long-term care facility to establish an effective pain control regimen. Which aspects of hospice care is the family using? Inpatient respite care General inpatient care Palliative care Continuous care

Palliative care Long-term care is increasing as a setting to provide palliative care that addresses management of symptoms such as pain. Inpatient respite care is a 5-day inpatient stay provided on an occasional basis to relieve the family caregivers. Continuous care is provided in the home to manage a medical crisis. General inpatient care provides inpatient stay for symptoms management that cannot be provided in the home.

A group of nursing students is reviewing information about palliative care. The students demonstrate a need for additional review when they identify which of the following? Palliative care is conceptually broader than hospice care. Palliative care is the same as hospice care. Palliative care developed after hospice care developed. Palliative care is often provided along with disease-lessening treatments.

Palliative care is the same as hospice care. Palliative care is not synonymous with hospice care. All hospice care is palliative but not all palliative care is hospice care. Palliative care is conceptually broader than hospice care and is an approach to care as well as a structured system for delivering care. Palliative care followed the development of hospice care. It does not begin when cure-focused treatment ends but is most helpful when provided along with disease-remitting treatment.

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities? Participate in a regular walking program. Use a heating pad to promote warmth. Massage the calf muscles if pain occurs. Keep the extremities elevated slightly.

Participate in a regular walking program. Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and to resume activity when pain subsides. Extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. Heating pads should not be used by anyone with impaired circulation to avoid burns. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.

A nurse is caring for a client with a terminal illness. The client asks the nurse to help him end his own life to alleviate his suffering and that of his family. When responding to the client, the nurse integrates knowledge of which of the following? Participating in assisted suicide violates the Code of Ethics for Nurses. Most states have enacted laws that allow for physician-assisted suicide. Nurses may administer medications prescribed by physicians to hasten end of life. A client has the right to make independent decisions about the timing of his or her death.

Participating in assisted suicide violates the Code of Ethics for Nurses. The American Nurses Association Position Statement on Assisted Suicide acknowledges the complexity of the assisted suicide debate but clearly states that nursing participation in assisted suicide is a violation of the Code for Nurses. Legally, nurses are not allowed to administer medications even if prescribed by a physician if that medication will hasten the client's end of life. Proponents of physician-assisted suicide argue that terminally ill people should have a legally sanctioned right to make independent decisions about the value of their lives and the timing and circumstances of their deaths. However, this is not the case at the present time. Two states have enacted legislation for physician-assisted suicide. These laws provide access to physician-assisted suicide by terminally ill clients under very controlled circumstances.

A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours? Peripheral pulses every 15 minutes after surgery Ankle-arm indices every 12 hours Blood pressure every 2 hours Color of the leg every 4 hours

Peripheral pulses every 15 minutes after surgery The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the client's status remains stable.

What is the most common complication of sore throat?

Peritonsillar abscess (begins as a collection of purulent exudate between the tonsillar capsule and the surrounding tissue)

The client with cardiac failure is taught to report which symptom to the physician or clinic immediately? Increased appetite Weight loss Ability to sleep through the night Persistent cough

Persistent cough Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite, weight gain, interrupted sleep, unusual shortness of breath, and increased swelling should also be reported immediately.

A nurse providing education about hypertension to a community group is discussing the high risk for cardiovascular complications. What are risk factors for cardiovascular problems in clients with hypertension? Select all that apply. Gallbladder disease Physical inactivity Diabetes mellitus Frequent upper respiratory infections Smoking

Physical inactivity Diabetes mellitus Smoking Risk factors for cardiovascular problems in clients with hypertension include smoking, dyslipidemia, diabetes mellitus, impaired renal function, obesity, physical inactivity, age, and family history.

The nurse is conducting a community program about prevention of respiratory illness. What illness does the nurse know is the most common cause of death from infectious diseases in the United States? Atelectasis Tracheobronchitis Pneumonia Pulmonary embolus

Pneumonia Pneumonia and influenza are the most common causes of death from infectious diseases in the United States. Pneumonia accounted for close to 51,000 deaths in the United States in 2009 and 1.1 million discharges from hospitals (Centers for Disease Control and Prevention [CDC], 2015b).

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? Myocardial infarction (MI) Heart failure Pulmonary embolism Pneumothorax

Pneumothorax Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.

A patient complains of a "stabbing pain and a burning sensation" in his left foot. The nurse notices that the foot is a lighter color than the rest of the skin. The artery that the nurse suspects is occluded would be the: Internal iliac. Common femoral. Posterior tibial. Popliteal.

Posterior tibial. Clinical symptoms of PAD are manifested in organs or muscle groups supplied by specific arterial blood flow. The posterior tibial artery is a major artery that is a common site for occlusion.

A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure? Potassium Calcium Platelet count White blood cell (WBC) count

Potassium Diuretics, such as furosemide (Lasix), are commonly used to treat acute heart failure. Most diuretics increase the renal excretion of potassium. The nurse should check the client's potassium level before administering diuretics, and obtain an order to replace potassium if the level is low. Other medications commonly used to treat heart failure include angiotensin-converting enzyme inhibitors, digoxin (Lanoxin), and beta-adrenergic blockers. Although checking the platelet count, calcium level, and WBC count are important, these values don't affect medication administration for acute heart failure.

A patient in the recovery room after cardiac surgery begins to have extremity paresthesia, peaked T waves, and mental confusion. What type of electrolyte imbalance does the nurse suspect this patient is having? Potassium Sodium Magnesium Calcium

Potassium Hyperkalemia (high potassium) can result in the following ECG changes: tall peaked T waves, wide QRS, and bradycardia. The nurse should be prepared to administer a diuretic or an ion-exchange resin (sodium polystyrene sulfonate [Kayexalate]); IV sodium bicarbonate, or IV insulin and glucose. Imbalances in the other electrolytes listed would not result in peaked T waves.

A client is taking amiloride and lisinopril for the treatment of hypertension. What laboratory studies should the nurse monitor while the client is taking these two medications together? Sodium level Magnesium level Calcium level Potassium level

Potassium level Amiloride (Midamor) is a potassium-sparing diuretic, meaning that it causes potassium retention. The nurse should monitor for hyperkalemia (elevated potassium level) if given with an ACE inhibitor, such as lisinopril (Zestril) or angiotensin receptor blocker.

A nurse is admitting a client with toxic epidermal necrolysis. What is the nursing priority in preventing sepsis? Limiting protein to limit liver failure Preventing infection Assessing for hemorrhage Hydrating to prevent renal failure

Preventing infection The major cause of death from toxic epidermal necrolysis is from sepsis. Monitoring vital signs closely and noticing changes in respiratory, kidney, and gastrointestinal function may help the nurse to quickly detect the beginning of an infection. Strict asepsis is always maintained during routine skin care measures. Hand hygiene and wearing sterile gloves when carrying out procedures are essential. Visitors should wear protective garments and wash their hands before and after coming into contact with the patient. People with any infections or infectious disease should not visit the patient until they are no longer a danger to the patient. The nurse is critical in identifying early signs and symptoms of infection and notifying the primary provider. Antibiotic agents are not generally begun until there is an indication for the use. Hemorrhage, renal failure, and liver failure are not the major causes of toxic epidermal necrolysis.

The nurse is caring for a client following a coronary artery bypass graft (CABG). The nurse notes persistent oozing of bloody drainage from various puncture sites. The nurse anticipates that the physician will order which medication to neutralize the unfractionated heparin the client received? Aspirin Alteplase Clopidogrel Protamine sulfate

Protamine sulfate Protamine sulfate is known as the antagonist for unfractionated heparin (it neutralizes heparin). Alteplase is a thrombolytic agent. Clopidogrel is an antiplatelet medication that is given to reduce the risk of thrombus formation after coronary stent placement. The antiplatelet effect of aspirin does not reverse the effects of heparin.

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description? Thrombin Phytonadione (vitamin K) Protamine sulfate Plasma protein fraction

Protamine sulfate Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock.

A nurse assesses an oncology client with stomatitis during a chemotherapy session. Which nursing intervention would most likely decrease the pain associated with stomatitis? Recommend that the client discontinue chemotherapy. Check regularly for signs and symptoms of stomatitis. Provide a solution of viscous lidocaine for use as a mouth rinse. Monitor the client's platelet and leukocyte counts.

Provide a solution of viscous lidocaine for use as a mouth rinse. To decrease the pain of stomatitis, the nurse should provide a solution of viscous lidocaine for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer systemic analgesics as ordered. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection, but wouldn't decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn't decrease the pain.

A patient is admitted for an excisional biopsy of a breast lesion. What intervention should the nurse provide for the care of this patient? Provide time for the patient to discuss her concerns. Provide aseptic care to the incision postoperatively. Clarify information provided by the physician. Counsel the patient about the possibility of losing her breast.

Provide time for the patient to discuss her concerns. Patients who are undergoing surgery for the diagnosis or treatment of cancer may be anxious about the surgical procedure, possible findings, postoperative limitations, changes in normal body functions, and prognosis. The patient and family require time and assistance to process the possible changes and outcomes resulting from the surgery. The nurse serves as the patient advocate and liaison and encourages the patient and family to take an active role in decision making when possible. If the patient or family asks about the results of diagnostic testing and surgical procedures, the nurse's response is guided by the information that was conveyed previously. The nurse may be asked to explain and clarify information for patients and families that was provided initially but was not grasped because of anxiety and overwhelming feelings. It is important that the nurse, as well as other members of the health care team, provide information that is consistent from one clinician to another.

A nurse assesses a client with dry, rough, scaly skin without lesions and the presence of itching on the legs. What skin assessment would the nurse document? Seborrhea Shingles Candidiasis Pruritus

Pruritus Pruritus (itching) is one of the most common symptoms of patients with dermatologic disorders. Itch receptors are unmyelinated, penicillate (brush-like) nerve endings that are found exclusively in the skin, mucous membranes, and cornea. Shingles is a skin condition with lesions. Candidiasis is a red condition often found in the folds of skin. Seborrhea refers to dry scaly patches usually located on the scalp.

During a physical examination, a child is noted to have nails with "ice-pick" pits and ridges. The nails are thick and discolored and have splintered hemorrhages easily separated from the nail bed. Which condition would cause this to occur?

Psoriasis

A patient is diagnosed with psoriasis after developing scales on the scalp, elbows, and behind the knees. The patient asks the nurse where this was "caught." What is the best response by the nurse? Psoriasis is an inflammatory dermatosis that results from an overproduction of keratin. Psoriasis results from excess deposition of subcutaneous fat. Psoriasis comes from dermal abrasion. Psoriasis is an inflammatory dermatosis that results from a superficial infection with Staphylococcus aureus.

Psoriasis is an inflammatory dermatosis that results from an overproduction of keratin. Current evidence supports an autoimmune basis for psoriasis (Porth & Matfin, 2009). Periods of emotional stress and anxiety aggravate the condition, and trauma, infections, and seasonal and hormonal changes may also serve as triggers. In this disease, the epidermis becomes infiltrated by activated T cells and cytokines, resulting in both vascular engorgement and proliferation of keratinocytes. Epidermal hyperplasia results.

A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.) Dyspnea Cough Ascites Jugular vein distention Pulmonary crackles

Pulmonary crackles Dyspnea Cough The clinical manifestations of pulmonary congestion associated with left-sided heart failure include dyspnea, cough, pulmonary crackles, and low oxygen saturation levels, but not ascites or jugular vein distention.

A breathing technique the nurse should teach the patient with COPD to promote exhalation is

Pursed-lip breathing

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important? Recent pelvic surgery History of increased aspirin use An active daily walking program A history of diabetes mellitus

Recent pelvic surgery The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe?

Red, swollen skin with inflammation spreading to surrounding tissues

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?

Reduce fluid accumulation and venous pressure Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?

The client's hepatic function is decreasing. The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.

A client is brought to the emergency department with reports of a bad headache and an increase in blood pressure. The blood pressure reading obtained by the nurse is 260/180 mm Hg. What is the therapeutic goal for reduction of the mean blood pressure? Reduce the blood pressure by 20% to 25% within the first hour of treatment. Rapidly reduce the blood pressure so the client will not suffer a stroke. Reduce the blood pressure by 50% within the first hour of treatment. Reduce the blood pressure to about 140/80 mm Hg.

Reduce the blood pressure by 20% to 25% within the first hour of treatment. A hypertensive emergency is a situation in which blood pressures are extremely elevated and must be lowered immediately (not necessarily to less than 140/90 mm Hg) to halt or prevent damage to the target organs (Chobanian et al., 2003; Rodriguez et al., 2010). Hypertensive emergencies are acute, life-threatening blood pressure elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. The therapeutic goals are reduction of the mean blood pressure by 20% to 25% within the first hour of treatment, a further reduction to a goal pressure of about 160/100 mm Hg over a period of up to 6 hours, and then a more gradual reduction in pressure over a period of days.

Which action by the nurse demonstrates an effective method to assess the client and the client's family's ability to cope with end-of-life interventions? Offering reassurance that the nurse has had 5 years of assisting clients in hospice and their families care for loved ones at the end of life Providing evidenced-based advice for end-of-life care based on the nurse's experiences with previous clients in hospice Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care Filling voids in conversation with information related to death and dying to avoid awkward moments during the admission interview

Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care A key to effective listening includes allowing the client and family sufficient time to reflect and respond after asking a question. Hospice nurses with effective listening skills resist the impulse to fill the empty space in communication with talk, avoid the impulse to give advice, and avoid responses indicating, "I know just how you feel.

A patient is scheduled for Mohs microscopic surgery for removal of a skin cancer lesion on his forehead. The nurse knows to prepare the patient by explaining that this type of surgery requires: A process of deep-freezing the tumor, thawing and refreezing. Destruction of the tissue by electrical energy. Removal of the tumor, layer by layer. The use of radiation therapy.

Removal of the tumor, layer by layer. Mohs micrographic surgery removes the tumor layer by layer. The first layer excised includes all evident tumor and a small margin of normal-appearing tissue. The specimen is frozen and analyzed by section to determine if all the tumor has been removed. If not, additional layers of tissue are shaved and examined until all tissue margins are tumor-free.

A client has been declared to have a terminal illness. What intervention will a nurse perform regarding the final decision of a dying client? Respect the client's and family members' choices Share emotional pain Abide by the dying client's wishes Ask the family members about spiritual care

Respect the client's and family members' choices In the final decisions of a dying client, the nurse will present options for terminal care and respect the client's and family members' choices. Sharing emotional pain is a role in providing care and comfort to dying clients and their families. When the client has a living will, physicians must abide by the client's wishes. The nurse should ask the family members about spiritual care only if the client wants someone associated with his or her religion.

As status asthmaticus worsens, the nurse would expect which acid-base imbalance? Metabolic acidosis Respiratory acidosis Respiratory alkalosis Metabolic alkalosis

Respiratory acidosis As status asthmaticus worsens, the PaCO2 increases and the pH decreases, reflecting respiratory acidosis.

A patient is being treated for status asthmaticus. What danger sign does the nurse observe that can indicate impending respiratory failure? Metabolic alkalosis Respiratory acidosis Metabolic acidosis Respiratory alkalosis

Respiratory acidosis In status asthmaticus, increasing PaCO2 (to normal levels or levels indicating respiratory acidosis) is a danger sign signifying impending respiratory failure. Understanding the sequence of the pathophysiologic processes in status asthmaticus is important for understanding assessment findings. Respiratory alkalosis occurs initially because the patient hyperventilates and PaCO2 decreases. As the condition continues, air becomes trapped in the narrowed airways and carbon dioxide is retained, leading to respiratory acidosis.

A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? Dilated and reactive pupils Heart rate of 100 beats/minute Urine output of 40 ml/hour Respiratory rate of 22 breaths/minute

Respiratory rate of 22 breaths/minute In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

Which finding indicates that hypertension is progressing to target organ damage? Retinal blood vessel damage Blood urea nitrogen concentration of 12 mg/dL Urine output of 60 mL over 2 hours Chest x-ray showing pneumonia

Retinal blood vessel damage Symptoms suggesting that hypertension is progressing to the extent that target organ damage is occurring must be detected early so that appropriate treatment can be initiated. All body systems must be assessed to detect any evidence of vascular damage. An eye examination with an ophthalmoscope is important because retinal blood vessel damage indicates similar damage elsewhere in the vascular system. The client is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed. A BUN concentration of 12 mg/dL and urine output of 60 mL over 2 hours are normal findings. The presence of pneumonia does not indicate target organ damage.

The nurse is caring for a client presenting to the emergency department (ED) reporting chest pain. Which electrocardiographic (ECG) finding would be most concerning to the nurse? Frequent premature atrial contractions (PACs) Sinus tachycardia ST elevation Isolated premature ventricular contractions (PVCs)

ST elevation The first signs of an acute MI are usually seen in the T wave and the ST segment. The T wave becomes inverted; the ST segment elevates (it is usually flat). An elevated ST segment in two contiguous leads is a key diagnostic indicator for MI (i.e., ST-elevation MI). This client requires immediate invasive therapy or fibrinolytic medications. Although the other ECG findings require intervention, elevated ST elevations require immediate and definitive interventions.

A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect? Contact dermatitis Dermatophytosis Scabies Impetigo

Scabies Signs and symptoms of scabies include gray-brown burrows, epidermal curved or linear ridges, and follicular papules. Clients complain of severe itching that usually occurs at night. Scabies commonly occurs in school-age children. The most common areas of infestation are the finger webs, flexor surface of the wrists, and antecubital fossae. Impetigo is a contagious, superficial skin infection characterized by a small, red macule that turns into a vesicle, becoming pustular with a honey-colored crust. Contact dermatitis is an inflammation of the skin caused by contact with an irritating chemical or allergen. Dermatophytosis, or ringworm, is a disease that affects the scalp, body, feet, nails, and groin. It's characterized by erythematous patches and scaling.

A client, newly admitted to the nursing unit, has a primary diagnosis of renal failure. When assessing the client, the nurse notes a blood pressure (BP) of 180/100. The nurse knows that this is what kind of hypertension? Secondary Essential Primary Malignant

Secondary Secondary hypertension is elevated BP that results from or is secondary to some other disorder. This type of hypertension is not primary, essential, or malignant.

Which term describes high blood pressure from an identified cause, such as renal disease? Primary hypertension Hypertensive emergency Rebound hypertension Secondary hypertension

Secondary hypertension Secondary hypertension is high blood pressure from an identified cause, such as renal disease. Primary hypertension denotes high blood pressure form an unidentified source. Rebound hypertension is pressure that is controlled with therapy and becomes uncontrolled (abnormally high) when that therapy is discontinued. A hypertensive emergency is a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage.

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? See if the chest tube is clogged. See if a kink has developed in the tubing. See if there are leaks in the system. See if the wall suction unit has malfunctioned.

See if there are leaks in the system. Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected.

A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to

Seek medical help if he experiences inability to swallow

The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm? Rectal bleeding Hematemesis Hypertensive crisis Severe back pain

Severe back pain Pressure from an enlarging or dissecting abdominal aortic aneurysm is likely to be exhibited as severe back pain. A decrease in blood pressure will result as the client goes into shock from hemorrhaging. Blood in emesis or rectal bleeding is not associated with rupture of AAA.

The school nurse is instructing a parent in the care and elimination of lice from their child's hair. The parent brings all of the products for care in a bag. Which contents are not appropriate for use? Permethrin (Nix) Plastic wide-toothed comb New hair clips Shampoo and conditioner

Shampoo and conditioner The nurse is correct to instruct the parent to avoid shampoo and conditioner because this coats the hair and protects the nits. Nix and a wide-toothed comb are recommended. New hair clips may be used once the infestation is gone.

After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered: Negative Significant Nonreactive Not significant

Significant An induration of 10 mm or greater is usually considered significant and reactive in people who have normal or mildly impaired immunity. Erythema without induration is not considered significant.

A patient has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritizeassessments related to what complication?

Sinus infections

The nurse is instructing a client who is newly prescribed an antihypertensive medication. Which nursing instruction is emphasized to maintain client safety? Take the medication at the same time daily. Do not operate a motor vehicle. Use a pillbox to store daily medication. Sit on the edge of the chair and rise slowly.

Sit on the edge of the chair and rise slowly. The nursing instruction emphasized to maintain client safety is to sit on the edge of the chair before rising slowly. By doing so, the client reduces the possibility of falls related to postural hypotension. Using a pillbox to store medications and taking the medication at the same time daily is good medication management instruction. There is no reason when taking antihypertensive medications to restrict driving.

Which is a potassium-sparing diuretic used in the treatment of heart failure? Spironolactone Chlorothiazide Bumetanide Ethacrynic acid

Spironolactone Spironolactone is a potassium-sparing diuretic. Chlorothiazide is a thiazide diuretic. Bumetanide and ethacrynic acid are loop diuretics.

The nurse is caring for a client who is prescribed medication for the treatment of hypertension. The nurse recognizes that which medication conserves potassium? Furosemide Chlorothiazide Chlorthalidone Spironolactone

Spironolactone Spironolactone is known as a potassium-sparing diuretic. Furosemide causes loss of potassium from the body. Chlorothiazide and chlorthalidone cause mild hypokalemia.

Which of the following medications would the nurse expect the physician to order for a client with cirrhosis who develops portal hypertension?

Spironolactone (Aldactone) For portal hypertension, a diuretic usually an aldosterone antagonist such as spironolactone (Aldactone) is ordered. Kanamycin (Kantrex) would be used to treat hepatic encephalopathy to destroy intestinal microorganisms and decrease ammonia production. Lactulose would be used to reduce serum ammonia concentration in a client with hepatic encephalopathy. Cyclosporine (Sandimmune) would be used to prevent graft rejection after a transplant.

A patient comes to the clinic for the third time in 2 months with chronic bronchitis. What clinical symptoms does the nurse anticipate assessing for this patient? Sputum and a productive cough Fever, chills, and diaphoresis Tachypnea and tachycardia Chest pain during respiration

Sputum and a productive cough Chronic bronchitis, a disease of the airways, is defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years.

A nurse is discussing asthma complications with a client and family. What complications should the nurse include in the teaching? Select all that apply. Thoracentesis Status asthmaticus Pertussis Atelectasis Respiratory failure

Status asthmaticus Respiratory failure Atelectasis Complications of asthma may include status asthmaticus, respiratory failure, and atelectasis. Pertussis is not an asthma complication. Thoracentesis is a diagnostic procedure, not a complication.

A nurse is administering a peripheral chemotherapeutic agent. What nursing actions are used for extravasation of a chemotherapeutic agent? Select all that apply. Apply warm compresses to the irritated site to encourage healing Stop the medication infusion at the first sign of extravasation Administer an antidote, if indicated Aspirate any residual drug from the IV line Schedule the client for implanted device

Stop the medication infusion at the first sign of extravasation Aspirate any residual drug from the IV line Administer an antidote, if indicated All of the answers except application of a warm compress are appropriate nursing actions. The application of warmth would be contraindicated because it would cause vasodilation, which would increase the absorption of irritant into the local tissues. Short term chemotherapy can be done with peripheral catheters so the client may not need an implanted device.

To help prevent infections in clients with COPD, the nurse should recommend vaccinations against two bacterial organisms. Which of the following are the two vaccinations? Streptococcus pneumonia and Hemophilus influenzae Hemophilus influenzae and varicella Hemophilus influenzae and Gardasil Streptococcus pneumonia and varicella

Streptococcus pneumonia and Hemophilus influenzae Clients with COPD are more susceptible to respiratory infections, so they should be encouraged to receive the influenza and pneumococcal vaccines. Clients with COPD aren't at high risk for varicella or hepatitis B. The HPV vaccine is to guard against cervical cancer and is recommended only for females ages 9 to 26 years.

A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia? Staphylococcus aureus Mycobacterium tuberculosis Pseudomonas aeruginosa Streptococcus pneumoniae

Streptococcus pneumoniae Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia in people younger than 60 years without comorbidity and in those 60 years and older with comorbidity (Wunderink & Niederman, 2012). S. pneumoniae, a gram-positive organism that resides naturally in the upper respiratory tract, colonizes the upper respiratory tract and can cause disseminated invasive infections, pneumonia and other lower respiratory tract infections, and upper respiratory tract infections such as otitis media and rhinosinusitis. It may occur as a lobar or bronchopneumonic form in patients of any age and may follow a recent respiratory illness.

What is the treatment for tonsillitis and adenoiditis?

Supportive measures - fluids, gargles, analgesics, antibiotics, tonsillectomy, adenoidectomy

The nurse is caring for a client who is status post operative from a vein stripping. What would the nurse monitor for? Warm, pink toes in the inoperative leg Blood on the dressing on the inoperative leg Swelling in the inoperative leg Swelling in the operative leg

Swelling in the operative leg When the client returns from surgery with a gauze dressing covered by elastic roller bandages on the operative leg, the nurse monitors for swelling in the operative leg(s) and its effect on circulation.

A client calls the oncology office nurse and reports nausea and vomiting one week after receiving chemotherapy. What action should the nurse recommend? Taking prescribed ondansetron Obtaining acupressure treatments Using imagery techniques Practicing relaxation techniques

Taking prescribed ondansetron Serotonin blockers, such as ondansetron (Zofran), may decrease nausea and vomiting. Once these symptoms are relieved, the client can use other strategies, such as relaxation, imagery, and acupressure. These strategies, when used with serotonin blockers, provide improved anti-emetic protection.

What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis? Inform the physician if the client's temperature remains low Offer cold applications to promote comfort and to enhance circulation Avoid elevating the area Teach the client how to apply an elastic sleeve

Teach the client how to apply an elastic sleeve In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. The nurse informs the physician if the client's temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.

A nurse is administering daunorubicin (DaunoXome) to a patient with lung cancer. Which situation requires immediate intervention? The client states he is nauseous. The laboratory reports a white blood cell (WBC) count of 1,000/mm3. The I.V. site is red and swollen. The client begins to shiver.

The I.V. site is red and swollen. A red, swollen I.V. site indicates possible infiltration. Daunorubicin is a vesicant chemotherapeutic agent and can be very damaging to tissue if it infiltrates. The nurse should immediately stop the medication, apply ice to the site, and notify the physician. Although nausea, WBC count of 1,000/mm3, and shivering require interventions, these findings aren't a high priority at this time.

The nurse is caring for a client with hypertension. The nurse is correct to realize that a 24-hour urine is ordered to determine if the cause of hypertension is related to the dysfunction of which of the following? The thymus The adrenal gland The pituitary gland The thyroid gland

The adrenal gland The 24-hour urine collection specimen is ordered to determine dysfunction of the adrenal gland. The 24-hour urine detects elevated catecholamines. The other options are not evaluated by a 24-hour urine.

A patient in cardiogenic shock after a myocardial infarction is placed on an intra-aortic balloon pump (IABP). What does the nurse understand is the mechanism of action of the balloon pump? The balloon keeps the vessels open so that blood will adequately deliver to the myocardium. The balloon will inflate at the beginning of systole and deflate before diastole to provide a long-term solution to a failing myocardium. The balloon delivers an electrical impulse to correct dysrhythmias the patient experiences. The balloon inflates at the beginning of diastole and deflates before systole to augment the pumping action of the heart.

The balloon inflates at the beginning of diastole and deflates before systole to augment the pumping action of the heart. The IABP uses internal counterpulsation through the regular inflation and deflation of the balloon to augment the pumping action of the heart. It inflates during diastole, increasing the pressure in the aorta during diastole and therefore increasing blood flow through the coronary and peripheral arteries. It deflates just before systole, lessening the pressure within the aorta before left ventricular contraction, decreasing the amount of resistance the heart has to overcome to eject blood and therefore decreasing left ventricular workload.

A nurse and physician are preparing to visit a hospitalized client with peripheral arterial disease. As you approach the client's room, the physician asks if the client has reported any intermittent claudication. The client has reported this symptom. The nurse explains to the physician which of the following details? The client's legs awaken him during the night with itching. The client experiences shortness of breath after walking about 50 feet. The client can walk about 50 feet before getting pain in the right lower leg. The client's fingers tingle when left in one position for too long.

The client can walk about 50 feet before getting pain in the right lower leg Intermittent claudication is caused by the inability of the arterial system to provide adequate blood flow to the tissues when increased demands are made for oxygen and nutrients during exercise. Pain is then experienced. When the client rests and decreases demands, the pain subsides. The client can then walk the same distance and repeat the process.

A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy? The client exhibits a heart rate above 100 beats/minute. The client demonstrates ability to tolerate more activity without chest pain. The client states that sublingual nitroglycerin usually relieves his chest pain. The client verbalizes the intention of making all necessary lifestyle changes except for stopping smoking.

The client demonstrates ability to tolerate more activity without chest pain. The ability to tolerate more activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. The client should have a normal electrocardiogram with no arrhythmias and a regular heart rate of 60 to 100 beats/minute. Smoking is a cardiovascular risk factor that the client must be willing to eliminate. A client who responds favorably to therapy shouldn't have chest pain.

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client? The development of chronic obstructive pulmonary disease (COPD) The development of cor pulmonale The development of left-sided heart failure The development of right-sided heart failure

The development of left-sided heart failure When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage.

Which of the following does not coincide with Kübler-Ross's stages related to a dying client? Some client regress, then move forward again. Clients don't always follow the stages in order. The client may be in several stages at once. The dying client usually exhibits anger first.

The dying client usually exhibits anger first. The dying client does not usually exhibit anger first. The client may be in several stages at once, clients don't always follow the stages in order, and some regress and then move forward.

A 44-year-old homeless man presented to the emergency department with hemoptysis. The patient was diagnosed with tuberculosis (TB) after diagnostic testing and has just begun treatment with INH, pyrazinamide, and rifampin (Rifater). When providing patient education, what should the nurse emphasize? The rationale and technique for using incentive spirometry The correct use of a metered-dose inhaler (MDI) for bronchodilators The need to maintain good nutrition and adequate hydration The importance of adhering to the prescribed treatment regimen

The importance of adhering to the prescribed treatment regimen Successful treatment of TB is wholly dependent on the patient's conscientious adherence to treatment. Patient education relating to this fact is a priority over MDIs, incentive spirometry, or nutrition, although each may be necessary.

A female patient with obstructive sleep apnea (OSA) has been recommended a continuous positive airway pressure (CPAP) machine for the treatment of her health problem. The nurse's priority for patient education should be: The need to use inhaled corticosteroids and bronchodilators each night prior to applying CPAP The need to have continuous pulse oximetry in place while the CPAP machine is in use The importance of complying with CPAP despite the inconvenience associated with its use The importance of participating in daily physical exercise when using CPAP on a regular basis

The importance of complying with CPAP despite the inconvenience associated with its use Although CPAP is effective in management of OSA, patient compliance with the treatment continues to be a major concern. Nursing interventions aimed at increasing compliance are consequently a priority. Steroids, bronchodilators, and pulse oximetry are not normally necessary. Daily exercise is beneficial but the promotion of compliance is a priority for patients using CPAP.

A patient with coronary artery disease (CAD) is having a cardiac catheterization. What indicator is present for the patient to have a coronary artery bypass graft (CABG)? The patient has at least a 70% occlusion of a major coronary artery. The patient has an ejection fraction of 65%. The patient has had angina longer than 3 years. The patient has compromised left ventricular function.

The patient has at least a 70% occlusion of a major coronary artery. For a patient to be considered for CABG, the coronary arteries to be bypassed must have approximately a 70% occlusion (60% if in the left main coronary artery).

The nurse is caring for a client who just learned of his terminal diagnosis. After the physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle? The principle of nonmaleficence The principle of autonomy The principle of justice The principle of fidelity

The principle of autonomy By promoting open discussion and informed decision making, the nurse is empowering the client to make his own decisions leading to autonomy. The principle of justice requires fairness and justice to all clients. The principle of nonmaleficence requires that nurse does not intentionally or unintentionally inflict harm on others. The principle of fidelity maintains that nurses are faithful to the care of the clients.

A 36-year-old man is receiving three different chemotherapeutic agents for Hodgkin's disease. The nurse explains to the client that the three drugs are given over an extended period because: The second and third drugs increase the effectiveness of the first drug. The three drugs can be given at lower doses. The first two drugs are toxic to cancer cells, and the third drug promotes cell growth. The three drugs have a synergistic effect and act on the cancer cells with different mechanisms.

The three drugs have a synergistic effect and act on the cancer cells with different mechanisms. Multiple drug regimens are used because the drugs have a synergistic effect. The drugs have different cell-cycle lysis effects, different mechanisms of action, and different toxic adverse effects. They are usually given in combination to enhance therapy. Dosage is not affected by giving the drugs in combination. The second and third drugs do not increase the effectiveness of the first. It is not true that the first two drugs are toxic to cancer cells while the third drug promotes cell growth.

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? Bloody drainage is observed in the collection chamber. Absence of bloody drainage in the anterior/upper tube The tissues give a crackling sensation when palpated. Skin around tube is pink.

The tissues give a crackling sensation when palpated. Subcutaneous emphysema is the result of air leaking between the subcutaneous layers. It is not a serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings. When two tubes are inserted, the posterior or lower tube drains fluid, whereas the anterior or upper tube is for air removal.

The nurse is conducting a morning assessment of an 80-year-old female patient who has a longstanding diagnosis of heart failure (HF). The nurse notes an elevation in jugular venous pressure (JVP) greater than 4 cm above the woman's sternal angle, a finding that did not exist the day before. What conclusion should the nurse draw from this assessment finding? The woman is also likely to experience shortness of breath. The woman is demonstrating the early signs of cardiogenic shock. The woman may be experiencing an exacerbation of right-sided HF. The woman has left-sided heart failure.

The woman may be experiencing an exacerbation of right-sided HF. Increased JVP is associated with right-sided HF. Dyspnea may or may not be present, but is more closely associated with left-sided HF. Increased JVP is not necessarily indicative of impending shock.

Which statement is true about malignant tumors? They usually grow slowly. They grow by expansion. They gain access to the blood and lymphatic channels. They demonstrate cells that are well differentiated.

They gain access to the blood and lymphatic channels. By gaining access to blood and lymphatic channels, a tumor can metastasize to other areas of the body. Cells of malignant tumors are undifferentiated. Malignant tumors demonstrate variable rates of growth; however, the more anaplastic the tumor, the faster its growth. A malignant tumor grows at the periphery and sends out processes that infiltrate and destroy surrounding tissues.

A patient with angina is beginning nitroglycerin. Before administering the drug, the nurse informs the patient that, immediately after administration, the patient may experience what? Throbbing headache or dizziness Tinnitus or diplopia Nervousness or paresthesia Drowsiness or blurred vision

Throbbing headache or dizziness Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. However, the patient usually develops a tolerance. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia don't occur as a result of nitroglycerin therapy.

Which term describes a fungal infection of the scalp? Tinea corporis Tinea cruris Tinea pedis Tinea capitis

Tinea capitis Tinea capitis is a fungal infection of the scalp. Tinea corporis involves fungal infections of the body. Tinea cruris describes fungal infections of the inner thigh and inguinal creases. Tinea pedis is the term for fungal infections of the foot.

A nurse receives a report on a client who has circular lesions on his neck. Which condition is the client most likely to have?

Tinea corporis

In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD? To prevent angiotensin II conversion To decrease homocysteine levels To decrease workload of the heart To dilate coronary arteries

To decrease workload of the heart Beta-adrenergic blockers are used in the treatment of CAD to decrease the myocardial oxygen by reducing heart rate and workload of the heart. Nitrates are used for vasodilation. Anti-lipid drugs (such as statins and B vitamins) are used to decrease homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.

A client with metastatic pancreatic cancer underwent surgery to remove a malignant tumor in the pancreas. Despite the tumor being removed, the physician informs the client that chemotherapy must be started. Why might the physician opt for chemotherapy? Fatigue Stomatitis To prevent metastasis Angiogenesis

To prevent metastasis Chemotherapy treats systemic and metastatic cancer. It can also be used to reduce tumor size preoperatively, or to destroy any remaining tumor cells postoperatively. Angiogenesis is the growth of new capillaries from the tissue of origin. This process helps malignant cells obtain needed nutrients and oxygen to promote growth. Fatigue and stomatitis are side effects of radiation and chemotherapy.

The nurse is triaging a client over the phone who states having a contact dermatitis rash. Which treatment option of over-the-counter preparations does the nurse suggest for the client? Select all that apply. Hydrocortisone cream Moisturizing cream Topical antihistamines Cosmetic lotions Lanolin based ointment

Topical antihistamines Hydrocortisone cream Moisturizing cream Lanolin based ointment The nurse is correct to suggest that the client apply a topical antihistamine or hydrocortisone cream to the rash area. This is helpful to decrease itchiness and swelling. Moisturizing cream, some lanolin based, is helpful in restoring lubrication. Cosmetic lotions have a scent or color, which is not suggested for use on rashes.

To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application? Tretinoin (retinoic acid [Retin-A]) Fluorouracil (5-fluorouracil, 5-FU [Efudex]) Zinc oxide gelatin Minoxidil (Rogaine)

Tretinoin (retinoic acid [Retin-A]) Tretinoin is a topical agent applied nightly to treat acne vulgaris. Minoxidil promotes hair growth. Zinc oxide gelatin treats stasis dermatitis on the lower legs. Fluorouracil is an antineoplastic topical agent that treats superficial basal cell carcinoma.

The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse? Emission of abnormal proteins Cells colonizing to distant body parts Tumor pressure against normal tissues Random, rapid growth of the tumor

Tumor pressure against normal tissues Benign tumors grow more slowly than malignant tumors and do not emit tumor-specific antigens or proteins. Benign tumors do not metastasize to distant sites. Benign tumors can compress tissues as it grows, which can result in impaired organ functioning.

The nurse is caring for a patient with venous insufficiency. What should the nurse assess the patient's lower extremities for?

Ulceration

Which term refers to preinfarction angina? Stable angina Variant angina Unstable angina Silent ischemia

Unstable angina Preinfarction angina is also known as unstable angina. Stable angina has predictable and consistent pain that occurs upon exertion and is relieved by rest. Variant angina is exhibited by pain at rest and reversible ST-segment elevation. Silent angina manifests through evidence of ischemia, but the client reports no symptoms.

A young college student recently had her tongue and lip pierced. She has developed a superinfection of candidiasis from the antibacterial mouthwash. Which of the following would be the correct recommendation for her? Rinse the mouth after eating food. Move the piercing back and forth during washing. Use a soft-bristled toothbrush. Use an antifungal mouthwash or salt water.

Use an antifungal mouthwash or salt water. The client can substitute an antifungal mouthwash or salt water if a superinfection of candidiasis develops from the antibacterial mouthwash. A soft-bristled toothbrush should be used to avoid additional oral injury, but it is not the recommended solution for this problem. After eating, the client should rinse her mouth for 30 to 60 seconds with an antifungal mouthwash or salt water. Moving the jewelry at the piercing area back and forth during washing helps clean the pierced tract but does not solve the problem.

A client is being treated for acne vulgaris. What warning must be given to this client regarding the application of benzoyl peroxide? Apply a thick layer to assure coverage. Use gloves with application. Only use with contact dermatitis. Use with over-the-counter drying agents.

Use gloves with application. Warn clients using acne preparations containing benzoyl peroxide that this ingredient is an oxidizing agent and may remove the color from clothing, rugs, and furniture. Thorough handwashing after drug use may not remove all the drug and permanent fabric discoloration may still occur. Users of products containing benzoyl peroxide should wear disposable plastic gloves when applying the drug.

The home health nurse is caring for a client with scabies. When instructing on the proper procedure to wash preworn contaminated clothing, which nursing instruction is essential? Pretreat clothing where scabies contact existed. Use hot water throughout wash cycle. Use commercial grade laundry detergent. Wash clothes through two laundry cycles.

Use hot water throughout wash cycle. The nurse is correct to use hot water throughout the wash cycle. Using hot water kills scabies and infectious agents on the laundry. If using the correct wash settings, the client does not need to use commercial-grade laundry detergent, the clothing does not need pretreated nor washed through two cycles.

It is cold season and you have been asked to provide an educational event for the PTO of the local elementary school. You are talking about URIs and their treatments. What would you include in teaching about the treatment of pharyngitis?

Use of warm saline gargles or throat irrigations

The nurse is instructing the parents of a child with head lice. Which statement should the nurse include? Use shampoo with Kwell. Use shampoo with piperonyl butoxide. Disinfect brushes and combs with bleach. Wash clothes in cold water.

Use shampoo with piperonyl butoxide. The nurse's instructions should include shampooing with piperonyl butoxide, washing clothes in hot water, and disinfecting brushes and combs with piperonyl butoxide shampoo.

The nurse is teaching a client about cancer prevention. The nurse evaluates teaching as most effective when a female client states that she will Exercise 30 minutes 3 times each week. Decrease tobacco smoking from one pack/day to half a pack/day. Obtain a cancer history from her parents. Use sunscreen when outdoors.

Use sunscreen when outdoors. Use of sunscreens play a role in the amount of exposure to ultraviolet light. Even decreasing the use of tobacco still exposes a person to risk of cancer. The American Cancer Society recommends adults to engage in at least 30 minutes of moderate to vigorous physical activity on 5 or more days each week. It is recommended to obtain a cancer history from at least three generations.

Which statements are true when the nurse is measuring blood pressure (BP)? Select all that apply. The client's arm should be positioned at the level of the heart. The client's BP should be measured 1 hour before consuming alcohol. Using a BP cuff that is too large will give a higher BP measurement. Using a BP cuff that is too small will give a higher BP measurement. The client should sit quietly while BP is being measured.

Using a BP cuff that is too small will give a higher BP measurement. The client's arm should be positioned at the level of the heart. The client should sit quietly while BP is being measured. These statements are all true when measuring a BP. When using a BP cuff that is too large, the reading will be lower than the actual BP. The client should avoid smoking cigarettes or drinking caffeine for 30 minutes before BP is measured.

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? Keeping the head of the bed at 15 degrees or less Using strict hand hygiene Turning the client every 4 hours to prevent fatigue Providing oral hygiene daily

Using strict hand hygiene The nurse should use strict hand hygiene to help minimize the client's exposure to infection, which could lead to pneumonia. The head of the bed should be kept at a minimum of 30 degrees. The client should be turned and repositioned at least every 2 hours to help promote secretion drainage. Oral hygiene should be performed every 4 hours to help decrease the number of organisms in the client's mouth that could lead to pneumonia.

The nurse knows that women and the elderly are at greater risk for a fatal myocardial event. Which factor is the primary contributor of this cause? Vague symptoms Chest pain is typical Gender bias Decreased sensation to pain

Vague symptoms Often, women and elderly do not have the typical chest pain associated with a myocardial infarction. Some report vague symptoms (fatigue, abdominal pain), which can lead to misdiagnosis. Some older adults may experience little or no chest pain. Gender is not a contributing factor for fatal occurrence but rather a result of symptoms association.

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gater area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?

Venous insufficiency -Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gater area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area.

The nurse is providing patient teaching to a young mother who has brought her 3-month-old infant to theclinic for a well-baby checkup. What action should the nurse recommend to the woman to prevent thetransmission of organisms to her infant during the cold season?

Wash her hands frequently.

What advice should the nurse give a client with dermatitis until the etiology of the dermatitis is identified? Rub the skin vigorously to dry. Use wool, synthetics, and other dense fibers. Wear rubber gloves when in contact with soaps. Use hot water for bathing.

Wear rubber gloves when in contact with soaps. The nurse should advise the client to wear rubber gloves when coming in contact with any substance such as soap or solvents. The client should avoid wool, synthetics, and other dense fibers. The client should use tepid bath water and should pat rather than rub the skin dry.

A client is admitted to the health care facility with active tuberculosis (TB). What intervention should the nurse include in the client's care plan? Wearing a disposable particulate respirator that fits snugly around the face Keeping the door to the client's room open to observe the client Instructing the client to wear a mask at all times Wearing a gown and gloves when providing direct care

Wearing a disposable particulate respirator that fits snugly around the face Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a disposable particulate respirators that fit snugly around the face when entering the client's room. Occupation Safety and Health Administration standards require an individually fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. A nurse who doesn't anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times.

Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty? Withhold anticoagulant therapy. Assess distal pulses. Inform client of diagnostic tests. Remove hair from skin insertion sites.

Withhold anticoagulant therapy. The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure. The nurse does inform the client of diagnostic test, will assess pulses, and prep the skin prior to the angioplasty, but this is not the most important action to be taken.

The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse? Administer atropine to speed the heart rate and then administer the digoxin. Withhold the medication and notify the physician of the heart rate. Administer the medications and then notify the physician. Administer the medication and inform the charge nurse about the rate.

Withhold the medication and notify the physician of the heart rate. Digitalis drugs are withheld if the heart rate is less than 60 or more than 120 beats/minute until a physician is consulted. The other choices would have the nurse administer the drug, which would not be the standard of practice.

A client is admitted to the emergency department with chest pain and doesn't respond to nitroglycerin. The health care team obtains an electrocardiogram and administers I.V. morphine. The health care provider also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms? Within 6 hours Within 12 hours Within 5 to 7 days Within 24 to 48 hours

Within 6 hours For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after an MI. Health care providers initiate I.V. heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7 days.

The nurse is caring for a client after cardiac surgery. What laboratory result will lead the nurse to suspect possible renal failure? a serum BUN of 70 mg/dL a urine specific gravity reading of 1.021 an hourly urine output of 50 to 70 mL a serum creatinine of 1.0 mg/dL

a serum BUN of 70 mg/dL These four laboratory results should always be assessed after cardiac surgery. Serum osmolality (N = >800 mOsm/kg) should also be included. A BUN reading of greater than 21 mg/dL is abnormal; a reading of greater than 60 mg/dL is indicative of renal failure. Urine output needs to be greater than 30 mL/hr. Normal urine specific gravity is 1.005-1.030. Normal serum creatinine values are between 0.5-1.2 mg/dL.

A client visits the physician's office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to order: an IV corticosteroid. a topical agent. an oral antibiotic. an IV antibiotic.

a topical agent. Although many drugs are used to treat skin disorders, topical agents — not IV or oral agents — are the mainstay of treatment.

Following are statements regarding medications taken by a patient diagnosed with COPD. Choose which statements correctly match the drug name to the drug category. Select all that apply. a) Ciprofloxacin is an antibiotic. b) Decadron is an antibiotic. c) Bactrim is a bronchodilator. d) Albuterol is a bronchodilator. e) Prednisone is a corticosteroid.

a) Ciprofloxacin is an antibiotic., d) Albuterol is a bronchodilator., e) Prednisone is a corticosteroid. Explanation: Theophylline, albuterol, and atropine are bronchodilators. Dexamethasone (Decadron) and prednisone are corticosteroids. Amoxicillin, ciprofloxacin, and cotrimoxazole (Bactrim) are antibiotics. These are all drugs that could be prescribed to a patient with COPD.

The nurse is having an information session with a women's group at the YMCA about lung cancer. What frequent and commonly experienced symptom should the nurse be sure to include in the session? a) Coughing b) Copious sputum production c) Severe pain d) Dyspnea

a) Coughing The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. The cough may start as a dry, persistent cough, without sputum production. When obstruction of airways occurs, the cough may become productive due to infection.

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? a) Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer b) Administering oxygen, coughing, breathing deeply, and maintaining bed rest c) Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer d) Administering pain medications, frequent repositioning, and limiting fluid intake

a) Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia.

The nurse is reviewing first-line pharmacotherapy for smoking abstinence with a patient diagnosed with COPD. The nurse correctly includes which of the following medications? Select all that apply. a) Nicotine gum b) Wellbutrin c) Zyban d) Chantix e) Catapres

a) Nicotine gum, b) Wellbutrin, c) Zyban First-line therapy includes nicotine gum, Zyban, and Wellbutrin. Second-line pharmacotherapy includes the antihypertensive agent clonidine (Catapres). However, the use of clonidine is limited by its side effects. Varenicline (Chantix), a nicotinic acetylcholine receptor partial agonist, may also assist in smoking cessation.

Which type of pneumonia has the highest incidence in AIDS patients and patients receiving immunosuppressive therapy for cancer? a) Pneumocystis b) TB c) Streptococcal d) Fungal

a) Pneumocystis Pneumocystis pneumonia incidence is greatest in patient with AIDS and patients receiving immunosuppressive therapy for cancer.

A nurse is caring for a male patient with COPD. While reviewing breathing exercises, the nurse instructs the patient to breathe in slowly through the nose, taking in a normal breath. Then, the nurse asks the patient to pucker his lips as if preparing to whistle. Finally, the patient is told to exhale slowly and gently through the puckered lips. The nurse teaches the patient this breathing exercise to accomplish which of the following? Select all that apply. a) Release trapped air in the lungs b) Strengthen the diaphragm c) Prevent collapse of the airways d) Condition the inspiratory muscles e) Control the rate and depth of respirations

a) Release trapped air in the lungs, c) Prevent collapse of the airways, e) Control the rate and depth of respirations The nurse is teaching the patient the technique of pursed-lip breathing. It helps slow expiration, prevents collapse of the airways, releases trapped air in the lungs, and helps the patient control the rate and depth of respirations. This helps patients relax and get control of dyspnea and reduces the feelings of panic they experience. Diaphragmatic breathing strengthens the diaphragm during breathing. In inspiratory muscle training the patient will be instructed to inhale against a set resistance for a prescribed amount of time every day in order to condition the inspiratory muscles.

A patient is receiving theophylline (Theo-Dur) for long-term control and prevention of asthma symptoms. Patient teaching related to this medication will include which of the following? a) The importance of blood tests to monitor serum concentrations b) Taking the medication at least 1 hour prior to meals c) Development of hyperkalemia d) Monitoring liver function studies as prescribed

a) The importance of blood tests to monitor serum concentrations The nurse should inform patients about the importance of blood tests to monitor serum concentration. The therapeutic range of theophylline is between 5 and 15 μg/mL. The patient is at risk of developing hypokalemia.

Why would a patient with COPD report feeling fatigued? Select all that apply. a) The patient is using all expendable energy just to breathe. b) There is a gradual decrease in muscle function over time in a patient with COPD. c) There is a gradual decrease in lung function over time in a patient with COPD. d) The patient is using all expendable energy for activities of daily living (ADLs).

a) The patient is using all expendable energy just to breathe., c) There is a gradual decrease in lung function over time in a patient with COPD. The patient is using all expendable energy just to breathe. There is a gradual decrease in lung function, not muscle function, over time in a patient with COPD. In the patient with COPD, fatigue and feeling of exhaustion stem directly from the disease, not from activity level.

Most cases of acute pharyngitis are caused by which of the following? a) Viral infection b) Bacterial infection c) Fungal infection d) Systemic infection

a) Viral infection Most cases of acute pharyngitis are caused by viral infection. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus.

To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals: a) dependent pallor. b) elevational rubor. c) a 30-second filling time for the veins. d) no rubor for 10 seconds after the maneuver.

a) dependent pallor If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor and increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves.

While in a skilled nursing facility, a male client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter's home, where six other persons are living. During her visit to the clinic, she asks a staff nurse, "What should my family do?" The most accurate response from the nurse is: a. "All family members will need to be treated." b. "If someone develops symptoms, tell him to see a physician right away." c. "Just be careful not to share linens and towels with family members." d. "After you're treated, family members won't be at risk for contracting scabies."

a. "All family members will need to be treated." When someone in a group of persons sharing a home contracts scabies, each individual in the home needs prompt treatment whether he's symptomatic or not. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.

Which assessment finding indicates an increased risk of skin cancer? a. A deep sunburn b. A dark mole on the client's back c. An irregular scar on the client's abdomen d. White irregular patches on the client's arm

a. A deep sunburn

The nurse is educating the pt diagnosed with acute pharyngitis on methods to alleviate discomfort. What interventions should the nurse include in the information? (Select all that apply.) a. Apply an ice collar .b. Stay on bed rest during the febrile stage of the illness. c. Gargle with an alcohol-based mouthwash. d. Try a liquid or soft diet during the acute stage of the disease e. Drink warm or hot liquids during the acute stage of the disease.

a. Apply an ice collar b. Stay on bed rest during the febrile stage of the illness. d. Try a liquid or soft diet during the acute stage of the disease

When writing a plan of care for a patient with psoriasis, the nurse would know that an appropriate nursing diagnosis for this patient would be what? a. Impaired skin integrity related to scaly lesions b. Acute pain of the skin and oral cavity related to blistering and erosions c. Risk for injury related to epidermal shedding d. Anxiety and depression related to disfigurement

a. Impaired skin integrity related to scaly lesions

Which procedure done for skin cancer conserves the most amount of normal tissue? a. Moh's micrographic surgery b. Electrosurgery c. Cryosurgery d. Surgical excision

a. Moh's micrographic surgery

A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? a. Scale b. Crust c. Ulcer d. Scar

a. Scale A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don't accompany psoriasis.

An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is:

acetaminophen Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Other medications commonly associated with liver injury include anesthetic agents, medications used to treat rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsants, and antituberculosis agents.

A client reports midsternal chest pain radiating down his left arm. The nurse notes that the client is restless and slightly diaphoretic, and measures a temperature of 99.6 °F (37.6 °C); a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. What assessment is the nurse's highest priority? body temperature acute pain anxiety cardiac output

acute pain The assessment of pain takes highest priority because it increases the client's pulse and blood pressure. During the acute phase of an MI, low-grade fever is an expected result of the body's response to myocardial tissue necrosis. The client's blood pressure and heart rate do not suggest a decreased cardiac output. Anxiety may be an important assessment, but addressing acute pain (the priority concern) may alleviate the client's anxiety.

A client with stage IV heart failure has a living will indicating a ventilator may not be used. The client begins experiencing severe dyspnea. What should the nurse who is caring for this client do? ask the client's family to consent to ventilator placement. call for respiratory therapy to intubate the client. administer oxygen and hope the client will reconsider. administer oxygen, morphine, and a bronchodilator for client comfort.

administer oxygen, morphine, and a bronchodilator for client comfort. A living will is a statement of a client's wishes in the event that a life-threatening illness or injury occurs. The client's comfort should be paramount and the nurse should respect the client's wishes. Morphine, oxygen, and bronchodilators can relieve dyspnea and make the client more comfortable, which will enable the client to breathe more easily. The nurse shouldn't arrange for intubation without the client's consent or ask family members for permission to initiate mechanical ventilation.

To combat the most common adverse effects of chemotherapy, a nurse should administer an: antiemetic. anticoagulant. antibiotic. antimetabolite.

antiemetic. Antiemetics, antihistamines, and certain steroids treat nausea and vomiting. Antimetabolites and tumor antibiotics are classes of chemotherapeutic medications. Anticoagulants slow blood clotting time, thereby helping to prevent thrombi and emboli.

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: pleural effusion. pulmonary edema. atelectasis. oxygen toxicity.

atelectasis. In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.

The nurse is caring for a client diagnosed with coronary artery disease (CAD). What condition most commonly results in CAD? atherosclerosis diabetes mellitus myocardial infarction renal failure

atherosclerosis Atherosclerosis (plaque formation) is the leading cause of CAD. Diabetes mellitus is a risk factor for CAD, but it isn't the most common cause. Myocardial infarction is a common result of CAD. Renal failure doesn't cause CAD, but the two conditions are related

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following? a) Neither venous nor arterial b) Arterial insufficiency c) Trauma d) Venous insufficiency

b) Arterial insufficiency Characteristics of arterial insuffiency ulcers include location at the tips of the toes, extreme painfulness, and circular shape with pale to black ulcer bases. Ulcers caused by venous insufficiency will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterier tibial area.

Which of the following is a characteristic of an arterial ulcer? a) Brawny edema b) Border regular and well demarcated c) Ankle-brachial index (ABI) > 0.90 d) Edema may be severe

b) Border regular and well demarcated Explanation: Characteristics of an arterial ulcer include a border that is regular and demarcated. Brawny edema, ABI > 0.90, and edema that may be severe are characteristics of a venous ulcer.

Which of the following is the most important risk factor for development of COPD? a) Air pollution b) Cigarette smoking c) Occupational exposure d) Genetic abnormalities

b) Cigarette smoking Risk factors for COPD include environmental exposures and host factors. The most important environmental risk factor for COPD worldwide is cigarette smoking. A dose-response relationship exists between the intensity of smoking (pack-year history) and the decline in pulmonary function. Other environmental risk factors include smoking pipes, cigars, and other types of tobacco. Passive smoking (i.e., second-hand smoke) also contributes to respiratory symptoms and COPD. Air pollution is a risk factor for development of COPD, but it is not the most important risk factor.

The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective? a) Public service announcements on television to promote the use of high-efficiency particulate air (HEPA) filters in homes b) Classes at community centers to teach about smoking cessation strategies c) Legislation that requires homes and apartments be checked for asbestos leakage d) Advertisements in public places to encourage cigarette smokers to have yearly chest x-rays

b) Classes at community centers to teach about smoking cessation strategies Lung cancer is directly correlated with heavy cigarette smoking, and the most effective approach to reducing lung cancer in the community is to help the citizens stop smoking.. The use of HEPA filters can reduce allergens, but they do not prevent lung cancer. Chest x-rays aid in detection of lung cancer but do not prevent it. Exposure to asbestos has been implicated as a risk factor, but cigarette smoking is the major risk factor.

A 76-year-old man presents to the ED complaining of "laryngitis." The triage nurse should ask if the patient has a past medical history that includes which of the following? a) Congestive heart failure (CHF) b) Gastroesophageal reflux disease (GERD) c) Chronic obstructive pulmonary disease (COPD) d) Respiratory failure (RF)

b) Gastroesophageal reflux disease (GERD) The nurse should ask if the patient has a past medical history of GERD. Laryngitis in the older adults is common and may be secondary to GERD. Older adults are more likely to have impaired esophageal peristalsis and a weaker esophageal sphincter. COPD, CHF, and RF are not associated with laryngitis in the older adult.

A patient is being admitted to the medical-surgical unit for the treatment of an exacerbation of acute asthma. Which of the following medications is contraindicated in the treatment of asthma exacerbations? a) Atrovent (Ipratropium) b) Intal (Cromolyn Sodium) c) Xopenex (Levalbuterol HFA) d) Proventil (Albuterol)

b) Intal (Cromolyn Sodium) Intal is contraindicated in patients with acute asthma exacerbation. Indications for Intal are long-term prevention of symptoms in mild, persistent asthma; it may modify inflammation. Intal is also a preventive treatment prior to exposure to exercise or known allergen. Proventil (albuterol), Xopenex (levalbuterol HFA), and Atrovent (ipratropium) can be used to relieve acute symptoms.

A home health nurse is teaching a client with peripheral arterial disease ways to improve circulation to the lower extremities. The nurse encourages which of the following in teaching? a) Elevation of the legs above the heart b) Keeping the legs in a neutral or dependent position c) Application of ace wraps from the toe to below the knees d) Use of antiembolytic stockings

b) Keeping the legs in a neutral or dependent position Keeping the legs in a neutral or dependent position assists in delivery of arterial blood from the heart to the lower extremities. All the other choices will aid in venous return, but will hinder arterial supply to the lower extremities.

Which of the following diagnostic test is the most accurate in assessing acute airway obstruction? a) Spirometry b) Pulmonary function studies c) Pulse oximetry d) Arterial blood gases (ABGs)

b) Pulmonary function studies Spirometry is used to evaluate airflow obstruction, which is determined by the ratio of FEV1 to forced vital capacity (FVC). Pulmonary function studies are used to help confirm the diagnosis of COPD, determine disease severity, and monitor disease progression. ABGs, and pulse oximetry are not the most accurate diagnostics for an airway obstruction.

When caring for a male client with severe impetigo, the nurse should include which intervention in the plan of care? a. Placing mitts on the client's hands b. Administering systemic antibiotics as prescribed c. Applying topical antibiotics as prescribed d. Continuing to administer antibiotics for 21 days as prescribed

b. Administering systemic antibiotics as prescribed Impetigo is a contagious, superficial skin infection caused by beta-hemolytic streptococci. If the condition is severe, the physician typically prescribes systemic antibiotics for 7 to 10 days to prevent glomerulonephritis, a dangerous complication. The client's nails should be kept trimmed to avoid scratching; however, mitts aren't necessary. Topical antibiotics are less effective than systemic antibiotics in treating impetig

The nurse is providing care for a young woman who has sought care because of signs and symptoms that are characteristic of psoriasis. When planning this woman's care, the nurse should be mindful of the fact that the etiology of the problem involves which of the following? a. Chronic infection b. Immune dysfunction c. Persistent physical irritation d. Benign neoplastic processes

b. Immune dysfunction

Nurse Troy discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should: a. wash hands, apply a pediculicide to the client's scalp, and remove any observable mites. b. isolate the client's bed linens until the client is no longer infectious. c. notify the nurse in the day surgery unit of a potential scabies outbreak. d. place the client on enteric precautions.

b. isolate the client's bed linens until the client is no longer infectious. To prevent the spread of scabies in other hospitalized clients, the nurse should isolate the client's bed linens until the client is no longer infectious — usually 24 hours after treatment begins. Other required precautions include using good hand-washing technique and wearing gloves when applying the pediculicide and during all contact with the client. Although the nurse should notify the nurse in the day surgery unit of the client's condition, a scabies epidemic is unlikely because scabies is spread through skin or sexual contact. This client doesn't require enteric precautions because the mites aren't found on feces.

The nurse is reviewing metered-dose inhaler (MDI) instructions with a patient. Which of the following patient statements indicates the need for further instruction? a) "Because I am prescribed a corticosteroid-containing MDI, I will rinse my mouth with water after use." b) "I will take a slow, deep breath in after pushing down on the MDI." c) "I can't use a spacer or holding chamber with the MDI." d) "I will shake the MDI container before I use it."

c) "I can't use a spacer or holding chamber with the MDI." Explanation: The patient can use a spacer or a holding chamber to facilitate the ease of medication administration. The remaining patient statements are accurate and indicate the patient understands how to use the MDI correctly.

A client complains of leg pain brought on by walking several blocks — a symptom that first arose several weeks earlier. The client's history includes diabetes mellitus and a two-pack-per-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and orders pentoxifylline (Trental), 400 mg three times daily with meals. Which instruction concerning long-term care should the nurse provide? a) "Reduce your level of exercise." b) "See the physician if complications occur." c) "Practice meticulous foot care." d) "Consider cutting down on your smoking."

c) "Practice meticulous foot care." Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing. Therefore, meticulous foot care is essential. The nurse should teach the client to bathe his feet in warm water and dry them thoroughly, cut the toenails straight across, wear well-fitting shoes, and avoid taking medications without the approval of a physician. Because nicotine is a vasoconstrictor, this client should stop smoking, not just consider cutting down. Daily walking is beneficial to clients with intermittent claudication. To evaluate the effectiveness of the therapeutic regimen, this client should see the physician regularly, not just when complications occur.

A patient is being treated in the ED for respiratory distress, coupled with pneumonia. The patient has no past medical history. However, the patient works in a coal mine and smokes 10 cigarettes a day. The nurse anticipates which of the following orders based on immediate needs for the patient? a) Completion of a 12-lead ECG b) Administration of corticosteroids and bronchodilators c) Administration of antibiotics d) Patient education: avoidance of irritants like smoke and pollutants

c) Administration of antibiotics Explanation: Antibiotics are administered to treat respiratory tract infections. Chronic bronchitis is inflammation of the bronchi caused by irritants or infection. Hence, smoking cessation and avoiding pollutants are necessary to slow the accelerated decline of the lung tissue. However, the immediate priority in this case is to cure the infection, pneumonia. Corticosteroids and bronchodilators are administered to asthmatic patients when they show symptoms of wheezing. An ECG is used to evaluate atrial arrhythmias.

Which type of chest configuration is typical of the patient with COPD? a) Pigeon chest b) Flail chest c) Barrel chest d) Funnel chest

c) Barrel chest In patients with COPD who have a primary emphysematous component, chronic hyperinflation leads to the "barrel chest" thorax configuration. This configuration results from a more fixed position of the ribs in the inspiratory position (due to hyperinflation) and from loss of lung elasticity. Pigeon chest results from a displaced sternum. Flail chest results when the ribs are fractured. Funnel chest occurs when there is a depression in the lower portion of the sternum; it is associated with Marfan's syndrome or rickets.

Which of the following are characteristics of arterial insufficiency? a) Aching, cramping pain b) Superficial ulcer c) Diminished or absent pulses d) Pulses are present, may be difficult to palpate

c) Diminished or absent pulses Explanation:A diminished or absent pulse is a characteristic of arterial insufficiency. Venous characteristics include superficial ulcer formation, an aching and cramping pain, and presence of pulses.

A patient diagnosed with asthma is preparing for discharge. The nurse is educating the patient on the proper use of a peak flow meter. The nurse will instruct the patient to complete which of the following? a) Take and record peak flow readings three times daily. b) Move the indicator to the top of the numbered scale. c) If coughing occurs during the procedure, repeat it. d) Sit down while completing a peak flow reading.

c) If coughing occurs during the procedure, repeat it. Steps for using the peak flow meter correctly include (1) Moving the indicator to the bottom of the numbered scale; (2) standing up; (3) taking a deep breath and filling the lungs completely; (4) placing mouthpiece in mouth and closing lips around mouthpiece; (5) blowing out hard and fast with a single blow; and (6) recording the number achieved on the indicator. If the patient coughs or a mistake is made in the process, repeat the procedure. Peak flow readings should be taken during an asthma attack.

The nursing instructor is teaching students about the types of lung cancer. Which type of lung cancer is characterized as fast growing and can arise peripherally? a) Adenocarcinoma b) Squamous cell carcinoma c) Large cell carcinoma d) Bronchoalveolar carcinoma

c) Large cell carcinoma Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and is usually slow growing. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located.

The nurse is assessing a patient for obstructive sleep apnea (OSA). Which of the following are signs and symptoms of OSA? Select all that apply. a) Pulmonary hypotension b) Evening headaches c) Polycythemia d) Insomnia e) Loud snoring

c) Polycythemia d) Insomnia e) Loud snoring Signs and symptoms include excessive daytime sleepiness, frequent nocturnal awakening, insomnia, loud snoring, morning headaches, intellectual deterioration, personality changes, irritability, impotence, systemic hypertension, dysrhythmias, pulmonary hypertension, corpulmonale, polycythemia, and enuresis.

A female client with herpes zoster is prescribed acyclovir (Zovirax), 200 mg P.O. every 4 hours while awake. The nurse should inform the client that this drug may cause: a. palpitations. b. dizziness. c. diarrhea. d. metallic taste.

c. diarrhea. Oral acyclovir may cause such adverse GI effects as diarrhea, nausea, and vomiting. It isn't associated with palpitations, dizziness, or a metallic taste.

the clinic nurse is caring for a client who has just been diagnosed with COPD. the client asks the nurse what COPD means. what would be the best response? a. it is an umbrella term for diseases like acute bronchitis b. it means that the lungs have been damaged in such a was that there is limited airflow in and out of the lungs c. it means your lungs cant expand and contract like the are supposed to which makes it hard for you to breathe. d. it is a term that covers so many lung diseases i cant list them all.

c. it means your lungs cant expand and contract like the are supposed to which makes it hard for you to breathe.

the nursing instructor is talking with the junior class of nursing students about lung cancer. what would be the best rationale the instructor could give for the difficulty of early diagnosis of lung cancer? a. symptoms are often minimized by clients b. there are no early symptoms of lung cancer c. symptoms often mimic other infectious diseases d. symptoms often do not appear until the disease is well established

c. symptoms often mimic other infectious diseases

A client with CAD thinks diltiazem (Cardizem) has been causing nausea. Diltiazem (Cardizem) is categorized as which type of drug? beta-adrenergic blocker diuretic calcium-channel blocker nitrate

calcium-channel blocker Calcium-channel blocking agents may be used to treat CAD as well, although research has shown that they may be less beneficial than beta-adrenergic blocking agents. Diltiazem (Cardizem) is an example of a calcium-channel blocker.

A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid: canned peas. angel food cake. ready-to-eat cereals. dried peas.

canned peas. There is a wide variety of foods that the client can still eat; the key is to have low-salt content. Canned vegetables are usually very high in salt or sodium, unless they have labels such as low-salt or sodium free or salt free. It is important to read food labels and look for foods that contain less than 300 mg sodium/serving.

The spouse of a terminally ill client is confused by the new terminology being used during discussions regarding the client's treatment. The nurse should explain that palliative care is: care that is provided at the very end of an illness to ease the dying process. care that will reduce the client's physical discomfort and manage clinical symptoms. an alternative therapy that uses massage and progressive relaxation for pain relief. offered to terminally ill clients who wish to remain in their homes in lieu of hospice care.

care that will reduce the client's physical discomfort and manage clinical symptoms. Palliative care is used in conjunction with other end-of-life treatments and has many principles. Its aim is to reduce physical discomfort and other distressing symptoms but does not alter a disease's progression. Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life. Palliative care of a terminally ill client not only provides relief from pain and other distressing symptoms but it integrates other facets of patient care as well, including psychological and spiritual aspects. Palliative care is part of hospice care.

The nurse is administering medications on a medical-surgical unit. A client is ordered to receive 40 mg oral nadolol for the treatment of hypertension. Before administering the medication, the nurse should weigh the client. check the client's heart rate. check the client's urine output. check the client's serum K+ level.

check the client's heart rate. Nadolol is a beta-blocker. A desired effect of this medication is to reduce the pulse rate in clients with tachycardia and elevated blood pressure (BP). The nurse should check the client's heart rate (HR) before administering nadolol to ensure that the pulse is not less than 60 beats per minute. The other interventions are not indicated before administering a beta-blocker medication.

Another term for clergyman's sore throat is aphonia. atrophic pharyngitis. hypertrophic pharyngitis. chronic granular pharyngitis.

chronic granular pharyngitis. In chronic granular pharyngitis, also referred to as clergyman's sore throat, the pharynx is characterized by numerous swollen lymph follicles. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has...

cirrhosis Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:

continue to take antibiotics for the entire 10 days.

The nurse is caring for a client with a blood pressure of 210/100 mm Hg in the emergency room. What is the most appropriate route of administration for antihypertensive agents? oral intramuscular sublingual continuous IV infusion

continuous IV infusion The medications of choice in hypertensive emergencies are best managed through the continuous IV infusion of a short-acting titratable antihypertensive agent. The nurse avoids the sublingual and IM routes as their absorption and dynamics are unpredictable. The oral route would not have as quick an onset as a continuous IV infusion.

The nurse is caring for a patient with COPD. The patient is receiving oxygen therapy via nasal cannula. The nurse understands that the goal of oxygen therapy is to maintain the patient's SaO2 level at or above what percent? a) 30%b) 50%c) 70%d) 90%

d) 90% Explanation:The goal of supplemental oxygen therapy is to increase the baseline resting partial arterial pressure of oxygen (PaO2) to at least 60 mm Hg at sea level and arterial oxygen saturation (SaO2) to at least 90%.

The nurse knows that there are three types of chronic pharyngitis. Which of the following is characterized by numerous swollen lymph follicles on the pharyngeal wall? a) Hypertrophic b) Aphonia c) Atrophic d) Chronic granular

d) Chronic granular Chronic granular pharyngitis is characterized by numerous swollen lymph follicles on the pharyngeal wall. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane.

During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events? a) Systemic hypotension b) Increased smooth muscle contractility c) Pulmonary hypotension d) Hypercapnia

d) Hypercapnia Repetitive apneic events result in hypoxia and hypercapnia, which triggers a sympathetic response (increased heart rate and decreased tone and contractility of smooth muscle).

The nurse is caring for a patient with COPD. In COPD, the body attempts to improve oxygen-carrying capacity by increasing the amounts of red blood cells. Which of the following is the term for this process? a) Emphysema b) Bronchitis c) Asthma d) Polycythemia

d) Polycythemia Polycythemia is an increase in the red blood cell concentration in the blood. In COPD, the body attempts to improve oxygen-carrying capacity by producing increasing amounts of red blood cells.

The nurse is a participant in a health fair that has been sponsored by the local VFW. An attendee has told the nurse about his wife's recent battle with skin cancer and others have replied with comments about the risk factors and prevention of the disease. What health education should the nurse provide to this group? a. "If you like to tan, it's important that you do so for less than 60 minutes at a time." b. "Any form of clothing will effectively block the sun's rays from damaging your skin." c. "Sunscreens have been shown to have little effect on the ultraviolet damage that is caused by the sun." d. "Even if it's cloudy outside, the sun's rays can still cause harm to your skin and contribute to skin cancer."

d. "Even if it's cloudy outside, the sun's rays can still cause harm to your skin and contribute to skin cancer."

The pharmacology class is learning about herpes zoster and mediations that are used to treat this disease process. When planning care of a patient with herpes zoster what medications, if administered within the first 24 hours of the initial eruption, can arrest herpes zoster? a. ADeltasone (Prednisone) b. Azathioprine (Imuran) c. Triamcinolone (Kenalog) d. Acyclovir (Zovirax)

d. Acyclovir (Zovirax)

A patient comes to the clinic complaining of a red rash of small, fluid-filled blisters. The patient is suspected of having herpes zoster. What should the nurse know about the distribution of lesions of herpes zoster? a. Grouped vesicles occurring on lips and oral mucous membranes b. Grouped vesicles occurring on the genitalia c. Rough, fresh, or gray skin protrusions d. Grouped vesicles in linear patches along a dermatome

d. Grouped vesicles in linear patches along a dermatome

While performing an initial assessment of a patient, the nurse observes an elevated blue-black lesion on the patient's ear. The nurse knows that this is indicative of what type of skin cancer? a. Basal cell carcinoma b. Squamous cell carcinoma c. Dermatofibroma d. Malignant melanoma

d. Malignant melanoma

The nurse working at a physician's office is providing teaching to the parent of a child diagnosed with Tinea captis (ringworm of the head). How often should the nurse instruct the parent to shampoo the child's hair with Nizoral or a selenium sulfide shampoo?

daily

A client asks the nurse if systolic heart failure will affect any other body function. What body system response correlates with systolic heart failure (HF)? increased blood volume ejected from ventricle dehydration decrease in renal perfusion vasodilation of skin

decrease in renal perfusion A decrease in renal perfusion due to low cardiac output (CO) and vasoconstriction causes the release of renin by the kidney. Systolic HF results in decreased blood volume being ejected from the ventricle. Sympathetic stimulation causes vasoconstriction of the skin, gastrointestinal tract, and kidneys. Dehydration does not correlate with systolic heart failure.

The nurse is admitting a client with frothy pink sputum. What does the nurse suspect is the primary underlying disorder of pulmonary edema? decreased right ventricular elasticity decreased left ventricular pumping increased left atrial contractility increased right atrial resistance

decreased left ventricular pumping Pulmonary edema is an acute event that results from heart failure. Myocardial scarring, resulting from ischemia, limits the distensibility of the ventricle, making it vulnerable to demands for increased workload. When the demand on the heart increases, there is resistance to left ventricular filling and blood backs up into the pulmonary circulation. Pulmonary edema quickly develops.

Nurses should implement measures to relieve emotional stress for clients with hypertension because the reduction of stress increases blood volume and improves the potential for greater cardiac output. increases the production of neurotransmitters that constrict peripheral arterioles. decreases the production of neurotransmitters that constrict peripheral arterioles. increases the resistance that the heart must overcome to eject blood.

decreases the production of neurotransmitters that constrict peripheral arterioles. Reduced stress decreases the production of neurotransmitters that constrict peripheral arterioles. Reduced stress may assist in reducing blood volume and resistance to the heart.

The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise: increases high-density lipoprotein (HDL) level. reduces stress. aids in weight reduction. decreases venous congestion.

decreases venous congestion. Regular walking is the best way to decrease venous congestion because using the leg muscles as a pump helps return blood to the heart. Regular exercise also aids in stress reduction and weight reduction and increases the formation of HDLs — which are all beneficial to a client with peripheral vascular disease. However, these changes don't have as significant an effect on the client's condition as decreasing venous congestion.

A client who is newly diagnosed with hypertension is going to be starting antihypertensive medicine. What is one of the main things the client and the client's spouse should watch for? persistent cough dizziness tremor blurred vision

dizziness A common adverse effect of all antihypertensive drugs is postural hypotension, which can lead to falls. The client and the client's spouse should be alerted to this possibility and provided with some tips for managing dizziness.

A 90-year-old home care client's son has been designated to make decisions regarding the client's medical care when the client is no longer able to do so. As the client nears the end of life, the son is consulted on an ever-increasing basis. What legal instrument activates the son's decision-making designation? power of attorney living will designated signer durable power of attorney for health care

durable power of attorney for health care A durable power of attorney (DPOA) for health care or healthcare proxy is the person the client designates to make medical decisions on the client's behalf when the client no longer can do so. It allows competent clients to identify exactly what life-sustaining measures they want to be implemented, avoided, or withdrawn and offers reassurance that others will carry out their wishes. Power of attorney is a legal term used in a different context. A living will is a written or printed statement describing a person's wishes concerning medical care and life-sustaining treatments that are wanted or unwanted in the event that a person is unable to personally make those decisions. Although a living will describes a person's wishes, it does not designate decision-making power to another person in the same was as a DPOA. Designated signer is not a term used in healthcare.

Frequently, what is the earliest symptom of left-sided heart failure? anxiety chest pain confusion dyspnea on exertion

dyspnea on exertion Dyspnea on exertion is often the earliest symptom of left-sided heart failure.

What is the treatment for peritonsillar abscess

early - antibiotics; severe - needle aspiration or incision and drain

The nurse is evaluating the client's risk for cancer. The nurse should recommend the client change which lifestyle choice? works as a secretary at a medical radiation treatment center eats red meat such as steaks or hamburgers every day drinks one glass of wine at dinner each night uses the treadmill for 30 minutes on 5 days each week

eats red meat such as steaks or hamburgers every day Dietary substances such as nitrate-containing and red meats appear to increase the risk of cancer. Exercising 30 minutes on 5 days or more is recommended for adults. Measures are taken to protect those people who work around radiation. Alcohol consumption recommendations include drink no more than one drink per day for women or two per day for men.

A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured? cardiac catheterization cardiac ultrasound echocardiogram electrocardiogram

echocardiogram The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan, not an electrocardiogram or cardiac ultrasound. Cardiac catheterization is not the diagnostic tool for this measurement.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: forcing blood into the deep venous system. encouraging ambulation to prevent pooling of blood. providing warmth to the extremity. elevating the extremity to prevent pooling of blood.

forcing blood into the deep venous system. Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity decreases edema but doesn't prevent DVT.

The nurse is working with a client who has had an allo-hematopoietic stem cell transplant (HSCT). The nurse notices a diffuse rash and diarrhea. The nurse contacts the physician to report that the client has symptoms of metastasis. acute leukopenia. graft-versus-host disease. nadir.

graft-versus-host disease. Graft-versus-host disease is a major cause of morbidity and mortality in clients who have had allogeneic transplant. Clinical manifestations of the disease include diffuse rash that progresses to blistering and desquamation, and mucosal inflammation of the eyes and the entire gastrointestinal tract with subsequent diarrhea, abdominal pain, and hepatomegaly.

The nurse is assessing a newly admitted client with chest pain. What medical disorder is most likely causing the client to have jugular vein distention? myocardial infarction (MI) pneumothorax abdominal aortic aneurysm heart failure

heart failure Elevated venous pressure, exhibited as jugular vein distention, indicates the heart's failure to pump. Jugular vein distention isn't a symptom of abdominal aortic aneurysm or pneumothorax. If severe enough, an MI can progress to heart failure, but an MI alone doesn't cause jugular vein distention.

The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed? ventricular access device implantable cardiac defibrillator (ICD) cardiac resynchronization therapy heart transplant

heart transplant Heart transplantation involves replacing a person's diseased heart with a donor heart. This is an option for advanced HF patients when all other therapies have failed. A ventricular access device, ICD, and cardiac resynchronization therapy would be tried prior to a heart transplant.

The laboratory values for a client diagnosed with coronary artery disease (CAD) have just come back from the lab. The client's low-density lipoprotein (LDL) level is 112 mg/dL. This nurses recognizes that this value is normal. low. extremely high. high.

high. If the LDL level ranges from 100 mg/dL to 130 mg/dL, it is considered to be high. The goal is to decrease the LDL level below 100 mg/dL.

The classic lesions of impetigo manifest as abscess of skin and subcutaneous tissue. comedones in the facial area. honey-yellow crusted lesions on an erythematous base. patches of grouped vesicles on red and swollen skin.

honey-yellow crusted lesions on an erythematous base. The classic lesions of impetigo are honey-crusted lesions on an erythematous base. Comedones in the facial area are representative of acne. A carbuncle is an abscess of skin and subcutaneous tissue. Herpes zoster is exhibited by patches of grouped vesicles on red and swollen skin.

A blood pressure (BP) of 140/90 mm Hg is considered to be prehypertension. hypertension. a hypertensive emergency. normal.

hypertension. A BP of 140/90 mm Hg or higher is hypertension. A blood pressure less than 120/80 mm Hg is considered normal. A BP of 120 to 139/80 to 89 mm Hg is prehypertension. Hypertensive emergency is a situation in which BP is severely elevated and there is evidence of actual or probable target organ damage.

The nurse is assessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion? nocturia hepatomegaly inadequate cardiac output ascites

inadequate cardiac output Pulmonary congestion occurs and tissue perfusion is compromised and diminished when the heart, primarily the left ventricle, cannot pump blood out of the ventricle effectively into the aorta and the systemic circulation. Ascites is fluid in the abdomen, not a cause of congestion. Hepatomegaly is an enlarged liver, which does not cause crackling breath sounds. Nocturia, or voiding at night, does not cause crackling breath sounds.

A client is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority?

ineffective breathing pattern n ascites, accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. If uncorrected, this problem may lead to atelectasis or pneumonia. Although fluid volume excess is present, the diagnosis Ineffective breathing pattern takes precedence because it can lead more quickly to life-threatening consequences. The nurse can deal with fatigue and altered nutrition after the client establishes and maintains an effective breathing pattern.

A client with a history of diabetes mellitus has recently developed furunculosis. What is causing the client's condition? diet hygiene unknown infection

infection Furuncles and carbuncles are caused by skin infections with organisms that usually exist harmlessly on the skin surface.

A client is being seen by the physician because of an unrelenting headache, facial tenderness, low-grade fever, and dark yellow nasal discharge. The client reports seeming to develop sinus infections "all the time." Which factor may predispose the client to sinusitis? interference with sinus drainage more than 8 hours of sleep per night excessive protein intake increased exposure to the health care environment

interference with sinus drainage The principal causes are the spread of an infection from the nasal passages to the sinuses and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis because trapped secretions readily become infected. Client with persistent sinus infections may have allergies, nasal polyps, or a deviated septum. Eating a well-balanced diet that includes but does not rely exclusively on protein is a measure that may help reduce incidences of sinusitis. Getting plenty of rest is a measure that may help reduce incidences of sinusitis. Increased exposure to the health care environment is not a specific cause of sinusitis, which is more commonly caused by allergies or blockage of the nasal passages.

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should: elevate the affected leg as high as possible. keep the affected leg level or slightly dependent. shave the affected leg in anticipation of surgery. place a heating pad around the affected calf.

keep the affected leg level or slightly dependent. While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.

A physician has ordered a wet-to-damp dressing for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to: reduce pain. debride the wound. prevent the spread of the infection. keep the wound moist.

keep the wound moist. Wet-to-damp dressings keep the wound bed moist, which helps promote the growth of granulation tissue. Because dead tissue adheres to a dry dressing, wet-to-dry dressings are used for debriding wounds. Wet-to-damp dressings don't prevent the spread of infection. Although these dressings provide a soothing, cool feeling, they don't relieve pain.

A client with a history of hypertension is receiving client education about structures that regulate arterial pressure. Which structure is a component of that process? parasympathetic nervous system kidneys limbic system lungs

kidneys The autonomic nervous system, the kidneys, and various endocrine glands regulate arterial pressure.

Which observation regarding ulcer formation on the client's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency?

large and superficial Ulcerations are in the area of the medial or lateral malleolus (gaiter area) and are typically large, superficial, and highly exudative. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows a beefy red to yellow fibrinous color.

A client diagnosed with heart failure presents with a temperature of 99.1° F, pulse 100 beats/minute, respirations 42 breaths/minute, BP 110/50 mm Hg; crackles in both lung bases; nausea; and pulse oximeter reading of 89%. Which finding indicates a need for immediate attention? nausea temperature blood pressure lung congestion

lung congestion Because pulmonary edema can be fatal, lung congestion needs to be relieved as quickly as possible. Supplemental oxygen or mechanical ventilation is used to support breathing. Inotropic medications, which improve myocardial contractility, are administered to relieve symptoms.

The nurse is caring for a client with heart failure who is receiving a diuretic medication. What implementation will help the nurse evaluate the client's response of the medication? using mechanical ventilation asking the client about comfort level obtaining cardiac output with a pulmonary catheter measuring intake and output

measuring intake and output To evaluate response to a diuretic, intake and output are monitored. Mechanical ventilation helps maintain a normal breathing pattern. A pulmonary artery catheter helps estimate cardiac output. Asking the client about comfort level will not assess urinary output.

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects:

melanoma

The nurse is admitting a client with an elevated creatine kinase-MB isoenzyme (CK-MB). What is the cause for the elevated isoenzyme? myocardial necrosis cerebral bleeding I.M. injection skeletal muscle damage due to a recent fall

myocardial necrosis An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injuries such as cerebral bleeding; skeletal muscle damage, which can result from I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.

A client who was recently diagnosed with prehypertension is to meet with a dietitian and return for a follow-up with the cardiologist in 6 months. What would this client's treatment likely include? pharmacological interventions observation only procedural interventions nonpharmacological interventions

nonpharmacological interventions Nonpharmacologic interventions are used for clients with prehypertension.

Papilledema is a fairly common symptom of elevated blood pressure. The best way to detect this condition is through: laboratory tests. using a sphygmomanometer. ophthalmic examination. an MRI.

ophthalmic examination. Papilledema is an edema of the optic nerves, and thus needs an ophthalmic examination for detection.

When the client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating paroxysmal nocturnal dyspnea. hyperpnea. orthopnea. dyspnea upon exertion.

orthopnea. Clients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler position. Dyspnea upon exertion refers to difficulty breathing with activity. Hyperpnea refers to increased rate and depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

A type of comprehensive care for clients whose disease is not responsive to cure is a terminal illness. palliative care. interdisciplinary collaboration. euthanasia.

palliative care. Palliative care is a type of comprehensive care for clients whose disease is not responsive to cure. Terminal illness is a progressive, irreversible illness that despite cure-focused medical treatment will result in the client's death. Euthanasia means the intentional killing by act or omission of a dependent human being for his or her alleged benefit. Interdisciplinary collaboration is communication and cooperation among members of diverse health care disciplines jointly to plan, implement, and evaluate care

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients:

pancreatitis Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.

The nurse is assessing a client with suspected post-pericardiotomy syndrome after cardiac surgery. What manifestation will alert the nurse to this syndrome? hypothermia decreased erythrocyte sedimentation rate (ESR) decreased white blood cell (WBC) count pericardial friction rub

pericardial friction rub Post-pericardiotomy syndrome is characterized by fever, pericardial pain, pleural pain, dyspnea, pericardial effusion, pericardial friction rub, and arthralgia. Leukocytosis (elevated WBCs) occurs, along with elevation of the ESR. Hypothermia is not a symptom of post-pericardiotomy syndrome.

A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective? postural hypotension skin rash peripheral edema bradycardia

peripheral edema Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective. The individual will also most like experience trachycardia instead of bradycardia if the heart failure is worsening ang not responding to captopril.

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what action should the nurse perform? place the client in high Fowler's position administer oxygen have the client take deep breaths and cough perform chest physiotherapy

place the client in high Fowler's position The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase oxygen content in the blood. Deep breathing and coughing will improve oxygenation postoperatively but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as hemothorax. pleural effusion. consolidation. pneumothorax.

pleural effusion. Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process.

The nurse is administering digoxin to a client with heart failure. What laboratory value may predispose the client to digoxin toxicity? calcium level of 7.5 mg/dL magnesium level of 2.5 mg/dL sodium level of 152 mEq/L potassium level of 2.8 mEq/L

potassium level of 2.8 mEq/L Conditions that may predispose a client to digoxin toxicity include hypokalemia (evidenced by a potassium level less than 3.5 mEq/L), hypomagnesemia (evidenced by a magnesium level less than 1.5 mEq/L), hypothyroidism, hypoxemia, advanced myocardial disease, active myocardial ischemia, and altered autonomic tone. Hypermagnesemia (evidenced by a magnesium level greater than 2.5 mEq/L), hypercalcemia (evidenced by an ionized calcium level greater than 5.3 mg/dl), and hypernatremia (evidenced by a sodium level greater than 145 mEq/L) aren't associated with a risk of digoxin toxicity.

The nurse is caring for a client after cardiac surgery. What is the most immediate concern for the nurse? bilateral rales and rhonchi serum glucose of 124 mg/dL weight gain of 6 ounces potassium level of 6 mEq/L

potassium level of 6 mEq/L Changes in serum electrolytes should be immediately reported, especially a potassium level of 6 mEq/L. An elevated blood sugar is common postoperatively, and the weight gain is not significant. The abnormal breath sounds are of concern, but the electrolyte imbalance is the most immediate condition that needs to be addressed.

A client is being admitted to an acute healthcare facility with an exacerbation of chronic obstructive pulmonary disease (COPD). The client had been taking an antibiotic at home with poor relief of symptoms and has recently decided to stop smoking. The nurse is reviewing at-home medications with the client. The nurse is placing this information on the Medication Reconciliation Record. Which of the following is incomplete information? -nicotine patch (Nicoderm) 21 mg 1 patch daily at 0800 -salmeterol/fluticasone (Seretide) MDI daily at 0800 -azithromycin (Zithromax) 600 mg oral daily for 10 days at 0800, on day 4 -prednisone 5 mg oral daily at 0800

salmeterol/fluticasone (Seretide) MDI daily at 0800 When providing information about medications, the nurse needs to include right drug, right dose, right route, right frequency, and right time. Salmeterol/fluticasone does not include how many puffs the client is to take.

According to the classification of hypertension diagnosed in older adults, hypertension that can be attributed to an underlying cause is termed secondary. essential. isolated systolic. primary.

secondary. Secondary hypertension may be caused by a tumor of the adrenal gland (e.g., pheochromocytoma). Primary, or essential, hypertension has no known underlying cause. Isolated systolic hypertension is demonstrated by readings in which the systolic pressure exceeds 140 mm Hg and the diastolic measurement is normal or near normal (less than 90 mm Hg).

The classification of Stage III of COPD is defined as at risk for COPD. mild COPD. very severe COPD. severe COPD. moderate COPD.

severe COPD. Stage III is severe COPD. Stage 0 is at risk for COPD. Stage I is mild COPD. Stage II is moderate COPD. Stage IV is very severe COPD.

Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and an rise in the death rates from pneumonia and cardiovascular disease. Besides death, what is the most serious complication of influenza?

staphylococcal pneumonia

The nurse is teaching a client about chronic untreated hypertension. What complication will the nurse explain to the client? stroke peripheral edema pulmonary insufficiency right-sided heart failure

stroke A stroke occurs if vessels in the brain rupture and bleed. If an aneurysm has developed in the aorta from chronic hypertension, it may burst and cause hemorrhage and shock. Peripheral edema, right-sided heart failure, and pulmonary insufficiency are not usually consequences of untreated chronic hypertension.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is:

subnormal serum glucose and elevated serum ammonia levels. In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.

A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. This change occurred because: the airways are so swollen that no air can get through. crackles have replaced wheezes. the swelling has decreased. the attack is over.

the airways are so swollen that no air can get through. During an acute asthma attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can't get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Crackles don't replace wheezes during an acute asthma attack.

The nurse teaches the client who demonstrates herpes zoster (shingles) that a person who has had chickenpox can contract it again upon exposure to a person with shingles. no known medications affect the course of shingles. the infection results from reactivation of the chickenpox virus. once the client has had shingles, they will not have it a second time.

the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a reactivation of latent varicella (chickenpox) virus and reflects lowered immunity. It is believed that the varicella zoster virus lies dormant inside nerve cells near the brain and spinal cord and is reactivated with weakened immune systems and cancers. A person who has had chickenpox is immune and therefore not at risk of infection after exposure to a client with herpes zoster. Some evidence indicates that infection is arrested if oral antiviral agents are administered within 24 hours of the initial eruption.

The nurse teaches the client who demonstrates herpes zoster (shingles) that no known medications affect the course of shingles. the infection results from reactivation of the chickenpox virus. once a client has had shingles, they will not have it a second time. a person who has had chickenpox can contract it again upon exposure to a person with shingles.

the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a reactivation of the latent varicella (chickenpox) virus and reflects lowered immunity. It is believed that the varicella zoster virus lies dormant inside nerve cells near the brain and spinal cord and is reactivated with weakened immune systems and cancers. A person who has had chickenpox is immune and therefore not at risk of infection after exposure to clients with herpes zoster. Some evidence shows that infection is arrested if oral antiviral agents are administered within 24 hours of the initial eruption.

The nurse is assessing a client with severe angina pectoris and electrocardiogram changes in the emergency room. What is the most important cardiac marker for the client? creatine kinase myoglobin lactate dehydrogenase troponin

troponin This client exhibits signs of myocardial infarction (MI), and the most accurate serum determinant of an MI is troponin level. Creatine kinase, lactate dehydrogenase, and myoglobin tests can show evidence of muscle injury, but the studies are less specific indicators of myocardial damage than troponin.

A dermatologist recommends an over-the-counter suspension to relieve pruritus. The nurse advises the patient that the lotion should be applied: Twice a day to prevent crusting on the skin. Every 3 to 4 hours for sustained effectiveness. Overnight to enhance absorption. Hourly to prevent evaporation.

very 3 to 4 hours for sustained effectiveness. Lotions are frequently used to replenish lost skin oils or to relieve pruritus. They are usually applied directly to the skin, but a dressing soaked in the lotion can be placed on the affected area. Lotions must be applied every 3 or 4 hours for sustained therapeutic effect because if left in place for a long period, they may crust and cake on the skin.

The classification of Stage IV of COPD is defined as at risk for COPD. mild COPD. very severe COPD. severe COPD. moderate COPD.

very severe COPD. Stage IV is very severe COPD. Stage 0 is at risk for COPD. Stage I is mild COPD. Stage II is moderate COPD. Stage III is severe COPD.

A nurse suspects that a client has digoxin toxicity. The nurse should assess for: vision changes. hearing loss. gait instability. decreased urine output.

vision changes. Vision changes, such as halos around objects, are signs of digoxin toxicity. Hearing loss can be detected through hearing assessment; however, it isn't a common sign of digoxin toxicity. Intake and output aren't affected unless there is nephrotoxicity, which is uncommon. Gait changes are also uncommon.

A nurse is evaluating a client with a terminal illness. What should the nurse report so that the health care team can consider alternative nutritional approaches and fluid administration routes for the client at the end of life? irregular eating habits altered gastrointestinal function drop in blood pressure and rapid heart rate weight loss and inadequate food intake

weight loss and inadequate food intake The nurse should report weight loss and inadequate food intake so that the team can consider adding appetite stimulants and the nutritionist can alter the meal plan to give more satisfying meals as a comfort measure. The nurse knows that changes of gastrointestinal function such as irregular eating or bowel changes occur as part of the dying process and are not relevant to the desired intervention. Deteriorating vital signs are part of the dying process so that these signs are not relevant to the desired intervention.

Dermatophytes (also called tinea) are parasitic fungi that invade the skin, scalp, and nails. How is a diagnosis made for this condition? Choose all that are correct.

• Visual examination • Wood's light

A client presents with silvery scales on the elbows and knees. The physician has made a diagnosis of plaque psoriasis. What is the probable cause(s) of psoriasis?

• genetic predisposition• a triggering mechanism, such as systemic infection, injury to the skin, vaccination, or injection