Med Surg HESI

The nurse assesses a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent nosocomial infection, which protocol should the nurse review with the rest of the staff? Follow contact isolation procedures. Wash hands after caring for the client. Correct Wear gloves when providing personal care. Restrict pregnant staff or visitors into the room.

The organism Candida albicans, that causes this infection, is part of the normal flora on the skin of most adults. Good handwashing is all that is needed to prevent nosocomial spread.

The nurse obtains a client's history that includes right mastectomy and radiation therapy for breast cancer 10 years ago. Which current health problem should the nurse consider is a consequence of the radiation therapy? Asthma. Myocardial infarction. Chronic esophagitis with gastroesophageal reflux. Pathologic fracture of two ribs on the right chest. Correct

The ribs lie in the radiation pathway and lose density over time, becoming thin and brittle, so the occurrence of two right-sided ribs with pathological fractures resulting without evidence of trauma is related to radiation damage.

A client has been hospitalized with a femur fracture and is being treated with traction. Which action by the nurse is the priority when caring for this client? Assess neurovascular status. Correct Change the client's position. Inspect the traction equipment. Review pain medication orders.

The use of traction for long bone fractures reduces the potential for damage to the surrounding tissues. Reports of increased pain may indicate circulatory compromise or tissue damage (compartment syndrome). Assessing the client's neurovascular status is the nurse's highest priority.

The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include? Limit dietary selection of cholesterol to 300 mg per day. Increase intake of soluble fiber to 10 to 25 grams per day. Correct Decrease plant stanols and sterols to less than 2 grams/day. Ensure saturated fat is less than 30% of total caloric intake.

To reduce risk factors associated with coronary heart disease, the daily intake of soluble fiber should be increased to between 10 and 25 grams per day. According to the American Heart Association, soluble fibers helps reduce LDL cholesterol levels.

Creatinine

More SPECIFIC THAN BUN. An elevated creatinine strongly indicates nephron loss, reducing filtration.

A client is admitted for reports of chest pain and aching for the past 4 days. The results for serum creatine kinase-MB (CK-MB) and troponin levels are obtained. What rationale should the nurse use to evaluate the laboratory findings? Serum myoglobin levels are needed to confirm myocardial damage. The most reliable indicator of myocardial necrosis is serum CK-MB. Serum cardiac markers are inconclusive in determining myocardial injury after waiting several days. Myocardial damage that occurred several days earlier is best validated by serum troponin levels. Correct

An elevated serum troponin has become the cardiac marker of choice for diagnosing an acute MI, according the American College of Cardiology (ACC) guidelines (2017) for NSTEMI. An elevated troponin will become evident within 2 to 3 hours of an MI in comparison to the CK-MB and other cardiac enzymes that can take up to 6 to 9 hours after the MI occurrence.

The nurse is caring for a client with human immunodeficiency virus (HIV) infection who develops Mycobacterium avium complex (MAC). Which is the most significant desired outcome for this client? Free from injury of drug side effects. Return to pre-illness weight. Correct Adequate oxygenation. Maintenance of intact perineal skin.

MAC is an opportunistic infection that presents as a tuberculosis-like pulmonary process. MAC is a major contributing factor to the development of wasting syndrome, so the most significant desired outcome is the client's return to a pre-illness weight using oral, enteral, or parenteral supplementation as needed.

While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test? Immediately after the exposure. Within one week of the exposure. Four to six weeks after the exposure. Correct Three months after the exposure.

A tuberculin skin test is effective 4 to 6 weeks after an exposure, so the individual with a known exposure should wait 4 to 6 weeks before having a tuberculin skin test.

The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? Diabetes mellitus. Correct Hypothyroidism. Parkinson's disease. Recurring pneumonia.

According to the National Stroke Association (2013), history of diabetes mellitus poses the greatest risk for developing a CVA, 2-4Xs more than those who do not have diabetes mellitus. The reason for this occurrence is related to the excess glucose circulating throughout the body not being utilized by the cells, leading to increased fatty deposits or clots inside the blood vessels in the brain or neck, eventually causing a stroke.

The nurse formulates the nursing problem of urinary retention related to sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention should the nurse implement? Teach the client techniques of intermittent self-catheterization. Correct Decrease fluid intake to prevent over distention of the bladder. Use incontinence briefs to maintain hygiene with urinary dribbling. Explain that anticholinergic drugs will decrease muscle spasticity.

Bladder control is a common problem for clients diagnosed with multiple sclerosis. A client with urinary retention should receive instructions about self-catheterization to prevent bladder distention.

The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care? "Have you ever experienced any paralysis of your arms or legs?" "Have you ever sustained a severe head injury?" "Have you ever been 'frozen' in one spot, unable to move?" Correct "Do you have headaches, especially ones with throbbing pain?"

Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to a spot and unable to move, referrerd to as being "frozen" in one spot.

A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider? Suprapublic pain and distention. Bounding pulse at 100 beats/minute. Fingerstick glucose of 300 mg/dl. Correct Small vesicular perineal lesions.

Elevated fingerstick glucose levels needs to be reported tot he healthcare provider, so a plan of care can be adjusted to treat the elevated glucose level. Also elevated glucose levels, spills into the urine and provide a medium for bacterial growth.

full-thickness burns

Full-thickness burns destroy the entire dermal layer. Included in this destruction is the regenerative tissue. For this reason, tissue regeneration does not occur, and skin grafting is necessary.

A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement? Give 20 mEq of potassium chloride. Initiate continuous cardiac monitoring. Correct Arrange a consultation with the dietician. Teach about the side effects of diuretics.

Hypokalemia (normal 3.5 to 5 mEq/L [3.5 to 5 mmol/L]) causes changes in myocardial irritability and ECG waveform, so it is most important for the nurse to initiate continuous cardiac monitoring to identify ventricular ectopy or other life-threatening dysrhythmias. After cardiac monitoring is initiated, then the potassium chloride should be given so that the effects of potassium replacement on the cardiac rhythm can be monitored.

The nurse is caring for a client who has been diagnosed with primary hyperaldosteronism. Which laboratory test result should the nurse expect an increase in the serum level? Sodium. Correct Antidiuretic hormone. Potassium. Glucose.

IN HYPERALDOSTERONISM, PTS RETAIN SODIUM AND LOSE K+. Clients with primary aldosteronism exhibit an increase in serum sodium levels (hypernatremia) and have profound decline in the serum levels of potassium (hypokalemia)--hypertension is the most prominent and universal sign. Antidiuretic hormone is decreased with diabetes insipidus. Glucose is not affected by primary aldosteronism.

The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? Present knowledge related to the skill of injection. Intelligence and developmental level of the client. Incorrect Willingness of the client to learn the injection sites. Correct Financial resources available for the equipment.

If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching.

How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring? Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line. Correct

In MCL I monitoring, the positive electrode is placed on the client's mid-chest to the right of the sternum, and the negative electrode is placed on the upper left part of the chest. The ground may be placed anywhere, but is usually placed on the lower left portion of the chest.

A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? Lower left quadrant pain and a low-grade fever. Correct Severe pain at McBurney's point and nausea. Abdominal pain and intermittent tenesmus. Exacerbations of severe diarrhea.

Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most common area for diverticula, and the inflammation of diverticula causes a low-grade fever.

A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing assessment is of greatest importance to this client? pulse rate, both apically and radially. blood pressure, both standing and sitting. temperature. Correct skin color and turgor.

Long term use of steroids by COPD clients is effective in suppressing inflammation in their airways making it easier for them to breath, but at the same time suppresses the immune system, placing the client at risk for infection, so it is very important to obtain the client's temperature.

The healthcare provider prescribes aluminum and magnesium hydroxide, 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. Which intervention should the nurse implement? Administer 30 minutes before eating. Evaluate the effectiveness 1 hour after administration. Instruct the client to swallow the tablet whole. Question the healthcare provider's prescription. Correct

Magnesium agents are not usually used for clients with CKD due to the risk of hypermagnesemia, so this prescription should be questioned by the nurse.

The nurse is caring for a client after a transurethral resection of the prostate (TURP) and determines the client's urinary catheter is not draining. What should the nurse implement? Reposition the catheter drainage tubing. Encourage the client to drink oral fluids. Irrigate the catheter. Correct Change drainage unit tubing.

Obstruction urinary flow after a TURP is most often due to blood clots, and sterile irrigation should be implemented to remove the clots that are blocking the catheter.

The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain? If suctioning will be needed for drainage of the wound. If the family would prefer a private or semi-private room. Prescription for removal of the drain. If the client's wound is infected. Correct

Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. The fact that the client has a penrose drain should alert the nurse to the possibility that the client is infected. To avoid contamination of another postoperative client, it is most for the nurse to verify the condition of the wound and if infected, important to place client in a private room.

The nurse is teaching a client diagnosed with peripheral arterial disease. Which genitourinary system complication should the nurse include in the teaching? Altered sexual response. Correct Sterility. Urinary incontinence. Decreased pelvic muscle tone.

Peripheral arterial disease (PAD) is a cardiovascular condition characterized by narrowing of the arteries and reduced blood flow to the extremities. PAD is known to alter the blood flow to the male's penis and is associated with erectile dysfunction in men.

Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma? Numbness, tingling, and cramps in the extremities. Headache, diaphoresis, and palpitations. Correct Cyanosis, fever, and classic signs of shock. Nausea, vomiting, and muscular weakness.

Pheochromocytoma is a catecholamine secreting non-cancerous tumor of the adrenal medulla, and a headache, profuse sweating and palpitations is the typical triad of symptoms depending upon the relative proportions of epinephrine and norepinephrine secretion. Surgical removal of the tumor is the only treatment.

A client with a recent history of blood in the stools is scheduled for a proctosigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.) Obtain consent for the procedure. Correct Initiate preoperative sedation. Begin fast the morning of the procedure. Correct Administer an enema before the procedure. Correct Provide a clear-liquid diet 48 hours before the procedure. Correct

Preoperative preparation for proctosigmoidoscopy includes obtaining the client's consent for the procedure, a clear-liquid diet for 24 to 48 hours prior to the procedure, administration of an enema, and fasting on the morning of the procedure.

Which description of pain is consistent with a diagnosis of rheumatoid arthritis? Joint pain is worse in the morning and involves symmetric joints. Correct Joint pain is better in the morning and worsens throughout the day. Joint pain is consistent throughout the day and is relieved by pain medication. Incorrect Joint pain is worse during the day and involves unilateral joints.

Rheumatoid arthritis (RA) is an autoimmune disease that causes joint pain and swelling. RA is characterized by pain that is worse when arising and involves symmetric joints.

The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli? Cyanosis of the fingertips. Correct Bradycardia and bradypnea. Presence of S3 and S4 heart sounds. 3+ pitting edema of the lower extremities.

Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands which may lead to gangrene.

Which preexisting diagnosis places a client at greatest risk of developing superior vena cava syndrome? Carotid stenosis. Steatosis hepatitis. Metastatic cancer. Correct Clavicular fracture.

Superior vena cava syndrome occurs when the superior vena cava (SVC) is compressed by outside structures, such as a growing tumor that impedes the return blood flow to the heart. Superior vena cava syndrome is likely to occur with metastatic cancer from a primary tumor in the upper lobe of the right lung that compresses the superior vena cava.

Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing home safety hazards with the client. The nurse suggests that the edges of the steps be painted which color? Black. White. Light green. Medium yellow. Correct

The color yellow is the easiest for a person with failing vision to see.

Which intervention should the nurse implement that best confirms placement of an endotracheal tube (ETT)? Use an end-tital CO2 detector. Correct Ascultate for bilateral breath sounds. Obtain pulse oximeter reading. Check symmetrical chest movement.

The end-tidal carbon dioxide detector indicates the prescence of CO2tidal by a color change or a number indicated on the detector, which is supporting evidence that the ETT is in the trachea, not the esophagus.

When planning care for a client with right renal calculi, which nursing diagnosis has the highest priority? Acute pain related to movement of the stone. Correct Impaired urinary elimination related to obstructed flow of urine. Risk for infection related to urinary stasis. Deficient knowledge related to need for prevention of recurrence of calculi.

The nursing diagnosis of the highest priority is "Acute pain related the the renal calculi's movement".

An elderly client is admitted with a diagnosis of bacterial pneumonia. When observing the client for the first signs of decreasing oxygenation, the nurse should assess for which clinical cues? Abominal distention. Undue fatigue. Cyanosis of the lips. Confusion and tachycardia. Correct

The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch. Cyanosis is a very late sign.

The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract? Wear a condom when having sexual intercourse. Avoid consuming alcohol and caffeinated beverages. Empty the bladder completely with each voiding. Have intercourse or masturbate at least twice a week. Correct

The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation decreases the number of microorganisms present and reduces the risk for further infection from stored contaminated seminal fluids.

A nurse is preparing to insert an IV catheter after applying an eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. What action should the nurse take to maximize its therapeutic effect? Rub a liberal amount of cream into the skin thoroughly. Cover the skin with a gauze dressing after applying the cream. Leave the cream on the skin for 1 to 2 hours before the procedure. Correct Use the smallest amount of cream necessary to numb the skin surface.

Topical anesthetic creams, such as EMLA, should be applied to the puncture site at least 60 minutes to 2 hours before the insertion of an IV catheter.

A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage? Creatine Kinase (CK-MB). Serum troponin. Correct Myoglobin. Ischemia modified albumin.

Troponin is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB.

The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? Serum PTT of 10 seconds. Serum calcium of 5 mg/dL. Correct Oxygen saturation of 90%. Hemoglobin of 10 g/dL.

Tumor lysis symdrome (TLS) results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia. A serum calcium level of 5, which is low, is an indicator of possible tumor lysis syndrome.

Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)? Hematuria. 2 pounds weight gain. 3+ bacteria in urine. Correct Steady, dull flank pain.

Urinary tract infections (UTI) for a client with polycystic kidney disease (PKD) require prompt antibiotic therapy to prevent renal damage and scarring which may cause further progression of the disease so bacteria in the urine would be significant finding.

uremic fetor

a urine-like odor on the breath of people with uremia. The odor occurs from the smell of ammonia, which is created in the saliva as a breakdown product of urea. Uremic fetor is usually associated with an unpleasant metallic taste (dysgeusia) and can be a symptom of chronic kidney disease.

Sarcoidosis

chronic inflammatory disease in which small nodules (granulomas) develop in lungs, lymph nodes, and other organs There is no cure for sarcoidosis, but most people do very well with no treatment or only modest treatment. In some cases, sarcoidosis goes away on its own. However, sarcoidosis may last for years and may cause organ damage. African Americans

Which assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? Wheezing becomes louder. Correct Cough remains unproductive. Vesicular breath sounds decrease. Bronchodilators stimulate coughing.

In an acute asthma attack, air flow may be so significantly restricted that breath sounds and wheezing are diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing should become louder as the air flow increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough should become more productive.

Three weeks after discharge for an acute myocardial infarction (MI), a client returns to the cardiac center for follow-up. When the nurse asks about sleep patterns, the client states that sleep is fine but that the spouse has moved into the spare bedroom to sleep after returning home. The client states, "I guess we will never have sex again after this." Which response is best for the nurse to provide? Sexual intercourse can be strenuous on the heart, but closeness and intimacy, such as holding and cuddling, can be maintained with your spouse. Sexual activity can be resumed whenever you and your spouse feel like it because the sexual response is more emotional than physical. Discuss questions about sexual activity with your healthcare provider because sexual activity may be limited by your heart damage. Sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities. Correct

Sexual intercourse after an MI has been found to require no more energy expenditure or cardiac stress than walking briskly up two flights of stairs, so if the client does not experience shortness of breath or chest discomfort doing the stairs then it should be okay to resume sexual activity.

A client with chronic atrial fibrillation and a slow ventricular response is scheduled for surgical placement of a permanent pacemaker. The client asks the nurse how this device will help. How should the nurse explain the action of a synchronous pacemaker? Ventricular irritability is prevented by the constant rate setting of the pacemaker. Ectopic stimulus in the atria is suppressed by the device usurping depolarization. An impulse is fired every second to maintain a heart rate of 60 beats per minute. An electrical stimulus is discharged when no ventricular response is sensed. Correct

The artificial cardiac pacemaker is an electronic device used to pace the heart when the normal conduction pathway is damaged or diseased, such as a symptomatic dysrhythmias like atrial fibrillation with a slow ventricular response. Pacing modes that are synchronous (impulse generated on demand or as needed according to the client's intrinsic rhythm) send an electrical signal from the pacemaker to the wall of the myocardium, stimulating it to contract when no ventricular depolarization is sensed.

A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the nurse how long will antibiotics have to be administered. Which information should the nurse communicate? Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis. Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks. Correct Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks.

Treatment of acute osteomyelitis requires administration of high doses of parenteral antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks.

Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. Which intervention would be most helpful to this client? Apply sequential compression devices (SCDs) bilaterally. Assess for a positive Homan's sign in each leg. Incorrect Pad all bony prominences on the affected leg. Advise the client to remain in bed with the leg elevated. Correct

For a client exhibiting symptoms of deep vein thrombosis (DVT), a complication of immobility, the initial care includes bedrest and elevation of the extremity.

Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire? Pulse oximetry reading of 80%. Expiratory stridor and nasal flaring. Cherry red color to the mucous membranes. Correct Presence of carbonaceous particles in sputum.

The saturation of hemoglobin molecules with carbon monoxide molecules, instead of oxygen molecules and the subsequent vasodilation induced cherry red color of the mucous membranes is an indication of carbon monoxide poisoning.

The nurse is assessing a client admitted from the emergency department with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.) Vagal stimulation. Correct An increased level of stress. Decreased duodenal inhibition. Correct Hypersecretion of hydrochloric acid. Correct An increased number of parietal cells. Correct

Hypersecretion of gastric juices and an increased number of parietal cells that stimulate secretion are most often the causes of ulceration. Vagal stimulation and decreased duodenal inhibition also increase the secretion of caustic fluids.

The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after the removal of the chest tube? Prepare the client for chest x-ray at the bedside. Correct Review arterial blood gases after removal. Elevate the head of bed to 45 degrees. Assist with disassembling the drainage system.

A chest x-ray should be performed immediately after the removal of a chest tube to ensure lung expansion has been maintained after its removal.

Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn? Full thickness burns rather than partial thickness. Supinates extremity but unable to fully pronate the extremity. Slow capillary refill in the digits with absent distal pulse points. Correct Inability to distinguish sharp versus dull sensations in the extremity.

A circumferential burn can form an eschar that results from burn exudate fluid that dries and acts as a tourniquet as fluid shifts occur in the interstitial tissue. As edema increases tissue pressure, blood flow to the distal extremity is compromised, which is manifested by slow capillary refill and absent distal pulses, so the healthcare provider should be notified about any compromised circulation that requires escharotomy.

A client who is HIV positive asks the nurse, "How will I know when I have AIDS?" Which response is best for the nurse to provide? "Diagnosis of AIDS is made when you have 2 positive ELISA test results." "Diagnosis is made when both the ELISA and the Western Blot tests are positive." "I can tell that you are afraid of being diagnosed with AIDS. Would you like for me to call your minister?" "AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual." Correct

AIDS is diagnosed when one of several processes defined by the CDC is present in an individual who is not otherwise immunosuppressed (PCP, candidacies, cryptococcus, cryptosporidiosis, Kaposi's sarcoma, CNS lymphomas) and/or a CD4+ T cell count less than 200 (normal count 1,000).

The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information? A description of inflammation, infection, and tumors. Continuous visualization of intracranial neoplasms. Imaging of tumors without exposure to radiation. An image that describes metastatic sites of cancer. Correct

PET scans provide information regarding certain diseases of the heart (determination of tissue viability), brain (dementia, Parkinson's disease), and early detection of tumors and their metastasis.

A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia? Propanolol. Correct Captopril. Furosemide. Dobutamine.

Propanolol is a beta adrenergic blocking agent, which causes decreased heart rate and decreased contractility.

Which discharge instruction is most important for a client after a kidney transplant? Weigh weekly. Report symptoms of secondary Candidiasis. Use daily reminders to take immunosuppressants. Correct Stop cigarette smoking.

After a renal transplantation, acute rejection is a high risk for several months. The organ recipient will have to take immunosuppressive therapy for the rest of their lives, such as corticosteroids and azathioprine, to prevent organ transplant rejection. Discharge instructions include measures such as daily reminders to ensure the client takes these medications regularly to prevent organ rejection from occurring.

During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client? Muscle weakness. Correct Urinary frequency. Abnormal involuntary movements. A decline in cognitive function.

Amyotrophic lateral sclerosis (ALS) is characterized by a degeneration of motor neurons in the brainstem and spinal cord and is manifested by muscle weakness and wasting.

A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? A scalp laceration oozing blood. Serosanguineous nasal drainage. Correct Headache rated "10" on a 0-10 scale. Dizziness, nausea and transient confusion.

Any nasal discharge following a head injury should be evaluated to determine the presence of cerebral spinal fluid which would indicate a tear in the dura making the client susceptible to meningitis.

The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old male? Increased WBC, decreased RBC. Increased serum bilirubin, slightly increased liver enzymes. Increased protein in the urine, slightly increased serum glucose levels. Correct Decreased serum sodium, an increased urine specific gravity.

As older adults age, the protein found in urine slightly rises as a result of kidney changes, and the serum glucose increases slightly, also due to changes in the kidney.

A client with osteoarthritis receives a prescription for naproxen. Which potential side effect should the nurse discuss with the client about this medication? Sensitivity to sunlight. Muscle fasciculations. Increased urinary frequency. Gastrointestinal disturbance. Correct

Prostaglandin synthesis inhibitors such as naproxen can have gastrointestinal side effects such as nausea and gastric burning. It is recommended that this medication be taken with food to avoid gastrointestinal upset.

A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? Stay out of direct sunlight. Restrict intake of high protein foods. Schedule extra rest periods. Correct Go to the emergency room immediately.

Exacerbations of the symptoms of MS occur most commonly as the result of fatigue and stress. The client should be encouraged to schedule extra rest periods to help reduce the symptoms.

A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and heart palpitations. Which symptom is characteristic of premenstrual syndrome? Heart palpitations. Correct Anorexia. Hypersomnia. Stress incontinence.

Characteristic features of premenstrual syndrome include heart palpitations, sleeplessness, increased appetite and food cravings, and oliguria or enuresis.

A client receiving cholestyramine for hyperlipidemia should be evaluated for which vitamin deficiency? K. Correct B12. B6. C.

Cholestyramine is administered to help lower the triglycerides levels. Side effects clients should be monitored for include increased prothrombin time and prolonged bleeding times which would alert the nurse to a vitamin K deficiency. These drugs reduce absorption of the fat soluble (lipid) vitamins A, D, E, and K.

A client's prostate-specific antigen (PSA) exam result showed a PSA density of 0.13 ng/ml. Which conclusion regarding this lab data is accurate? Probable prostatitis. Low risk for prostate cancer. Correct The presence of cancer cells. Biopsy of the prostate is indicated.

Clients with a PSA density less than 0.15 ng/ml are considered at low risk for prostate cancer.

In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? Sodium. Antidiuretic hormone. Potassium. Correct Glucose.

Clients with primary hyperaldosteronism exhibit a profound decline in the serum levels of potassium (hypokalemia). Hypertension, along with the hypokalemia are the most prominent and universal signs for this condition. If both of these findings are present, there is a 50% likelihood the client will be diagnosed with hyperaldosteronism.

The registered nurse (RN) is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." What information should the RN provide to the client about the prescribed treatement? The development of resistant strains of TB are decreased with a combination of drugs. Correct Compliance to the medication regimen is challenging but should be maintained. Side effects are minimized with the use of a single medication but is less effective. The treatment time is decreased from 6 months to 3 months with this standard regimen.

Combination therapy is necessary to decrease the development of resistant strains of TB and ensure treatment efficacy.

Which nail color alteration should the nurse expect to observe in a client with chronic kidney disease? Horizontal white banding. Correct Diffuse blue discoloration. Diffuse brown discoloration. Thin, dark red vertical lines.

Fingernails and toenails can be affected by chronic kidney disease. This condition may cause horizontal white lines or bands (leukonychia) to appear on the nails.

The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? Compress the flank and upper buttocks. Correct Measure the client's abdominal girth. Gently palpate the lower abdomen. Apply light pressure over the shins.

Dependent edema collects in dependent areas, such as the flank and upper buttocks of the client who is persistently flat in bed. By compressing these areas, the nurse can determine if any pitting edema is present.

A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. Which initial medication should the nurse anticipate administering to the client? Xylocaine. Procainamide. Phenytoin. Digoxin. Correct

Digoxin is administered for uncontrolled, symptomatic atrial fibrillation resulting in a decreased cardiac output. Digoxin slows the rate of conduction by prolonging the refractory period of the AV node, thus slowing the ventricular response, decreasing the heart rate, and effecting cardiac output.

Which physical assessment finding should the nurse anticipate in a client with long-term gastroesophagealreflux disease (GERD)? Hoarseness. Correct Dry mouth. Mouth ulcers. Weight loss.

Dyspepsia and regurgitation are the main symptoms of gastroesophageal reflux disease (GERD); however, hoarseness is one of the most common long-term symptoms of GERD due to the irritation of the reflux of gastric secretions.

The nurse is planning preoperative teaching for a client who will undergo a radical neck dissection and total laryngectomy. Which information has the greatest priority for this client? Prognosis after treatment is excellent. Techniques for esophageal speech are relatively easy to learn with practice. The stoma should never be covered after this type of surgery. There is a radical change in appearance as a result of this surgery. Correct

Radical neck dissection is the removal of lymphatic drainage channels and nodes, sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and submandibular area. The overall outcome of this type of surgery causes the neck to be disfigured, so the radical change in appearance, "Alteration in body image" will be a priority in the care of this client.

A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? Losing weight. Decreasing caffeine intake. Avoiding large meals. Raising the head of the bed on blocks. Correct

Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux and subsequent aspiration is the most non-pharmacological effective recommendation for a client experiencing severe gastroesophageal reflux during sleep.

When teaching a client with breast cancer about the prescribed radiation therapy for treatment, what information is important to include? Dry, itchy skin changes may occur. Correct There is a possibility of long bone pain. Incorrect Permanent pigment changes to the breast may result. A low-residue diet may be prescribed to reduce the likelihood of diarrhea.

Side effects from radiation to the breast most often include temporary skin changes such as dryness, tenderness, redness, swelling, and pruritus.

A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history? Jewish European ancestry. Correct H. pylori bowel infection. Family history of irritable bowel syndrome. Age between 25 and 55 years.

Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi ancestry.

The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. Which action should the nurse implement? Prepare the client for transcutaneous pacemaker. Shock the client with 200 joules per hospital policy. Correct Use a magnet to deactivate the implanted pacemaker. Observe the monitor until the onset of ventricular fibrillation

A client with an automatic defibrillator who is experiencing pulseless ventricular tachycardia (VT) must be externally shocked with 200 joules per hospital policy to restore an effective cardiac rhythm. The automatic defibrillator is obviously malfunctioning.

A male client with a prostatic stent is preparing for discharge. Which information is most important for the nurse to provide the client prior to discharge? Ongoing antibiotic therapy is needed for one year. The client should not undergo magnetic resonance imaging. Increased frequency of assessment for prostatic cancer is needed. The client should not be catheterized through the stent for at least three months. Correct

A prostatic stent is a cylinder shape tube that is placed in the urethra to relieve prostatic pressure from an enlarged prostate and improve urine flow. To prevent complications, the client should be cautioned against catheterization through the prostatic stent for three months after stent placement.

An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. Which is the priority nursing diagnosis for this client? Risk for injury. Impaired comfort. Correct Disturbed body image. Ineffective health maintenance.

In menopausal women, the vaginal mucous membrane responds to low estrogen levels causing the vaginal walls to become thinner, drier, and susceptible to infection, which leads to atrophic vaginitis. Perineal cutaneous candidiasis contributes to other manifestations of vaginal infections, such as vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia, which supports the primary nursing diagnosis, "impaired comfort."

A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client? Stage II. Invasive infiltrating ductal carcinoma. T1N0M0. Inflammatory with peau d'orange. Correct

Inflammatory breast cancer onset is very rapid and a very rare form of breast cancer and is considered the most aggressive form of breast malignancies. It is often mistaken for a breast infection because it has a thickened appearance like an orange peel (peau d'orange), causing the breast to become swollen and tender.

A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL. The nurse provides the client with 6 ounces of orange juice. In 15 minutes the client's capillary glucose is 74 mg/dL. What action should the nurse take? Obtain a specimen for serum glucose level. Administer insulin per sliding scale. Provide cheese and bread to eat. Correct Collect a glycosylated hemoglobin specimen.

Once blood glucose is greater than 70 mg/dL, the client should eat a regularly scheduled meal or a snack that contains protein and carbohydrates to help prevent hypoglycemia from recurring.

The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess? Upper chest subcutaneous emphysema. Correct Tidaling (fluctuation) of fluid in the water-seal chamber. Constant air bubbling in the suction-control chamber. Pain rated "8" (0-10) at the insertion site.

Subcutaneous emphysema is a complication and indicates air is leaking beneath the skin surrounding the chest tube.

A client is admitted to the emergency department after being lost for four days while hiking in a national forest. Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse make? Body mass index. Skin elasticity and turgor. Thought processes and speech. Exposure to cold environmental temperatures. Correct

TSH influences the amount of thyroxine secretion which increases the rate of metabolism to maintain body temperature near normal. Prolonged exposure to cold environmental temperatures stimulates the hypothalamus to secrete thyrotropin-releasing hormone, which increases anterior pituitary serum release of TSH.

The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit? A decreased total lung capacity. Incorrect Normal arterial blood gases. Normal skin coloring. Correct An absence of sputum.

The differentiation between the "pink puffer" and the "blue bloater" is a well-known method of differentiating clients exhibiting symptoms of emphysema (normal color but puffing respirations) from those exhibiting symptoms of chronic bronchitis (edematous, cyanotic, shallow respirations).

The nurse is assisting a client out of bed for the first time after surgery. Which action should the nurse do first? Place a chair at a right angle to the bedside. Encourage deep breathing prior to standing. Help the client to sit and dangle legs on the side of the bed. Incorrect Allow the client to sit with the bed in a high Fowler's position. Correct

The first step in assisting a client out of bed for the first time after surgery is to raise the head of the bed to a high Fowler's position, which allows venous return to compensate from lying flat and the vasodilation effects of perioperative drugs. This helps prevent the client from becoming light-headed and decreases the chance of a client fall.

During the initial outbreak of genital herpes simplex in a female client, what should be the nurse's primary focus in planning care? Promotion of comfort. Correct Prevention of pregnancy. Instruction in condom use. Information about transmission.

The initial outbreak of genital herpes simplex in a woman causes severe discomfort. Promotion of comfort is the first priority.

During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. Which would be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? This is a normal auscultatory finding. May indicate pneumothorax. May indicate pneumonia. Correct May indicate severe emphysema.

This test (whispered pectoriloquy) demonstrates hyperresonance and helps determine the clarity with which spoken words are heard upon auscultation. Normally, the spoken word is not well transmitted through lung tissue, and is heard as a muffled or unclear transmission of the spoken word. Increased clarity of a spoken word is indicative of some sort of consolidation process (e. g., tumor, pneumonia), and is not a normal finding.

An older adult male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain would further confirm this suspicion? Pain in the calf awakening him from a sound sleep. Calf pain on exertion which stops when standing in one place. Pain in the calf upon exertion which is relieved by rest and elevating the extremity. Correct Pain upon arising in the morning which is relieved after some stretching and exercise.

Thrombophlebitis pain is relieved by rest and elevation of the extremity. It typically occurs with exercise at the site of the thrombus, and is aggravated by placing the extremity in a dependent position, such as standing in one place.

A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide 0.04 mg/kg q12 hours IV is prescribed. Which is the priority nursing diagnosis for this client? Impaired communication related to paralysis of skeletal muscles. Correct High risk for infection related to increased intracranial pressure. Potential for injury related to impaired lung expansion. Social isolation related to inability to communicate.

To increase the client's tolerance of endotracheal intubation and/or mechanical ventilation, a skeletal-muscle relaxant, such as vecuronium, is usually prescribed. Impaired communication is a serious outcome because the client cannot communicate his/her needs due to intubation and diaphragmatic paralysis caused by the drug.

The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first? Potassium 6.0 mEq. Correct Daily urine output of 400 ml. I Peripheral neuropathy. Uremic fetor.

When assessing a client with chronic kidney disease (CKD), hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal arrhythmias, so the elevation of the potassium level is a nursing priority.

Tenesmus

a continual or recurrent inclination to evacuate the bowels, caused by disorder of the rectum or other illness.

Asterixis

tremor of the hand when the wrist is extended Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist, causing rapid, nonrhythmic extension and flexion of the wrist while attempting to hold position.

Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation? Maintain the residual limb on three pillows at all times. Incorrect Place a large tourniquet at the client's bedside. Correct Apply constant, direct pressure to the residual limb. Do not allow the client to lie in the prone position.

A large tourniquet should be placed in plain sight at the client's bedside, in the event severe bleeding occurs. The purpose is to have the tourniquet available to apply to the residual limb to control bleeding if hemorrhaging was to occur.

In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which positioning should the nurse should use to maintain optimal functioning? Mid-Fowler's with knees supported. Supine with trochanter rolls to the hips. Sim's position alternated with right lateral position q2 hours. Left lateral, supine, brief periods on the right side, and prone. Correct

After an acute stroke, a positioning and turning schedule that minimizes lying on the affected side is recommended because it prevents impaired circulation and reduces pain. The prone position helps prevent flexion contractures of the hips and prepares the client for optimal functioning and ambulating.

After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 mL for the last 2 hours. Which priority nursing action should be implemented? Report the findings to the surgeon. Correct Irrigate the indwelling urinary catheter. Apply manual pressure to the bladder. Increase the IV flow rate for 15 minutes. Incorrect

After surgery, an adult who weighs 132 pounds (60 kg) should produce about 60 mL of urine hourly (1 mL/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the surgeon.

Which statement made by a client with chronic pancreatitis indicates that further education is needed? I will cut back on smoking cigarettes daily. Correct I will avoid drinking caffeinated beverages. I will rest frequently and avoid vigorous exercise. Incorrect I will eat a bland, low-fat, high-protein diet.

To prevent exacerbations of chronic pancreatitis, clients should be instructed to avoid nicotine entirely. Additional teaching includes avoiding caffeinated beverages, resting frequently as needed, and eating a bland diet low fat and high in protein.

A client asks the nurse about the purpose of beginning chemotherapy (CT) because the tumor is still very small. Which information supports the explanation that the nurse should provide? Side effects are less likely if therapy is started early. Collateral circulation increases as the tumor grows. Sensitivity of cancer cells to CT is based on cell cycle rate. The cell count of the tumor reduces by half with each dose. Correct

Initiating chemotherapy while the tumor is small provides a better chance of eradicating all cancer cells because 50% of cancer cells or tumor cells are killed with each dose.

The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome? Prevent the formation of effusion fluid. Correct Remove fluid from the intrapleural space. Debulk tumor to maintain patency of air passages. Relieve empyema after pneumonectomy.

Instillation of a sclerosing agent to create pleurodesis is aimed at preventing the formation of a pleural effusion by causing the pleural spaces sealed together, thereby preventing the accumulation of pleural fluid.

When preparing a client who has had a total laryngectomy for discharge, which instruction is most important for the nurse to include in the discharge teaching? Recommend that the client carry suction equipment at all times. Instruct the client to have writing materials with him at all times. Tell the client to carry a medic alert card stating that he is a total neck breather. Correct Tell the client not to travel alone.

It is imperative that total neck breathers carry a medic alert notice so, that if they have a cardiac arrest, mouth-to-neck breathing can be done.

The nurse is planning care to prevent complications for a client with multiple myeloma. Which intervention is most important for the nurse to include? Safety precautions during activity. Assess for changes in size of lymph nodes. Maintain a fluid intake of 3 to 4 L per day. Correct Administer narcotic analgesic around the clock.

Multiple myeloma is a malignancy of plasma cells that infiltrate bone causing demineralization and hypercalcemia, so maintaining a urinary output of 1.5 to 2 L per day requires an intake of 3 to 4 L to promote excretion of serum calcium.

Which instruction should the nurse include in the discharge teaching for a client who needs to perform self-catheterization technique at home? Catheterize every 3 to 4 hours. Correct Maintain sterile technique. Use the Cred maneuver before catheterization. Drink 500 mL of fluid within 2 hours of catheterization.

The average interval between catheterizations for adults is every 3 to 4 hours. Although sterile technique is indicated in healthcare facilities, clean technique is often followed by the client when performing self-catheterization at home.

The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different? Method of insertion. Correct Location of the tubes. Diameter of the tubes. Procedure for feedings.

The best explanation of how a percutaneous endoscopic gastrostomy (PEG) tube differs from a gastrostomy tube (GT) is by the method of insertion. GT insertion involves making an incision in the wall of the abdomen and suturing the tube to the gastric wall. A PEG tube is more commonly used as it does not require general anesthesia and is less invasive. Insertion is performed with endoscopic visualization through the esophagus into the stomach and then pulled through a small incision in the abdominal wall. It is held in place by a tiny plastic device called a "bumper" that holds the g-tube in place with a small water-filled balloon securing it against the abdominal wall.

sphyg·mo·ma·nom·e·ter

an instrument for measuring blood pressure, typically consisting of an inflatable rubber cuff which is applied to the arm and connected to a column of mercury next to a graduated scale, enabling the determination of systolic and diastolic blood pressure by increasing and gradually releasing the pressure in the cuff.

Buerger's disease (thromboangiitis obliterans)

disease strongly related to smoking or the use of some other form of tobacco which affects the circulation in the arms and legs leading to infection and gangrene and sometimes amputation of the affected area. The most effective means of controlling symptoms and disease progression is through smoking cessation. The cause of Buerger's disease is unknown; a genetic predisposition is possible, but unproven.

Which findings are within expected parameters of a normal urinalysis for an older adult? (Select all that apply.) pH 6. Correct Nitrate small. Protein small. Sugar negative. Correct Bilirubin negative. Correct Specific gravity 1.015. Correct

A pH of 6.0 is within the normal pH range for urine. Glucosuria and bilirubinuria are abnormal and should be negative upon urinalysis. Normal changes associated with aging include decreased creatinine clearance and decreased concentrating and diluting abilities which influence the normal range of urine specific gravity, 1.001 to 1.035. Although common health problems associated with aging include renal insufficiency, urinary incontinence, urinary tract infection, and enlarged prostate, these are indicative of pathology which should be treated.

Which assessment finding should most concern the nurse who is monitoring a client two hours after a thoracentesis? New onset of coughing. Correct Low resting heart rate. Distended neck veins. Decreased shallow respirations.

A pneumothorax (partial or complete lung collapse) is the potential complication of a thoracentesis. Manifestations of a pneumothorax include new onset of a nagging cough, tachycardia, and an increased shallow respiration rate.

In preparing to administer intravenous albumin to a client following surgery, which are the priority nursing interventions? (Select all that apply.) Set the infusion pump to infuse the albumin within four hours. Correct Compare the client's blood type with the label on the albumin. Assign a UAP to monitor blood pressure q15 minutes. Administer through a large gauge catheter. Correct Monitor hemoglobin and hematocrit levels. Correct Assess for increased bleeding after administration. Correct

Albumin should be infused within four hours because it does not contain any preservatives. Any fluid remaining after four hours should be discarded. A large gauge catheter allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin (HgB) and hematocrit (HCT) levels, so the HgB and HCT levels should be monitored while monitoring for bleeding because of the increased blood volume and blood pressure.

The nurse is preparing a teaching plan for a client with newly diagnosed glacoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using over-the-counter (OTC) medications for allergies? Notify your healthcare provider if there is an increase in heart rate. Increase fluid intake while taking an antihistamine or decongestant. Avoid allergy medications that contain pseudoephedrine or phenylephrine. Correct Ophthalmic lubricating drops may be used for eye dryness due to allergy medications.

OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine, which can cause adrenergic side effects, such as increased intraocular pressure, so a client with glaucoma should avoid using these OTC medications.

Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock? Faint pedal pulses. Decrease in blood pressure. Lethargy. Correct Slow breathing.

One of the early signs of hypovolemic shock is changes in the client's level of consciousness due to the decrease perfusion to the brain which can manifests as lethargy or confusion. all others are sort of grouped together as intermediate s/s

Which action should the nurse implement on the scheduled day of surgery for a client with type 1 diabetes mellitus (DM)? Obtain a prescription for an adjusted dose of insulin. Correct Administer an oral anti-diabetic agent. Give an insulin dose using parameters of a sliding scale. Withhold insulin while the client is NPO.

Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM who is NPO for scheduled surgery should receive a prescribed adjusted dose of insulin.

The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.) Remove the diaphragm immediately after intercourse. Wash the diaphragm with an alcohol solution. Use the diaphragm to prevent conception during the menstrual cycle. Do not leave the diaphragm in place longer than 8 hours after intercourse. Correct Replace the old diaphragm every 3 months. Correct

The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent pregnancy but should not remain for longer than 8 hours to avoid the risk of toxic shock syndrome. The diaphragm should be replaced every 3 months to maintain integrity.

During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first? Notify the healthcare provider for reinsertion. Attempt to reinsert the tracheostomy tube. Correct Position the client in a lateral position with the neck extended. Ventilate client's tracheostomy stoma with a manual bag-mask.

The nurse should attempt to reinsert the tracheostomy tube by using a hemostat to open the tracheostomy or by grasping the retention sutures (if present) to spread the opening and insert a replacement tube (with its obturator) into the stoma. Once in place, the obturator should immediately be removed.