NCLEX Practice Standalone

a. Smoking tobacco b. Drinking alcohol a. and b. Correct: Tobacco is the #1 cause of preventable cancer. Alcohol plus tobacco are co-carcinogenic. c. Incorrect: A low fiber diet is bad. You don't have much motility in your intestines, so you are retaining carcinogens longer. d. Incorrect: Increasing fish consumption is a good thing. You want to avoid increased red meat consumption and animal fat. e. Incorrect: Tanning beds are just as bad as exposure to sunlight. Both cause exposure to ultra-violet radiation.

The nurse is preparing a class on cancer prevention. Which risk factor should the nurse discuss with the class as being a preventable risk factor? Select All That Apply a. Smoking tobacco b. Drinking alcohol c. Eating a high fiber diet d. Increasing fish consumption e. Protect skin from sunlight by using tanning beds

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

The nurse is preparing to administer magnesium sulfate IV to an alcoholic client with hypomagnesemia. Prior to the initiation of IV magnesium, which assessment data would be important for the nurse to document? Select All That Apply a. Liver function b. Respiratory rate c. Calcium levels d. Deep Tendon Reflexes (DTRs) e. Urinary output

d. Heart rate 56 BPM This is a beta blocker. If a client's heart rate is less than 60 BPM, notify the primary healthcare provider and ask if the client should receive this medication. You can identify that nadolol is a beta blocker because it ends in "lol." "a" is icorrect. Beta blockers are prescribed to lower BP. When the baseline BP is not known, worry about a BP of 90/60 or below. If the client's BP drops below that, the beta blocker should be held and the primary HCP notified. "b" is incorrect. This is a normal glucose level. If the client is diabetic, beta blockers can mask the signs of hypoglycemia. "c" is incorrect. The urinary output (UOP) is adequate. Beta blockers do not alter renal function.

The nurse is preparing to administer nadolol to a hospitalized client. Which client data would indicate to the nurse that the medication should be held and the primary healthcare provider notified? a. Blood pressure 102/68 b. Glucose 118 mg/dL c. UOP 440 mL over 8 hour shift. d. Heart rate 56 BPM

d. 0.01 The numeric value of the metric prefix "centi" is 0.01, or one-hundredth.

What is the numeric value of the metric prefix "centi"? a. 100 b. 10 c. 0.1 d. 0.01

d. 0.1 The numeric value of the metric prefix "deci" is 0.1, or one-tenth.

What is the numeric value of the metric prefix "deci"? a. 100 b. 10 c. 0.01 d. 0.1

d. Carbon monoxide poisoning d. CORRECT. Carbon monoxide is a colorless, odorless, tasteless gas which permeates the blood stream, displacing the oxygen in hemoglobin. Symptoms are often confused with other illnesses, such as the flu. Assuming exposure is not fatal, the client may also experience extreme weakness, dizziness and blurred vision with confusion. Additionally, the carbon monoxide will cause lips and skin to become red in color. Without treatment, the client will die. a. INCORRECT. Guillian-Barre is a muscle disorder occurring when the immune system attacks peripheral nerves, destroying the surrounding myelin sheath. The damage can develop over hours or days, but will take months to resolve. The client experiences severe weakness, drooping of the eye muscles and pain or tingling in hands and feet. The client also develops paresthesia and paralysis, which was not reported as symptoms in the scenario. Of major concern would be paralysis of the respiratory muscles. b. INCORRECT. Although the client reported nausea and vomiting, there are no assessment findings in the scenario to corroborate severe dehydration. c. INCORRECT. The client has reported flu-like symptoms, such as dizziness, nausea and vomiting along with headache. However, additional reported symptoms like blurred vision suggest a different problem.

An elderly client arrives at the emergency room reporting a severe headache and blurred vision. The client indicates having awakened this morning with flu-like symptoms including nausea, vomiting and dizziness. The nurse notes the client appears very weak with shortness of breath and dark cherry red lips. Based on assessment findings, what life-threatening problem does the nurse expect? Choose One a. Guillian Barre b. Severe dehydration c. Advanced influenza d. Carbon monoxide poisoning

400 The decimal point is moved three places. The answer 0.4 mg = 400 mcg (Move the decimal point three places to the right from the milli place to the micro place)

Convert 0.4 milligrams (mg) into micrograms (mcg). Use the metric line to solve the problem. Include only the numeral (not the units) in your answer.

1500 The metric symbol for the prefix "deci" is "d," the starting place on the metric line. The metric symbol for the prefix "milli" is "m," the desired place. To convert from the deci place to the milli place, a decimal point is added to the whole number 15, and then the decimal point is moved two places to the right. The answer is 1500 mL. The "L" indicates liters (volume) and is the base unit of measurement in this problem.

Convert 15 deciliters (dL) into milliliters (mL). Use the metric line to solve the problem. Include only the numeral (not the units) in your answer.

0.0321 The metric symbol for the prefix "milli" is "m," the starting place on the metric line. The desired place is the meter place, also the base unit. To convert from the milli place to the base unit, the decimal point is moved three places to the left. The answer is 0.0321 m. Remember to always use a leading zero with the decimal fraction less than one unit.

Convert 32.1 millimeters (mm) into meters. Use the metric line to solve the problem. Include only the numeral (not the units) in your answer.

a. Unusual fatigue. b. Indigestion. c. Aching jaw. d. Feeling faint e. Pain between the shoulder blades. a., b., c., d., and e. Correct: Look at the hints - elderly, female, choking sensation. Women often present with GI signs and symptoms, epigastric complaints, or pain between the shoulders, aching jaw, or choking sensation. The triad of symptoms: feeling of fullness in the abdomen, unusual fatigue, and an inability to "catch one's breath". Remember that the elderly may just faint or only have SOB. f. Incorrect: Left arm paresthesia sounds more like a stroke rather than an MI.

A 70 year old female client reports an occasional choking sensation over the past 12 hours. What additional symptoms reported by the client would indicate to the nurse that the client may be having a myocardial infarction? Select All That Apply a. Unusual fatigue. b. Indigestion. c. Aching jaw. d. Feeling faint e. Pain between the shoulder blades. f. Left arm paresthesia.

a. Celecoxib b. Ibuprofen c. Naproxen e. Indomethacin a, b, c, and e are correct. NSAIDs, such as celecoxib, ibuprofen, naproxen, and indomethacin preven platelet aggregation. This can result in a tendency for bleeding after a laminectomy with spinal fusion surgery. "d" is incorrect. Acetaminophen is a peripheral-acting analgesic and not an NSAID.

A client has bee instructed not to take non-steroidal anti-inflammatory drugs (NSAIDs) post lumbar laminectomy with spinal fusion. The nurse knows that education was successful when the client identifies which medications should be avoided? a. Celecoxib b. Ibuprofen c. Naproxen d. Acetaminophen e. Indomethacin

a. Fever d. Dry cough e. Dyspnea a, d, and e are correct. Pneumocystis carinii pneumonia (PCP), now known as pneumocystis jirovecii, is caused by a fungus and occurs in clients with weakened immune systems. Expected assessment findings include fever, dry non-productive cough and dyspnea. Any additional symptoms are related to other co-morbidities and not the pneumonia itself. "b" is incorrect. Night sweats are an early symptom of active TB and are often the difinitive symptom, along with a productive cough, that indicates the need for immediate testing and isolation. "c" is incorrect. Hemoptysis is among the late signs of lung cancer, in addition to weight loss. Lung cancer is asymptomatic in its early stages.

A client has been admitted with a diagnosis of pneumocystis carinii pneumonia (PCP). What initial assessment findings would the nurse expect? Select all that apply. a. Fever b. Night sweats c. Hemoptysis d. Dry cough e. Dyspnea

b. Mouthwash and hand sanitizer b. Correct: Mouthwash and hand sanitizers have alcohol in them, which the client may drink. a. Incorrect: There is not alcohol content in shampoo and conditioner, so these items do not have to be removed from the client's room. c. Incorrect: We do not want the client to come into contact with anything that contains alcohol. Toothpaste and dental floss are safe for the client to have available. d. Incorrect: There is no alcohol content in these items, so there is no need to remove them from the room.

A client is admitted to a chemical dependency unit for addiction treatment. Which of the client's belongings should the nurse remove from the client's room? Choose One a. Shampoo and conditioner b. Mouthwash and hand sanitizer c. Toothpaste and dental floss d. Lotion and foot powder

a. Spironolactone a., Correct: The client's potassium level is low. Spironolactone is a potassium sparing diuretic which would cause the potassium to be retained. b. Incorrect: Furosemide is a potassium depleting diuretic which would further deplete the potassium level. c. Incorrect: Bumetanide is a potassium depleting diuretic which would further deplete the potassium level. d. Incorrect: Hydrochlorothiazide also leads to potassium loss, which would further deplete the potassium level.

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

b. Provide music therapy. c. Provide ginger ale to drink. d. Apply accupressure bands to wrists. e. Place pepperment essential oil diffuser in room. b., c., d., and e. Correct: All of these interventions will help prevent or decrease nausea and vomiting. Music therapy is a form of behavioral therapy that can help with relaxation and distraction. Ginger is a natural antiemetic, so providing ginger ale to drink is beneficial. Sea bands or accupressure bands on the wrist help to relieve nausea and vomiting. Peppermint is one essential oil that relieves nausea. It can be used in a diffuser so that client can small the peppermint. a. Incorrect: Antiemetic medications should be given one hour prior to chemotherapy rather than after receiving chemotherapy.

A client receiving chemotherapy reports nausea and vomiting after every treatment. What interventions should the nurse initiate to reduce this side effect? Select All That Apply a. Administer antiemetic immediately after treatment. b. Provide music therapy. c. Provide ginger ale to drink. d. Apply accupressure bands to wrists. e. Place pepperment essential oil diffuser in room.

c. 10 mg : 1 tablet Each tablet of Norvasc contains 10 mg. This is expressed as 10 mg : 1 tablet.

Read the medication label and identify the correct dosage strength. a. 10 mg : 90 tablets b. 90 mg : 1 tablet c. 10 mg : 1 tablet d. 10 mcg : 1 tablet

b. 250 mg : 5 mL Dosage strength is 250 mg per 5 mL; this is expressed as 250 mg : 5 mL. Once reconstituted, there are 60 mL of medication in the bottle.

Read the medication label and identify the correct dosage strength. a. 5 mg : 250 mL b. 250 mg : 5 mL c. 250 mg : 60 mL d. 5 mg : 60 mL

b. µ The Greek letter "µ" represents micro (mc) and should not be used in a medication order since it may lead to a medication error.

The Institute of Medicine identified abbreviations and symbols that should not be used in writing and transcribing medication orders due to the high risk for error. Which of the following, if written in a medication order, should be questioned? a. Units b. µ c. IM d. mL

a. Perform pin care daily. c. Clean with chlorhexidine. a. and c. Correct: Pin care is prescribed 48 to 72 hours after insertion. The pin care is initiated once a day. Chlorhexidine is prescribed to clean the pin insertion site. b. Incorrect: The pins are rinsed with sterile saline and not water. d. Incorrect: The area around the pin site is dried with sterile gauze. The use of clean gauze is not appropriate. e. Incorrect: The pin site is assessed. Every 10 hours is not often enough to monitor for infection.

The nurse has been assigned to a client with a Steinman pin insertion 48 hours ago. Which pin site care interventions would the nurse implement? Select All That Apply a. Perform pin care daily. b. Rinse pins with water. c. Clean with chlorhexidine. d. Dry the area with clean gauze. e. Monitor pin site every 10 hours.

b. Semi-Fowler If a client has increasing abdominal girth, they have more pressure on their abdomen and need to sit up. The head of the bed may be elevated 30 degrees or higher if the client needs help breathing. "a" and "c" are incorrect. They would make it more difficult to breath. "d" would not benefit the client.

The nurse is assessing a client with advanced cirrhosis and notes an abdominal girth increase of 5 inches (12.7 cm) since yesterday. What is the best position for the nurse to place this client? a. Supine b. Semi-Fowler c. Trendelenburg d. Lateral, left side

a. The ordered dose c. The units The Institute of Medicine recommends that the word "units" should be spelled out in when used in the medication order. Use of the abbreviation "u" is potentially dangerous and may lead to a medication error. In addition, 1,200,000 should be written as 1.2 million.

The nurse is reviewing the physician's order found on the patient's electronic medical record. Which part(s) of the medication order would the nurse question? Select all that apply. a. The ordered dose b. The drug name c. The units d. The frequency e. The route

a. 100 The numeric value of the metric prefix "hecto" is 100.

What is the numeric value of the metric prefix "hecto"? a. 100 b. 10 c. 0.1 d. 0.01

c. 1,000 The numeric value of the metric prefix "kilo" is 1,000.

What is the numeric value of the metric prefix "kilo"? a. 100,000 b. 10,000 c. 1,000 d. 100

c. Beta blockers Beta blockers help anxiety and tremors. They reduce the effects of adrenaline in the body. In times of stress and emergency, the adrenal gland produces adrenaline which acts on various organs to enable us to deal with the situation. For example, the heart beats faster due to adrenaline. The beta receptors on various organs allow them to accept adrenaline. Blocking them prevents them from accepting adrenaline reducing anxiety and feeling jittery. "a" is incorrect. Steroids influence the body system in several ways, but they are used mostly for their strong anti-inflammatory effects and in conditions related to immune function (e.g., arthritis, colitis [ulcerative colitis and Crohn's disease], asthma, bronchitis). Corticosteroids are used to treat systemic lupus, severe psoriasis, leukemia, lymphomas, idiopathic thrombocytopenic purpura, and autoimmune hemolytic anemia.

Which medication does the nurse expect will help decrease tremors in a client diagnosed with hyperthyroidism? a. Steroids b. Anticonvulsants c. Beta blockers d. Iodine compounds

d. Warfarin Sodium The warfarin sodium label notes that it is a highly potent anticoagulant and requires the package brochure be given to the patient. The guide provides information of the potential risks and side effects related to the use of the drug.

Which of the following prescription drugs contains a black box warning? a. Accupril b. Lanoxin c. Amoxicillin d. Warfarin Sodium

c. Obtain the proper spill kit for the specific chemotherapy drug used. c. Correct: The first step in handling an accidental chemotherapy spill is to obtain the specific spill kit for that type of drug since each medication may require a different cleanup protocol. a. Incorrect: This is step 4: Each kit includes special absorbent pads and usually a powder designed to solidify liquid, making it easier to contain. b. Incorrect: This is step 3. The nurse should then apply all the personal protective equipment (PPE) in the kit, including gown, mask, goggles, shoe covers and two pairs of special chemo gloves. Chemo drugs are deadly, whether ingested, injected or inhaled. The nurse needs to avoid any potential contact with the drug. d. Incorrect: This is step 2. Inside the kit is the "Caution-Chemo Spill" sign, which must immediately be posted outside the room and the door closed to contain the spill. Step 5: Once the spill is safely cleaned up, the nurse must report the spill to the facility supervisor and the client's primary healthcare provider in addition to completing an incident report.

While preparing chemotherapy, the nurse accidently punctures the bag, spilling the solution on the floor. After activating the emergency spill protocol, what action should the nurse take first? Choose One a. Place absorbent pads and absorbent powder over the spill. b. Apply chemotherapy approved personal protective gown and gloves. c. Obtain the proper spill kit for the specific chemotherapy drug used. d. Post the "Caution-Chemo Spill" sign outside the room door.

a. Plate guards b. Transfer belt c. Raised toilet seat d. Long handles shoe horn e. Wide grip utensils The goal is to promote self-care by the client as much as possible. The case manager should evaluate the need for assistive devices to help with eating, bathing, dressing, and ambulating. The plate guard will prevent food from being pushed off of the plate. The transfer belt will provide safety for the client and family member who is assisting the client to get up into a chair or back in bed. A raised toilet seat makes it easier for the client to sit on the toilet without falling. The long handled shoe horn allows the client to put on shoes without assitance. Wide grip utensils accommodate a weak grip. "f" is incorrect. It is hard for someone with hemiplegia to use buttons. Velcro fasteners are best.

A case manager is evaluating a client diagnosed with hemiplegia due to cerebral vascular accident for assistive devices that will be needed upon discharge. Which resources should the case manager include for this client? Select all that apply. a. Plate guards b. Transfer belt c. Raised toilet seat d. Long handles shoe horn e. Wide grip utensils f. Large button closeures on clothes

a. Assign staff to stay with client. d. Frequently reorient client to reality. a. and d. CORRECT. Auditory hallucinations, also called "paracusia", are extremely frightening. The client's intense fear may result in striking out at staff, visitor or other clients, and can even cause the client to do self-harm. Nurses must focus on safety by remaining with the client at all times in a quiet room. Reinforcing that feeling of being safe while frequently reorienting the client to reality are priority actions that may continue for hours until the client becomes calmer. b. INCORRECT. Though the idea of a quiet environment with decreased stimuli is important, a frightened client with hallucinations should never be left alone. c. INCORRECT. Asking a client to explain hallucinations feeds into the delusion. If the client indicates hearing messages or commands being given, the nurse would acknowledge the hallucination may seem real to the client, but is not perceived by anyone else. e. INCORRECT. The best approach for a hallucinating client is to decrease stimuli and move client to a quiet environment. Chaos or loud noises would not mask hallucinations perceived within the client's mind.

A client admitted to a psychiatric facility is refusing all medications. The nurse notes the client appears to be responding to auditory hallucinations. What actions by the nurse would be appropriate? Select All That Apply a. Assign staff to stay with client. b. Place client into a seclusion room. c. Ask client to explain auditory sounds. d. Frequently reorient client to reality. e. Turn up radio to mask hallucinations.

b. Renal lithiasis b. Correct: These signs and symptoms are classic for renal lithiasis or kidney stones. a. Incorrect: Glomerulonephritis does present with flank pain but not as severe as a kidney stone and not radiating to the lower abdomen. There is no mention of edema seen with this client. c. Incorrect: What do you see with neprhotic syndrome? Massive edema or anasarca. d. Incorrect: Nausea and vomiting can occur with acute kidney injury because of all of the retained toxins. But there is no mention of hypertension, edema, and other s/s of acute kidney injury.

A client arrives at the clinic reporting a sharp pain, rated 10/10, radiating from the right flank around to the lower right abdomen. The client also reports nausea and vomiting. Based on this data, what problem does the nurse suspect? Choose One a. Glomerulonephritis b. Renal lithiasis c. Nephrotic syndrome d. Acute kidney injury

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

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

22.5 Total head (front and back) is 9% Front of torso is 18% Back of torso is 18% Total SA of each arm (front and back) is 9% Gentalia is 1% Total SA of each leg (front and back) is 18% Rationale: Posterior Trunk = 18% Posterior arm = 4.5% TBSA burned = 18 + 4.5 = 22.5%

A client arrives at the emergency department after sustaining full thickness burns. What does the nurse estimate the total body surface area (TBSA) burned to be when using the rule of nines?

b. Begin discharge teaching to the client and spouse. b. CORRECT. Internal radiation, also called brachytherapy, is placed inside the body as close to the cancer as possible. Internal radiation therapy can be permanent or temporary as well as sealed or unsealed, which refers to the amount of radiation risk posed by the client. Implanted seeds used to treat prostate cancer are a type of sealed radiation, indicating the body fluids are not radioactive. Emptying the urinal poses no risk to the spouse. a. INCORRECT. Implanted seeds are a type of sealed radiation. Therefore, the client's body fluids are not radioactive, though the spouse should use some precautions when in proximity to the client for a few days. No need to check the spouse for radiation levels. c. INCORRECT. Even though the client will be immunosuppressed, there is no need for the spouse to use sterile gloves. However, washing hands and using regular gloves is always a good idea. d. INCORRECT. The spouse does not need to remain outside the room, particularly since the client is about to be discharged home. The client's body fluids are not radioactive.

A client had radiation seeds implanted to treat prostate cancer. When entering the room to initiate discharge teaching, the nurse observes the spouse emptying the client's urinal. What is the nurse's priority action? Choose One a. Immediately escort spouse to ED to check radiation levels. b. Begin discharge teaching to the client and spouse. c. Have spouse wash hands thoroughly and apply sterile gloves. d. Explain that spouse must remain outside the room until urinal is emptied.

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

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

d. "You seem very concerned about your memory." d. CORRECT. The nurse/client relationship is collaborative and nonjudgmental with the goal of facilitating the client's emotional growth. Open-ended statements or questions encourage the client to express feelings and continue verbalizing. This comment by the nurse is open-ended and acknowledges the client's concerns. a. INCORRECT. Although the nurse has indicated the time frame for memory loss would be greater than two weeks, telling the client not to worry denies the client's right to express feelings. b. INCORRECT. This question is closed-ended because the client can respond with yes or no. Also, the nurse has suggested feelings of fear, instead of letting the client identify a specific emotion. c. INCORRECT. It is not appropriate for the nurse to transfer care of the client to another individual currently. Instead, first the nurse should address the client's concerns directly and immediately.

A client has responded positively to a series of electroconvulsive treatments (ECT), but reports concerns about on-going memory loss. What is the most appropriate response by the nurse? Choose One a. "It's only been a couple weeks so don't worry." b. "Are you afraid your memory will not return?" c. "I will ask the psychiatrist to come talk with you." d. "You seem very concerned about your memory."

a. Abdominal pain c. Jaundice d. Pruritus e. Diarrhea a., c., d., and e. These are early signs of rejection that the nurse must monitor for: abdominal pain, jaundice, pruritus or itching, and diarrhea. b. Incorrect: There is nothing wrong with the color of this urine. A problem would be dark, tea colored urine. This indicates the breakdown of red blood cells.

A client has returned to the room post stem cell transplant. What early signs of rejection should the nurse monitor for in the client? Select All That Apply a. Abdominal pain b. Straw colored urine c. Jaundice d. Pruritus e. Diarrhea

b. "It helps us to monitor and adjust the dose to work better." The nurse has clearly stated the prupose of the frequent venipunctures in a simple and non-technical manner that answers the client's questions. "a" is not correct because it does not address the inquiry about every 6 hour bloodwork, plus the phrasing of the statement could easily frighten the client. "c" is incorrect. This standard response does not answer the client's question about blood work nor does it provide further information about the treatment. "d" is incorrect because it is vague and does not address the client's question about frequent blood work.

A client hospitalized with a deep vein thrombosis (DVT is on a heparin infusion. The client asks the nurse why it is necessary to have blood drawn every six hours. What is the best explanation for the nurse to provide? a. "The medicine might make your blood much too thin." b. "It helps us to monitor and adjust the dose to work better." c. "it is required for anyone getting heparin intravenously." d. "The test results tell us whether the treatment is working."

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

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

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

A client is admitted following a severe burn. What changes related to fluid status would the nurse anticipate? Select All That Apply a. Fluid volume excess b. Hypovolemia c. Third spacing d. Increased urine output e. Low CVP f. Increased urine specific gravity

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

A client is admitted to the ICU with diabetes insipidus following a head injury. Which finding would the nurse anticipate in this client? Choose One a. Low serum hematocrit b. High serum glucose c. High urine protein d. Low urine specific gravity

a. Shortness of breath d. Chest pain e. Cough f. Subcutaneous emphysema a., d., e., and f. Correct: With a hemothorax, we recall that blood has accumulated in the pleural space, and with a pneumothorax, we know that it is air that has accumulated in the pleural space. The presence of either of these causes the lung to collapse. The signs that the nurse expects to see includes shortness of breath, chest pain, and cough. We may also see subcutaneous emphysema as the air that escaped from the lung becomes trapped in the surrounding tissues. b. Incorrect: What happens to gas exchange when there is a hemothorax or a pneumothorax? That's right! It decreases. When hypoxia is present, the body responds by increasing the heart rate. Therefore, we would not expect the heart rate to be decreased in this situation. c. Incorrect: Wheezing occurs when air tries to get through narrowed passages. With a hemothorax or pneumothorax, the lung sounds will be diminished over the affected area where the lung has collapsed.

A client is admitted to the emergency department (ED) following blunt trauma to the chest from a motor vehicle accident. A hemothorax and pneumothorax are suspected. What signs and symptoms would the nurse anticipate recording to support this diagnosis? Select All That Apply a. Shortness of breath b. Decreased heart rate c. Wheezing in the affected area d. Chest pain e. Cough f. Subcutaneous emphysema

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

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

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

A client is admitted with hypocalcemia. Which treatment would the nurse anticipate for this client? Select All That Apply a. PO Calcium b. Rapid IV Push Calcium c. Vitamin D d. Sevelamer hydrochloride e. Phosphate supplements

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

A client is admitted with prolonged nausea and vomiting. The client's admission sodium level is 149 mEq/L (149 mmol/L). What action by the nurse would be most appropriate at this time? Choose One a. Administer 3% NS at 150 mL/hr b. Perform neurological assessment c. Increase oral intake of sodium d. Decrease fluid intake

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

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

a. Instruct client to deep breathe with the nurse. a. Correct: The most important action for the nurse to take is to slow down the client's breathing so that they do not end up in respiratory alkalosis from hyperventilation. b. Incorrect: Now is not the time to teach! They cannot concentrate on anything but the panic they feel. c. Incorrect: Again teach them this when they are not having a panic attack. Also teach ways to stop the anxiety from escallating. d. Incorrect: Approach the client in a nonthreatening manner. Give them space. Do not add to the anxiety by getting in their space.

A client is experiencing a panic attack. What priority action should the nurse take? Choose One a. Instruct client to deep breathe with the nurse. b. Teach relaxation techniques. c. Inform client that symptoms will be gone in 20-30 minutes. d. Hold the client gently for 5 minutes.

a. Use antimicrobial soap for handwashing. b. Post neutropenic precautions sign on door. e. Vital signs at least every 4 hours. a., b., and e. Correct: We want to use antimicrobial soap to wash hands. Anyone planning to enter the client's room needs to know what to do prior to entering, so a sign with necessary instructions should be placed on the closed door. Vital signs should be done every 4 hours, minimally. If needed, take vital signs more frequently. c. Incorrect: Don't administer acetamenophen. It can be toxic to the liver. d. Incorrect: Platelets are not needed for a low white count. They are given when the client is thrombocytopenic.

A client is placed on neutropenic precautions. What interventions should the nurse initiate? Select All That Apply a. Use antimicrobial soap for handwashing. b. Post neutropenic precautions sign on door. c. Administer acetaminophen for fever greater than 101 degree F (38.3 degrees C). d. Administer platelets as prescribed. e. Vital signs at least every 4 hours.

c. Monitor tracheostomy for pulsations with heart beat. d. Provide mouth care every 2 hours. e. Maintain a humidified environment. c., d., and e. Correct: If a client's trach is pulsating with the heartbeat, you need to notify the primary healthcare provider immediately, as this could lead to rupture of the innominate artery. Frequent mouth care will decrease the bacterial count in the mouth. We are trying to prevent pneumonia. When breathing in and out through a trach, the client will not be able to warm, filter, and humidify the air. The air is really dry, so it irritates the trach. That is why when the client first gets the trach it has a lot of secretions. A humidified environment will help. a. Incorrect: Where is the surgery? At the neck. Swelling! So place mid-fowlers, head of bed 35-45 degrees. b. Incorrect: Peristalsis can disrupt the suture line. NG tube feedings will be provided to protect the suture line.

A client is scheduled to be admitted to the surgical unit post total laryngectomy. What nursing intervention should the nurse include in the plan of care? Select All That Apply a. Position left-side lying, supine. b. Place on clear liquid diet after peristalsis returns. c. Monitor tracheostomy for pulsations with heart beat. d. Provide mouth care every 2 hours. e. Maintain a humidified environment.

b. Skin shedding c. Erythema with pain d. Pancytopenia e. Exhaustion b.,c.,d., and e. CORRECT. External beam radiation uses high energy proton rays to deliver radiation from outside the body. This therapy prevents cell reproduction and destroys cancer cells. Expected side effects can be topical or physiological, depending on the area radiated. Skin radiated by the beam becomes reddened (erythema), dry and peeling. Shedding skin and even blistering may occur because of multiple treatments. As radiation enters tissues, damage affects even healthy tissue like bone marrow. The client may eventually develop pancytopenia: a lack of all blood components, including red cells, white cells and platelets. As the body struggles with cancer and the effects of radiation, the client may experience severe or overwhelming fatigue which needs reported to the primary healthcare provider. a. INCORRECT. Nausea and vomiting, along with other gastrointestinal symptoms, are usually associated with the use of chemotherapy and not necessarily radiation therapy.

A client is to begin external beam radiation for Ewing's sarcoma. What symptoms would the nurse teach the client to expect during radiation treatments? Select All That Apply a. Nausea and Vomiting b. Skin shedding c. Erythema with pain d. Pancytopenia e. Exhaustion

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

A client presents to the emergency department (ED) with flu symptoms, fever, and chills. The nurse notes that the vital signs are: T 102.8°F (39.3°C), P 128, RR 30, B/P 154/88. ABG results are: pH-7.5, PaCO2 32, HCO3 23. What acid/base imbalance does the nurse determine that this client has developed? Choose One a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

b. Obtain client's blood pressure. c. Auscultate lung sounds. b. and c. Correct: The client is dizzy and weak. This client is at risk for falling, so think safety and get the client back in bed. Use a wheelchair to accomplish this. Then obtain the client's BP. It may be low, indicating poor tissue perfusion to the vital organs. One cause of premature ventricular contractions (PVCs) includes heart failure, so assess the lungs for adventitious sounds. a. Incorrect: This client is dizzy and weak. Having the client ambulate back to the bed is a safety risk. The client could fall or the condition could deteriorate while ambulating. d. Incorrect: Cardioversion is not indicated with an underlying rhythm that is normal (NSR) with PVCs. Oxygen may decrease the PVCs. If not, medication can be administered to decrease the rate of the PVCs. e. Incorrect: Oxygen may abate the PVCs; however, it should be initiated at 2 liters/NC rather than at 100% per nonrebreather mask. Start with the least amount of oxygen that could relieve symptoms.

A client reports dizziness and weakness while walking down the hall. The nurse notes the client's cardiac rhythm displayed on the telemetry monitor. What actions should the nurse take? Exhibit Select All That Apply a. Assist client in ambulating back to bed. b. Obtain client's blood pressure. c. Auscultate lung sounds. d. Prepare for cardioversion. e. Initiate 100% oxygen per nonrebreather mask.

c. Semi-fowler's c. Correct: After any major abdominal surgery, the position of choice is to elevate the head of the bed 35-45 degrees. This will decrease pressure on the abdomen and suture line. a. Incorrect: Sims' is a semi-prone position where the client assumes a posture halfway between lateral and prone. This is used for clients who need their airway protected. b. Incorrect: Prone is not recommended. This will put more pressure on the suture line and abdomen. d. Incorrect: Slightly side lying would be okay if the head of the bed was elevated to decrease abdominal and suture line pressure. The best position is semi-fowler's immediately post op.

A client returns to the room post appendectomy. In what position should the nurse place the client? Choose One a. Sims' b. Prone c. Semi-fowler's d. Right lateral

b. Place personal items within easy reach. c. Maintain eye patch over right eye. d. Administer antiemetic for reports of nausea. b, c, and d are correct. Place all personal articles and the call light within reach. These measures prevent stretching and straining by the client. An eye patch or shield will prevent injury to the affected eye. We do not want the client to vomit, so admiister an antiemetic for reports of nausea. Vomiting will increase intraocular pressure. "a" is incorrect. Approach the client on the unaffected side. This approach facilitates eye contact and communication. "e" is incorrect. The goal is to prevent anything that will increase intraocular pressure. That means coughing should be avoided. "f" is incorrect. Lying prone will increase intraocular pressure. After surgery for a detached retina, the client is positioned so that the detachment is dependent. For example, if the outer portion of the right retina is detached, the client is positioned on the right side. Positioning so that the detachment is inferior maintains pressure on that area of the retina, improving its contact with the choroid.

A client returns to the unit post scleral buckling of the right eye. Which nursing interventions should the nurse include? a. Approach the client from the right side. b. Place personal items within easy reach. c. Maintain eye patch over right eye. d. Administer antiemetic for reports of nausea. e. Assist client to turn, cough, and deep breathe every 2 hours. f. Place client prone for 1 hour.

a. Assess entry and exit wound. b. Monitor vital signs. c. Place on a spine board. d. Connect to cardiac monitor. f. Apply cervical collar to neck. a., b., c., d., and f. Correct: You need to understand that high-voltage current of electricity damages the vascular system and the nerves nearby. This alteration in the vascular system can damage vital organs, so we worry about organ failure. Electrical burns have two wounds: an entrance burn wound that is generally small and an exit burn wound that is much larger. The electricity goes throughout the body causing damage, and then exits the body. So look for 2 burn wounds. Remember, vessels, nerves, and organs can be damaged. The nurse needs to monitor vital signs frequently, especially those assessing the respiratory and cardiac systems, since we worry about organ damage. Electricity can damage the heart muscle, so the client is at risk for dysrhythmias within 24 hours following an electrical burn. Put the client on continuous cardiac monitoring during this time. Why place the client on a spine board and put a c-collar on? Contact with electricity can cause muscle contractions strong enough to fracture bones, or vertebrae. The force of the electricity can actually throw the victim forcefully. e. Incorrect: This statement is false. The rule of nines is not used for electrical burns, but for thermal burns. Most of the damage from electrical burns is internal and cannot be determined by using the rule of nines.

A client sustains a high-voltage electrical injury while at work. Which interventions should the occupational health nurse initiate? Select All That Apply a. Assess entry and exit wound. b. Monitor vital signs. c. Place on a spine board. d. Connect to cardiac monitor. e. Perform the rule of nines. f. Apply cervical collar to neck.

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

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

b. The prescribed opioid does not relieve the pain. d. The pain in the forearm is described as a 9 on a 10 scale and throbbing. b. and d. Correct: Compartment syndrome occurs when swelling occurs within the compartment. This results in increased pressure on the capillaries, nerves, and muscles in the compartment. The pain is very intense. The client is expressing pain at a 9 on a 10 scale and throbbing. The pain is also unrelieved by opioid administration. a. Incorrect: The location of pain at the elbow area does not indicate the presence of compartment syndrome. The pain related to compartment syndrome would not occur in the elbow. The swelling and bleeding will occur in the compartment of the forearm due to the swelling or bleeding. c. Incorrect: The swelling will not be reduced by elevating the forearm as result of the constant increased pressure in the compartment. e. Incorrect: Applying a cold compress on the forearm that decreases the swelling is not a symptom of compartment syndrome. The increased pressure in the compartment results in a decrease of the blood flow to the muscles and nerves.

A client was diagnosed with a fractured ulna 8 hours ago. Which assessment data may indicate a compartment syndrome? Select All That Apply a. The pain is located at the elbow area. b. The prescribed opioid does not relieve the pain. c. When forearm is elevated, the swelling in the forearm is reduced. d. The pain in the forearm is described as a 9 on a 10 scale and throbbing. e. When placing a cold compress on the forearm, the pain level is reduced.

338 The American Burn Association formula is 2 - 4mL x weight in kilograms x total surface area burned. Based on the Rule of Nines for adults, a leg is 9% on the front and 9% on the back, which includes the feet. So both legs equal 36% (9% times 4) total surface area burned. The standard multiplier for thermal burns is considered to be 2 mL. Therefore: 2mL x 75 kg x 36 = 5,400 mL for 24 hours. Half that amount, or 2700 mL, should be infused in the first eight hours. Dividing that amount by 8 hours, the infusion rate would be 338 mL per hour.

A client weighing 166 pounds (75 kg) is brought to the emergency room with burns to the front and back of both legs and feet. Using the American Burn Association formula to calculate the amount of fluid needed for the first 24 hours, the nurse should set the infusion rate at what for the first eight hours? (Round to nearest whole number).

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

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

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

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

a. "I will ask your primary healthcare provider to increase your dose of medication." a. Correct: There is no ceiling on the dose of an opioid for a cancer client. Dosage is only limited by side effects. It is client dependent, so this is an appropriate response by the nurse. b. Incorrect: This statement is not true for the cancer client and would be an inappropriate response by the nurse. c. Incorrect: This client is dying. We are not worried about addiction. We are worried about easing the pain and helping the client die with as little to no pain as possible. d. Incorrect: Lemon essential oil is helpful in decreasing nausea. It is not useful in relieving pain. At this stage in the client's illness, opioid medication is the "gold standard".

A client who has terminal cancer tells the nurse that the opioid prescription, which is at the highest recommended dose, is not relieving the pain. What should the nurse tell the client? Choose One a. "I will ask your primary healthcare provider to increase your dose of medication." b. "You cannot have a higher dose of pain medication since you are at the maximum dose." c. "Opioid addiction is a major concern. You don't want to take too much of this medication." d. "Let's try some lemon essential oil to decrease your pain level."

a. Liver c. Ibuprofen d. Sardines e. Ascorbic acid a, c, d, and e are correct. The following foods can cause a false positive reading: red meats, liver, turnips, broccoli, cauliflower, melons, salmon, sardines, and horseradish. Medications altering the test include aspirin, ibuprofen, ascorbic acid, indomethacin, colchines, corticosteroids, cancer chemotherapeutic agents, and anticoagulants. Ingestion of vitamin rich foods can cause a false negative result. "b" is incorrect/false. A tomato is not on the food list for false positive reading and does not have to be avoided.

A client who needs to have a stool speciman for an occult blood test is instructed by the nurse to avoid which substances two hours prior to testing? Select all that apply. a. Liver b. Tomato c. Ibuprofen d. Sardines e. Ascorbic acid

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

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

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

A client with chronic liver disease has ascites and is being treated with an albumin infusion. What should the nurse anticipate and monitor in this client? Choose One a. Fluid volume excess b. Cellular edema c. Severe hypotension d. Decreasing CVP

a. Hematocrit c. Potassium d. Creatinine a., c., and d. CORRECT. The physiology of the body changes significantly following a major burn. Hematocrit increases as the fluid from the vascular spaces leaks into the interstitial tissues. Because of lysis of cells, potassium is released into the circulation, leading to hyperkalemia. The kidneys are impacted by the decreased cardiac output as well as the myoglobin released by the lysed cells. This causes creatinine to become elevated. b. INCORRECT. Albumin, a body protein, is lost through the damaged skin areas and secondary to increased capillary permeability. e. INCORRECT. Magnesium is a major electrolyte necessary for both muscle and nerve function. Since the body does not produce magnesium naturally, humans need a well-balanced diet which includes a variety of vegetables and seeds. Levels of magnesium are not affected during the initial period after a burn.

A client with deep partial thickness burns to arms and legs is admitted to the burn unit. The nurse knows elevated results are most likely to be noted initially in what laboratory tests? Select All That Apply a. Hematocrit b. Albumin c. Potassium d. Creatinine e. Magnesium

c. "Buspirone does not depress the central nervous system like lorazepam does, so you should not have as much sedation." Buspirone does not depress the central nervous system and is believed to produce the desired effects through interaction with serotonin, dopamine, and other neurotransmitters. "a" is incorrect. Buspirone takes 1-2 weeks to take effect and can take up to 4-6 weeks to achieve full clinical benefits. Lorazepam is a benzodiazepine and begins to work within a few hours to 1-2 days. "b" is incorrect. The client should not stop taking any antianxiety medication abruptly. Serious withdrawal symptoms can occur: depression, insomnia, anxiety, vomiting, sweating, convulsions, delirium. "d" is incorrect. The nurse should be able to discuss medication administration with the primary HCP.

A client with the diagnosis of mild anxiety asks the nurse why the primary HCP switched medications from lorazepam to busipirone. What should the nurse tell the client? a. "Lorazepam takes longer to start working than buspirone, so the primary HCP decided to switch medications." b. "Buspirone can be stopped quickly if necessary." c. "Buspirone does not depress the central nervous system like lorazepam does, so you should not have as much sedation." d. "You need to ask your primary HCP why the medication was changed from lorazepam to buspirone."

a. Pain c. Muscle spasm d. Bone displacement a., c., and d. Correct: The purpose of traction is to stabilize and realign bone fractures and reduce pain. If the skeletal traction is interrupted by losing the traction on the bone, the result may include pain, muscle spasm, and bone displacement. b. Incorrect: Foot drop is the weakness or paralysis of the muscles that lift the front part of the foot. Causes of foot drop may include; nerve injury, muscle or nerve disorders, brain and spinal cord disorders, and immobility. e. Incorrect: The client would not experience any itching under any straps or cords due to the accidental release of the skeletal traction.

A client's skeletal traction has been accidently released. What signs/symptoms does the nurse expect to see? Select All That Apply a. Pain b. Foot drop c. Muscle spasm d. Bone displacement e. Itching under the straps

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

A client, admitted to the surgical unit post left thoracotomy, is drowsy. Vital signs on admit are T 99.8ºF (37.6ºC), HR 94, R 16/shallow, BP 100/68. ABGs are pH 7.33, PCO2 48, HCO3 24. What action should the nurse initiate? Choose One a. Have client take deep breaths. b. Administer naloxone. c. Tell the client to breathe faster. d. Medicate for pain.

c. CDU is sitting upright on the bedside table with fluid levels as prescribed. e. 190 mL of drainage noted in drainage collection chamber at 8 PM. c. and e. Correct: Do you see the problem with the bedside table? Yes! It's too high! The chest tube system should always be kept below the level of the chest to prevent backflow of drainage or air into the pleural space. You want to promote gravity drainage. The next problem that we see is excessive drainage. The chest tube was inserted at 5 PM and the client was admitted to the unit 2 hours later. The amount of drainage at upon arrival at 7 PM was 80 mL. At 8 PM, there was 190 mL of drainage. This is 110 ml of drainage in one hour. Drainage of 100 mL or greater any hour after the first hour is considered excessive. The healthcare provider would need to be notified of this amount of drainage. a.. Incorrect: Gentle, continuous bubbling in the suction control chamber is normal. b. Incorrect: Intermittent bubbling in the water seal chamber when the client coughs, sneezes, or exhales is considered normal. d. Incorrect: A slight rise and fall (fluctuation) of the water in the water seal chamber as the client breathes is called tidaling and is normal.

A client, who received blunt chest trauma from an all-terrain vehicle accident, is admitted to the unit at 7 PM following insertion of a chest tube at 5 PM. The drainage collection chamber has 80 mL of drainage present upon arrival to the unit. Which assessment finding would be of concern to the nurse? Select All That Apply a. Continuous bubbling is occurring in the suction control chamber. b. Intermittent bubbling is noted in the water seal chamber. c. CDU is sitting upright on the bedside table with fluid levels as prescribed. d. Slight fluctuations of water level in water seal chamber with respirations. e. 190 mL of drainage noted in drainage collection chamber at 8 PM.

d. Reinforce the importance of the fluid restriction with the client. d. Correct: Educate the client on appropriate choices and lifestyle changes that are necessary to manage the client's condition. a. Incorrect: It is ultimately the client's choice to drink a soft drink. Education will help the client make an informed decision. b. Incorrect: The nurse should reinforce the purpose of fluid restriction, not just document noncompliance. Perhaps it is just a matter of lack of knowledge. c. Incorrect: The client has the right to make choices and the nurse should reinforce teaching.

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

d. Client with an open chest wound that is beginning to show signs of tacheal deviations. b. Client with blunt trauma to the spine that is unable to move extremities. c. Client with a 4 inch (10.16 cm) laceration to the lower leg with moderate bleeding. a. Client with traumatic amputations with agonal respirations. d. The client with a open chest wound should be seen first. This client is one whose life could potentially be spared if lifesaving measures are taken. This client may be developing a pneumothorax and may need an immediate needle decompression. The client would also need a dressing that is taped down on 3 sides applied over the chest wound. b. The second client to be seen is the one with blunt trauma to the spine. Although this client needs emergency treatment ASAP due to having probable spinal infury with paralysis, this client's condition is not likely to deteriorate as fast as the client with the open chest wound who is developing a tension. c. The third client to be assessed by the nurse should be the client with the laceration. Did you see laceration with bleeding adn think that something would have to be done immediately? Well, there is only moderate bleeding, so although this client needs obvious treatment, this client can wait and would not be a priority over the clients with the open chest wound and the blunt trauma to the spine. d. The last client to be assessed should be the client with agonal respirations. Although this client is still alive, during a mass casualty, the nurse would recognize that the client has agonal respirations and would not have a very good chance of survival with intervention. This client would not take priority over a critical client who has a better chance of survival.

A mass casualty disaster has occurred and clients are being received at the emergency department. In what order should the nurse assess these clients? Sort from highest priority to lowest priority. a. Client with traumatic amputations with agonal respirations. b. Client with blunt trauma to the spine that is unable to move extremities. c. Client with a 4 inch (10.16 cm) laceration to the lower leg with moderate bleeding. d. Client with an open chest wound that is beginning to show signs of tacheal deviations.

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

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

c. Administer the prescribed analgesic. The client described in this question is port-thoracotomy. With ANY post-op client, the number one concern, especially as a brand new nurse, is preventing pneumonia. A thorocotomy is very painful and the client is unlikely to breathe deeply unless the pain is relieved; this is why the respirations are shallow. Temperature of 100 degrees F (37.8 degrees C), HR 92, RR 24, bilateral crackles (indicating atelectasis) all reveal this client is heading for pneumonia. Pain needs to be controlled first so the client can take deep breaths to prevent pneumonia. "a" is incorrect because the client will not deep-breathe if the client is in severe pain. "b" is incorrect because 100 degrees F is not a fever and acetaminophen is not potent enough to reliece pain from a thorocotomy. "d" is incorrect because although ambulation is important post-surgery, another problem should be prioritized first.

A nurse is caring for a client on the second day after a thoracotomy, reporting incisional pain. The nurse assesses the client and evaluates the vital signs. Based on the data documented in the chart, what action should the nurse take first? a. Have the client cough and deep breathe. b. Administer acetaminophen for fever c. Administer the prescribed analgesic. d. Assist the client to ambulate

b. Calcium 12 mg/dL (3 mmol/L) d. Phosphate 2.8 mg/dL (0.9 mmol/L) b. and d. Correct: Normal calcium range is 9.0 -10.5 mg/dl (2.25-2.62 mmol/L). The client's calcium level is 12 mg/dL (3 mmol/L) which is above normal range. Parathyroids secrete parathormone (PTH) for remodeling of the bones. PTH stimulates transfer calcium from the bone to the blood. Parathyroidism, an excess of PTH production by the parathyroids, will result in an increase in calcium movement from the bone to the blood. The normal range for phosphate is 3.0 - 4.5 mg/dL (0.97-1.45 mmol/L). The client's phosphate level is 2.8 mg/dL (0.9 mmol/L) which is below normal range. Parathyroidism, an excess of PTH production by the parathyroids, reduces the reabsorption of phosphorus in the kidneys. The result is that there is an increase in the excretion of phosphorus in the urine resulting in a decreased serum phosphorus level. a. Incorrect: The normal range for BUN is 10-20 mg/dl (3.6-7.1 mmol/L). The client's BUN level is 12 mg/dL (4.28 mmol/L). c. Incorrect: The normal range for sodium is 135 - 145 mEq/L (135-145 mmol/L). The client's sodium level is 140 mEq/dL (140 mmol/L). e. Incorrect: The normal range for potassium is 3.5 -5.0 mEq/L (3.5-5.0 mmol/L). The client's potassium level is 3.5 mEq/dL (3.5 mmol/L).

A nurse is caring for a client with a possible diagnosis hyperparathyroidism. Which serum laboratory value would validate this diagnosis? Select all that apply. a. BUN 12 mg/dL (4.28 mmol/L) b. Calcium 12 mg/dL (3 mmol/L) c. Sodium 140 mg/dL (140 mmol/L) d. Phosphate 2.8 mg/dL (0.9 mmol/L) e. Potassium 3.5 mEq/L (3.5 mmol/L)

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

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

d. Calcitriol capsule .25 mg PO AM and PM The Institute of Medicine recommends the use of a leading zero for any dose less than one measurement unit. A zero should be placed in front of the decimal point (0.25) to avoid a medication error.

A nurse is reviewing the medication administration record of a patient who was transferred from another facility. Which of the following medication orders would the nurse question? a. Lanoxin 125 mcg PO daily b. Lanoxin 125 mcg PO every morning c. Calcitriol capsule 0.25 mg PO q12h d. Calcitriol capsule .25 mg PO AM and PM

c. States hands are tingling. c. Correct. Hypocalcemia is a severe complication of a thyroidectomy due to damage to the parathyroid. The negative feedback of a low parathyroid hormone (PTH) results in a decrease in serum calcium. PTH regulates the amount of calcium levels in the blood. Symptoms of hypocalcemia include numbness, and tingling on the extremities and face. As the calcium levels decrease the client may present with tetany and spasm of the larynx. a. Incorrect: The postoperative diet for a client post thyroidectomy begins with ice chips and progresses to a liquid diet for approximately 2 days, and then a soft diet. The last dietary step is diet as tolerated. As the diets progress, the nurse should assess the ability of the client to swallow and changes in the voice such as hoarseness may indicate swelling. b. Incorrect: On the 3rd postoperative day the client's bed can be positioned at 15 degrees. The nurse should monitor the client's airway for any problems with breathing. If the client experiences any airway difficulty, the nurse should change the bed to a semifowlers or high fowlers position. d. Incorrect: Whenever a client problem such as pain is identified, a nursing intervention must address the problem. The priority intervention is to address the assessment of the client stating that their hands are tingling. Symptoms of hypocalcemia include numbness and tingling of the extremities and face.

A nurse on a surgical unit is assigned a client who had a total thyroidectomy 3 days ago. As the nurse enters the room which nursing assessment is the priority for this client? Choose one. a. Eating a soft diet. b. Positioned at 15 degrees in bed. c. States hands are tingling. d. Expresses frontal neck pain level of 5 out of 10.

d. Aminoglycoside d. Correct: Aminoglycoside antibiotics are nephrotoxic. Nephrotoxic medications can cause damage to the kidneys. Examples of aminoglycoside antibiotics are tobramycin, gentamicin, streptomycin, and paromomycin. Clients with kidney damage should not be prescribed aminoglycoside antibiotics. a. Incorrect: Opioid medications are not classified as nephrotoxic. b. Incorrect: Antidiabetic medications are not classified as nephrotoxic. c. Incorrect: Corticosteroid medications are not classified as nephrotoxic.

A nursing instructor is presenting a discussion on nephrotoxic medications? Which class of medications would the instructor discuss? Choose One a. Opioids b. Antidiabetic c. Corticosteroids d. Aminoglycoside

b. Ensure that circulation to extremities is not compromised. c. Assist client with needs related to nutrition and elimination. d. Provide help with personal hygiene. e. Renew restraint prescription in 4 hours if needed. b., c., d., and e. Correct: These are correct interventions for safety when a violent client requires restraints. When applying restraints you do not want the restraint so tight that extremity circulation is diminished. The client must still be provided with proper nutrition, hydration, and allowed to go to the restroom. If the client is restrained, the client will need help with basic care and comfort measures. Prescriptions for restraints used on an adult client must be renewed every 4 hours if needed. a. Incorrect: The client in restraints should be observed every 15 minutes. Safety of the client is extremely important. Physical needs, such as food and toileting, should also be addressed.

A primary healthcare provider has prescribed restraints for a violent adult client. Which measures would the nurse provide as proper interventions for this client? Select All That Apply a. Observe the client in restraints every hour. b. Ensure that circulation to extremities is not compromised. c. Assist client with needs related to nutrition and elimination. d. Provide help with personal hygiene. e. Renew restraint prescription in 4 hours if needed.

c. Gather and apply dressings to open wounds. An LPN/VN's scope of practice includes tasks such as wound care. Covering open wounds will help decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. If the LPN notes any serious bleeding situations, it would need to be reported immediately to the RN. "a" is incorrect. Although it will be crucial to identify each incoming client, the LPN/VN's scope of practive does not include assessment. THat task would require an RN or primary healthcare provider. "b" is incorrect. In a mass casualty situation, triage allows the nurse or primary healthcare provider to quickly determine which clients are critical versus those stable enough to wait. Because this involves assessment, an LPN/VN would not be assigned this task. "d" is incorrect. Initiating intravenous lines is not within the scope of practice of the LPN/VN. Additionally, the decision to apply oxygent involves assessment of the respiratory system, which also is not within the LPN/VN's scope of practice.

An LPN/VN has been floated to the emergency room following a chemical plant explosion. What task would be best to assign to the LPN/VN? a. Identify and assess each incoming client. b. Triage and assign color-coded tags to each client. c. Gather and apply dressings to open wounds. d. Initiate oxygen and IV lines as needed.

d. Assign a staff member to stay with the client. d. CORRECT. The client is newly admitted following a repeat suicide attempt and therefore safety is the priority issue. The client should not be left alone, even when using the bathroom, until the primary healthcare provider determines the risk of suicide has abated. a. INCORRECT. A suicidal client is never left unattended immediately after admission. Checking the client just once an hour increases the potential risk for another suicide attempt. b. INCORRECT. Demanding an explanation of the client is not an appropriate nursing action and is non-therapeutic. Some clients may be unable to provide an answer while others may be unwilling to discuss the situation with the nurse. This does not focus on client safety. c. INCORRECT. A suicidal client should not be placed in seclusion, and definitely not in a darkened environment. Such actions do not provide a safe environment for the client and may increase the risk for another suicide attempt.

An adolescent is admitted to the psychiatric unit following a repeat suicide attempt. What is the nurse's priority action? Choose One a. Have staff check on client once every hour. b. Ask client to explain why suicide was a choice. c. Place client in quiet seclusion with lights off. d. Assign a staff member to stay with the client.

c. The changes in vital signs indicate an expected response to fluids c. CORRECT. The purpose of infusing large amounts of fluid into burn victims during the first 24 hours is to help maintain perfusion until the body's physiology returns to normal functioning. The serial vital signs indicate the cardiovascular system is stabilizing, as evidenced by pulse decreasing to the normal range while blood pressure increases. Though respirations are still slightly elevated, the client would likely be experiencing pain. Most importantly, the CVP (central venous pressure) has increased to the normal range, indicating the fluid replacement is adequate at this time. a. INCORRECT. There is no evidence indicating possible cardiac overload. The client's vital signs are stabilizing and the central venous pressure (CVP) has returned to normal limits. b. INCORRECT. When fluid replacement is calculated for burn clients, the amount is based on client weight in kilograms and total surface area burned. Those parameters do not change during the initial treatment. Therefore the amount of fluid needed during the first 24 hours remains unchanged until after that time frame, even if vital signs improve. d. INCORRECT. The hourly data does not reflect deterioration. Vital signs are slowly returning to within normal range and there is no mention in the scenario about the extent of burns.

An elderly client with partial and full-thickness burns has begun receiving fluids at 600 ml/hour, as determined by the Parkland (Consensus) Formula. Based on the assessment data for the first four hours, what should the nurse report to the primary healthcare provider? Choose One a. The cardiovascular system is becoming seriously overloaded b. The speed of the IV should be reduced since CVP is now normal c. The changes in vital signs indicate an expected response to fluids d. The client is deteriorating because of age and extent of the burns

a. Lack of experience of the new graduate RN. The new graduate RN may not have the knowledge, assessment skills, and experience needed to care for clients who are unstable or have complex health issues. Follow the 5 Rights of Delegation: right task, right person, right circumstance, right direction, right supervision. "b" is incorrect. Preferences should not guide delegation decisions. This takes the focus off of what is best for the client and places focus on the nurse. "c" is incorrect. The possibility for conflict when delegation decisions are made should not influence these decisions. "d" is incorrect. Although is seems "fair" that each nurse have the same number of clients, the delegation decisions should be based on the experience of the new nurse. Client safety could be compromised by assigning the new RN to clients who are unstable or have complex health issues. Delegation to the LPN must include consideration of the LPN's scope of practice.

An experienced RN snf zlpn are working with an RN who has just recently passed the NCLEX. THe team is assigned to care for 12 clients on the medical-surgical unit. Which factor is most important to consider when delegating? a. Lack of experience of the new graduate RN. b. The preferences of the LPN who has experience. c. The RN's desire to avoid confrontation. d. The assignment of equal number of clients to the RN, the LPN, and the new nurse.

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

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

12500 The metric symbol for the prefix "hecto" is "h," the starting place on the metric line. The metric symbol for the prefix "centi" is "c," the desired place. To convert from the hecto place to the centi place, the decimal point is moved four places to the right. The answer is 12500 cg.

Convert 1.25 hectograms (hg) into centigrams (cg). Use the metric line to solve the problem. Include only the numeral (not the units) in your answer.

d. Glycosylated hemoglobin level (HbA1C) d. Correct: The glycosylated hemoglobin (Hb A1C) test identifies the average serum glucose attached to hemoglobin over 90 days. The 90 days is correlated with 90 day life of hemoglobin. This test is reflective of how well the client's diabetes is controlled. The client has no restrictions prior to the test. a. Incorrect: A fasting blood level indicates only the glucose level for at least 8 hours. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. b. Incorrect: Urine glucose testing is not an accurate reflection of blood glucose level and does not identify the average glucose level over a prolonged time. The test will identify whether there is an elevated amount of glucose in the urine. c. Incorrect: Glucose tolerance requires the client fast for the first serum sample and then drink a glucose drink with serum samples taken at specified times. This client has not fasted prior to the office visit. This test is not appropriate at this time.

During a clinic visit 3 months following a client's diagnosis of type 2 diabetes, the client reports following a 1200 calorie diet and did not bring their glucose-monitoring record. The nurse will anticipate the prescription of which laboratory test? Choose one. a. Fasting blood glucose test b. Urine glucose test c. Glucose tolerance test (GTT) d. Glycosylated hemoglobin level (HbA1C)

a. Request to change IM antiemetic medication to oral pill. c. Obtain client's temperature at least every two hours. e. Remove fresh flowers and limit visits from children. a., c., and e. CORRECT. The client has neutropenia, an extreme decrease in the neutrophils of white blood cells. As the main infection fighting faction of WBCs, the client will be at great risk for infection. Reducing invasive procedures by eliminating an intramuscular injection is an important and positive change. Fever is generally an early sign of infection, so taking the client's temperature frequently may alert staff to problems before a serious complication occurs. Fresh flowers contain a variety of bacteria that could be deadly to this client while children are often carriers of viruses without actually showing indications of illness. b. INCORRECT. Actually, clients with neutropenia are instructed to avoid fresh or raw fruits and vegetables since even proper handling and cleaning can leave traces of bacteria behind. d. INCORRECT. Although the client should be placed in a private room with a closed door, negative airflow is not necessary. This type of room is reserved for those with active tuberculosis.

Following chemotherapy for acute lymphocytic leukemia (ALL), the client's lab results indicate a white blood count of 1000 cells mm3. What measures should the nurse institute immediately? Select All That Apply a. Request to change IM antiemetic medication to oral pill. b. Have client increase fresh fruits and vegetables in diet. c. Obtain client's temperature at least every two hours. d. Move client into isolation with a negative flow room. e. Remove fresh flowers and limit visits from children.

a. Respiratory acidosis e. Uncompensated a. and e. Correct. Now will a pH of 7.30 make the patient have acidosis or alkalosis? Well it's less than 7.35 so that's a low pH, and you know that a low pH is acidosis. So now we know acidosis, but we still must figure out if it is respiratory or metabolic. Look at the PaCO2, it is 55. That's a lot of CO2, and it's greater than the normal range of 35-45, so the PaCO2 must be acidosis. Now the Bicarb is 25, and a Bicarb of 25 is within the normal range of 22-26. To determine whether this is respiratory or metabolic acidosis, we need to match the pH with either the PaCO2 or the HCO3. The pH that we're trying to match is acidosis, so keep in mind you're trying to match the word acidosis with one of the chemicals. Well look at our problem, the CO2 is also acidosis. So, since these two match and they are both acidosis, we can say this is clearly Respiratory Acidosis because the "respiratory" chemical (CO2) is the one that matches the pH. Now, look at the Bicarb level. The bicarb is normal and doesn't match our pH which is acidosis, so, we can just mark it out. There you have it; this is Respiratory Acidosis. So, is there any compensation going on? No, not yet. The bicarb is still within normal limits. These values indicate uncompensated respiratory acidosis. b. Incorrect. The pH would need to be above 7.45 and the PaCO2 below 35 for the client to have respiratory alkalosis. c. Incorrect. The pH would need to be below 7.35 and the Bicarb below 22 for the client to have metabolic acidosis. d. Incorrect. The pH would need to be above 7.45 and the Bicarb above 26 for the client to have metabolic alkalosis. f. Incorrect. When partial compensation begins, the bicarb level will be above 26 as it goes UP to put more base in the body. g. Incorrect. Full compensation will occur when the pH comes back to normal.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? Select All That Apply a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis e. Uncompensated f. Partially compensated g. Fully compensated

c. Metabolic acidosis g. Fully compensated c. and g. Correct. These ABG values indicate metabolic acidosis. The pH is normal, but it is on the acidosis side of normal at 7.35. Now, which other chemical says acidosis? Look at the bicarb; the bicarb is low, indicating acidosis so there's your match! The bicarb matches the pH. What chemical problem does the bicarb relate to - respiratory or metabolic? It's metabolic. Metabolic acidosis. Has compensation begun? Yes. The lungs are compensating for the metabolic acidosis by getting rid of CO2, which is an acid. Therefore, the PaCO2 is below the normal range of 35-45. Since the pH is normal, full compensation has occurred. a. Incorrect. For this problem to indicate respiratory acidosis, the pH would need to be less than 7.35 (or if fully compensated, the pH would be less than 7.40 to be on the acidotic side of normal) and the CO2 would need to be greater than 45. In this problem, we see the CO2 has been blown off to help get rid of the acid. b. Incorrect. This is not a respiratory problem. The lung chemical, carbon dioxide does not match the acidotic pH. The pH indicates acidosis, not alkalosis. d. Incorrect. Metabolic alkalosis would have pH greater than 7.45 (or if fully compensated, the pH would be greater than 7.40 to be on the alkalotic side of normal) and a Bicarb level greater than 26. The pH is on the acidosis side of normal, and the bicarb (metabolic chemical) indicates acidosis here. The lungs have compensated by bringing down the CO2 level to decrerase the acidotic state. d. Incorrect. The pH is normal even though the PaCO2 and the bicarb values are abnormal so compensation has occurred. The pH would be abnormal and the PaCO2 would be normal if compensation had not begun. This client has fully compensated. e. Incorrect. The pH is normal even though the PaCO2 and the bicarb values are abnormal so compensation has occurred. With partial compensation, the pH, PaCO2, and bicarb would all be abnormal. This client has fully compensated.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? Select All That Apply a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis e. Uncompensated f. Partially compensated g. Fully compensated

d. Metabolic alkalosis g. Fully compensated d. and g. Correct. The pH is on the alkalosis side of normal (7.35-7.45). Anything above 7.0 is on the alkalotic side of normal. Look at the CO2. The CO2 is high, which indicates acidosis, so this does not match the alkalotic pH, does it? No. Look at the Bicarb. The bicarb is high, indicating alkalosis, so there is your match. The bicarb is higher than 26, so there is a lot of base in the body. So, this is metabolic alkalosis. Has compensation begun? Yes. The PaCO2 is high. The lungs are attempting to compensate by holding on to carbon dioxide, an acid, to make the pH normal. Since the pH is normal, full compensation has occurred. a. Incorrect. For this problem to indicate respiratory acidosis, the pH would need to be less than 7.35 (or less than 7.40 if fully compensated to be on the acidotic side of normal) and the CO2 would need to be greater than 45. This pH does not indicate acidosis, so the lungs are not the problem. The lungs are compensating for a metabolic problem. b. Incorrect. This is not a respiratory problem. The lung chemical, carbon dioxide is high, which would cause acidosis. However, this does not match the alkalotic pH. The pH indicates alkalosis, not acidosis. c. Incorrect. The pH would need to be below 7.35 (or if fully compensated, the ph would be less than 4.0 to be on the acidotic side of normal) and the Bicarb below 22 for the clint to have metabolic acidosis. e. Incorrect. The pH is normal even though the PaCO2 and the bicarb values are abnormal, so compensation has occurred. The pH would be abnormal and the PaCO2 would be normal if compensation had not begun. This client has fully compensated. f. Incorrect. The pH is normal even though the PaCO2 and the bicarb values are abnormal so compensation has occurred. With partial compensation, the pH, PaCO2, and bicarb would all be abnormal. This client has fully compensated.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? Select All That Apply a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis e. Uncompensated f. Partially compensated g. Fully compensated

b. Trousseau's sign noted when taking blood pressure. When a client begins to lose large amounts of stool, important electrolytes, such as magnesium, are also lost. The presences of Trousseau's sign indicates the client has developed hypomagnesemia or hypocalcemia, and is at risk for more serious problems. The nurse should notify the primary HCP immediately. "a" is incorrect. Many health issues can contribute to fatigue, including hospitalization, illness, and tube feedings. Dehydration secondary to the feedings could increase fatigue and the nurse will need to investigate further. However, another symptom is more concerning. "c" is incorrect. Resisting care could be related to the discomfort of frequent turning and cleaning of the skin breakdown. It is important for hospitalized patients to remain mobile if possible. They should also be encouraged to participate in their care. "d" is incorrect. There is no data on why the patient is hospitalized. Therefore, abdominal cramping may already be an existing symptom and not concerning.

Staff notifies the nurse that the client receiving tube feedins has increased liquid stool with new rectal excoriation. Following an assessment, the nurse is most concerned about what additional symptom? a. Reports feeling increasingly tired. b. Trousseau's sign noted when taking blood pressure. c. Increased resistance to care activities. d. Reports of abdominal cramping.

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

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

58 Answer: 58 units per day 97 kg x 0.6 units = 58.2 units = 58 units The average adult dose of insulin is 0.4-1.0 units/kg/day. Rounding Rules for Whole Units: 0.1 -0.4 = round down to whole unit 0.5-0.9 = round up to whole unit

The client has been prescribed 0.6 units of insulin/kg /day. The client weighs 214 pounds (97 kg). What is the amount of insulin the client can receive in a day? (Round to the nearest whole number)

d. Elevate the extremities in bed for 30 minutes before application. The client should have extremities elevated to encourage venous return and reduce the risk of swelling before the stockings are applied. These stockings must be the right size and fit for maximum benefit. "a" is incorrect. Placing the stockins on immediately will cause further venous stasis and swelling. "b" is incorrect. The extremities should be elevated before stocking application. "c" is incorrect. This instruction alone does not give the client adequate information about the need to keep the lower extremities elevated before applying the stockings. This also delays care.

The client needs assistance to apply anti-embolism stockins each day in the long-term care facility. Today, as the nurse enters the room to apply the stockings, she finds that the client has been walking about the unit for 30 minutes. What should the nurse do first to lesson the risk of swelling of the lower extremities? a. Ask the client to lie down and place the stockings on the legs. b. Ask the client to sit on the bedside and place the stockings on the legs. c. Tell the client that the nurse will return later to assist with the application. d. Elevate the extremities in bed for 30 minutes before application.

a. pH 7.32 b. PaCO2 32 a. and b. Correct: In DKA, the client is acidotic. Normal pH is 7.35-7.45. A pH of 7.32 indicates acidosis and will be expected for a client in DKA. Normal PaCO2 is 35-45. Remember CO2 is considered an acid. The client in DKA will have an increased respiratory rate, so the PaCO2 will either be normal or low. This value of 32 is low and is an expected finding as the body is compensating for the acidosis. c. Incorrect: Normal HCO3 is 22-26. HCO3 is a base. Initially, the acids bind to the bicarb to reduce the acid levels. Therefore, the HCO3 would be less than 22. So, in DKA, the expected initial finding is a low HCO3​. Keep in mind that with acidosis, as the body compensates later, the kidneys will retain bicarb and you will see the bicarb levels increase. d. Incorrect: Normal PaO2 is 80-100. An expected finding in DKA will be normal or increased PaO2, not decreased. e. Incorrect: The client in DKA is kussmauling to blow off the CO2 (acid), so the oxygen saturation of blood will be high if there is no respiratory issue. In this question you are not told that there is a respiratory problem, so you would not expect a low oxygen saturation level.

The emergency department nurse is monitoring a client being admitted in diabetic ketoacidosis (DKA). Which arterial blood gas value would be expected? Select All That Apply a. pH 7.32 b. PaCO2 32 c. HCO3 25 d. PaO2 78 e. SaO2 82

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

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

d. Communicating the client's impending death to the family while they are together. Communicating news of the client's impending death to the family while they are together is the nurse's most important role. It is compassionate communication. The family needs to be informed about the situation so that they are prepared for the client's death and can provide support to one another. "a" is incorrect. Providing respite time when death is imminent is not a priority. Family should be allowed to spend time with the client. They will, more than likely, want to be with the client in the last hours. "b" is incorrect. When death is imminent, education of what to expect is appropriate, but it does not take priority over compassionate communication. "c" is incorrect. Silence and listening sends a message of acceptance and comfort. Although important, allowing for expression of feelings is not more important than preparing the client for imminent death.

The hospice nurse has beed assigned a new client who is being cared for at home by family members. Based upon the client's physical assessment, the nurse is aware that the client's death is imminent. What is the nurse's most important role in the care of the family at this time? a. Providing care for the client, allowing the family to rest. b. Providing education regarding the symptoms the client will likely experience. c. Allowing the family to express their feelings and actively listening. d. Communicating the client's impending death to the family while they are together.

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

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

a. Contact The client with Hep A needs to be placed on contact precautions. Hep A can be transmitted through feces. "b" is incorrect. Hep A is not transmitted through the air. "c" is incorrect. The client does not need to be on neutropenic precautions. This is for someone with a low WBC count. "d" is incorrect. Hep A is not transmitted though droplets.

The nurse has been assigned to care for a client with Hepatitis A. Which infection control precautions will the nurse take while providing care? a. Contact b. Airborne c. Neutropenic d. Droplet

a. "I plan to elevate the head of my bed on concrete blocks so I can sleep better." e. "A low sodium diet will help decrease swelling in my legs." a. and e. Correct: Lying flat when a client has heart failure will cause excess fluid, which has pooled in the extremities while up, to move into the thorax and back up into the lungs. This is why the client can breathe better when the head of the bed is elevated. A low sodium diet decreases fluid retention which decreases preload, the amount of fluid entering the right side of the heart. So, yes, a low sodium diet can help decrease dependent edema. b. Incorrect: Salt substitutes are high in potassium and can be dangerous when taking an ACE inhibitor. ACE inhibitors block aldosterone, which causes the body to lose sodium and water and retain potassium. c. Incorrect: The client should weigh self daily, not weekly, and report a weight gain of more than 2-3 pounds (1-2 kg). d. Incorrect: This client needs to eat food low in potassium since ACE inhibitors cause the retention of potassium.

The nurse has informed a client diagnosed with heart failure about the treatment plan, including prescriptions for an ACE inhibitor and a 2 gm sodium diet. Which statement by the client would indicate to the nurse that the client understands the treatment plan? Select All That Apply a. "I plan to elevate the head of my bed on concrete blocks so I can sleep better." b. Instead of using salt, I should use a salt substitute to season my food." c. "It is important that I weigh myself weekly to monitor for weight gain." d. "I need to eat foods high in potassium while taking an ACE inhibitor." e. "A low sodium diet will help decrease swelling in my legs."

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

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

d. Prepare for immediate pericardiocentesis. d. Correct: The assessment findings point to cardiac tamponade, which is an emergency situation. Did you pick up on the classic s/s of this? Here we see the decreasing level of consciousness and evidence of poor perfusion from decreased cardiac output, distended neck veins from the backward pressure, muffled heart sounds from the fluid collection around the heart, increasing CVP, and the narrowing pulse pressure as the heart is being compressed. Treatment involves a pericardiocentesis to remove blood that has formed around the heart. The primary healthcare provider will insert a needle into the pericardial space to remove the fluid. a. Incorrect: Clopidogrel is an anti-platelet medication that will not correct cardiac tamponade. b. Incorrect: If the client were re-occluding, then the client would go to the cath lab or back to surgery. This is not the problem indicated by the signs/symptoms. c. Incorrect: A central line is not going to correct cardiac tamponade. Immediate removal of the fluid compressing the heart is needed.

The nurse is assessing a client one hour post coronary artery bypass graft surgery (CABG). Based on the assessment data, what action should the nurse take? Exhibit Choose One a. Administer stat dose of clopidogrel. b. Notify cath lab to prepare for angioplasty. c. Set up for a central catheter line. d. Prepare for immediate pericardiocentesis.

c. A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. e. A client who takes phenytoin for partial seizures. c and e are correct. A client with severe N?V after chemo is at an increased risk for ineffective oral hygiene due to vomiting, decreased oral intake, and the effects of the chemo on the oral mucosa. Phenytoin causes gingival overgrowth, swelling, and bleeding of the gums. This can make oral hygiene more difficult. "a" is incorrect. The client can perform oral hygiene with minimal assistance. Knee surgery and opioid pain medication do not interfere with oral hygiene. "b" is incorrect. Movement for one side of the body is controlled by the opposite side of the brain. This client's right hand would not be impacted by a right-sided stroke. "d" is incorrect. This client can perform oral hygiene with minimal assistance. Ther is no information in this option that would put this client at risk for ineffective oral hygiene.

The nurse is assignent five clients on a medical flood. When planning care, the nurse recognizes which clients to be at greatest risk for ineffective oral hygiene? Select all that apply. a. A client who has just had knee surgery taking opioids for pain. b. A right handing client who had a stroke affecting the right hemisphere of the brain. c. A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. d. An elderly client experiencing loss of appetite. e. A client who takes phenytoin for partial seizures.

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

The nurse is caring for a client being admitted to the emergency department after being stabbed in the chest. An occlusive dressing is covering the chest wound upon arrival. The client's condition begins to deteriorate. Assessment reveals tracheal deviation, diminished breath sounds bilaterally, and asymmetrical chest wall movement. What would be the priority nursing intervention? Choose One a. Administer high flow O2 per face mask. b. Remove the occlusive dressing. c. Notify the healthcare provider. d. Initiate rapid IV resuscitation.

c. Urine output 175 mL for one hour. c. Correct: Bumetanide is a diuretic that can be given IVP or continuous IV to provide rapid fluid removal. We know the medication is working because we have a good hourly urinary output. a. Incorrect: The heart rate is still too fast and irregular. As excess fluid is removed, the heart rate should come down to a regular rate. b. Incorrect: Pulmonary edema will cause the client to have a productive cough with pink, frothy (foamy) sputum. The presence of foamy sputum does not indicate that the medication has been effective. d. Incorrect: The respiratory rate is too fast, so the pulmonary edema has not resolved. As fluid is pulled off the body, the respiratory rate should decrease.

The nurse is caring for a client diagnosed with heart failure who has developed pulmonary edema. Which finding best indicates that bumetanide is having a therapeutic effect? Choose One a. Apical pulse 108/irregular. b. Foamy sputum. c. Urine output 175 mL for one hour. d. Respiratory rate 28/min

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

The nurse is caring for a client following a cholecystectomy. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms? Select All That Apply a. Drink between meals. b. Reduce intake of carbohydrates. c. Eat small, frequent meals daily. d. Sit semi-recumbent for meals. e. Remain upright for one hour after eating. f. Lie down on left side after eating.

d. Slight oozing of blood. d. Correct: The number 1 complication is bleeding. So slight oozing of blood is a problem. Assume the Worse! This is bleeding and you must do something. a. Incorrect: 2+/4+ is a normal pulse amplitude. We worry about 1+. b. Incorrect: This is a normal capillary refill. Remember, we want color to return within 2 seconds. c. Incorrect: Erythema is redness of the skin or mucous membranes, caused by an increased blood flow in superficial capillaries. We are worried about decreased blood flow which would be evidenced by pallor.

The nurse is caring for a client post cardiac catheterization that was performed via the right femoral artery. What assessment finding in the right lower extremity would be of concern to the nurse? Choose One a. Right pedal pulse 2+/4+. b. Capillary refill 2 seconds. c. Erythema. d. Slight oozing of blood.

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

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

a. Give one cigarette to client at a time. c. Have finger foods available at mealtime. d. Give high calorie fluids between meals. a., c., and d. Correct: We need to protect this client from hazards in their environment. They have no control or awareness of these hazards. If they smoke, only give the client one or two cigarettes at a time, or the client will light a whole pack at once. Finger foods should be provided because the cleint is too busy to stop and eat. They are also too busy to drink, so they can become dehydrated. This is why we provide high calorie fluids for them throughout the day. b. Incorrect:You are not supposed to talk a lot about the client's delusions. Let the client know that you accept their need for the belief, but that you do not believe it. e. Incorrect: We want to decrease the stimuli in this client's environment, so that means turning off the TV and radio. Any stimulating activity needs to be interrupted.

The nurse is developing the plan of care for a client admitted for the treatment of mania. Which interventions should the nurse include? Select All That Apply a. Give one cigarette to client at a time. b. Discuss delusional belief with client. c. Have finger foods available at mealtime. d. Give high calorie fluids between meals. e. Provide soothing music in room during waking hours.

c. Adolescent obesity is usually an inability to recognize signals of hunger or satiety. While all the options could be true in some cases, the mose accurate and comprehensive basis for obesity is an individual's failure to recognize, or achkowledge, signals of hunger or satiety. Neural circuitry, along with specific body hormones, drives sensations of hunger and feeling satisfied. Adolescents experience fluctuating hormones, physical changes and emotional adjustments which can disrupt body functions, including recognitions of brain signals. "a" is incorrect. Though self-esteem or concern about physical appearance is common with adolescents, it is not necessarily a cause for obesity. "b" is incorrect. Weight issues are often related to an imbalance between caloric intake and energy expenditure. While adolescents frequently snack on high-calorie junk foods in response to stress or boredom, there are more significant contributing factors for teen obesity. "d" is incorrect. It is possible that undiagnosed issues of the thyroid or pituitary could contribute to adolescent obesity. Howeverm these disorders are not common and might also lead to extreme weight loss.

The nurse is discussing information on adolescent obesity with parents of highschool students. What statement by the nurse is most comprehensive regarding obesity among teens? a. Obesity among teens is often accompanied by psychologic issues like poor self-esteem. b. Weight issues among teens are often due to excess eating out of boredom or stress. c. Adolescent obesity is usually an inability to recognize signals of hunger or satiety. d. Undiagnosed problems of the thyroid or pituitary contribute to teen obesity.

b. Produces clotting factors. c. Detoxifies the body. e. Breaks down medications. b., c., and e. Correct: Three of the four functions are listed: the liver produces clotting factors, detoxifies the body, and breaks down medications. It also synthesizes albumin. a. Incorrect: The spleen, not the liver, removes old RBCs from the body. d. Incorrect: The exocrine function of the pancreas releases digestive enzymes into the small intestine.

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

a. Nitroglycerin increased blood flow to the heart. c. Sit or lie down when taking nitroglycerin. d. The most common side effect is a headache. a., c., and d. Correct: Nitroglycerin dilates the coronary arteries to allow more oxygen to get to the heart muscle. Because nitroglycerin also dilates all arteries and veins, the client's BP will drop. So they could faint. To prevent this, they should sit or lie down when taking the nitro. The most common side effect is that the client will get a headache. It is not life threatening, but advise the client that this will occur. b. Incorrect: One Nitroglycerin can be taken SL every five minutes up to three doses. If pain is not relieved, the EMS should be activated. The client may be having an MI rather than angina. e. Incorrect: Nitroglycerin should be stored in a dark, glass bottle so that it does not lose its potency.

The nurse is educating a client newly diagnosed with chronic stable angina about Nitroglycerin SL. What points should the nurse include? Select All That Apply a. Nitroglycerin increased blood flow to the heart. b. Take one nitroglycerin every five minutes until pain stops. c. Sit or lie down when taking nitroglycerin. d. The most common side effect is a headache. e. Keep nitroglycerin in a clear, plastic bottle.

a. Annual mamogram starting at age 45. d. Colonoscopy beginning at age 45. a. and d. Correct: Secondary prevention includes screenings to pick up on cancer early. Screening is very important because then we have a greater chance for cure or control. Annual mamogram starting at age 45 with two views of each breast is recommended if the client has no family history of breast cancer. Colonoscopy at age 45, then every 10 years after that if there has been no problem is also recommended. b. Incorrect: Maintaining a normal body weight is considered primary prevention (ways to help prevent the actual occurrence of cancer). c. Incorrect: Support groups and rehabilitation programs are considered tertiary prevention (focuses on the management of long term care for clients with complex treatments for cancer). e. Incorrect: Limiting or eliminating alcohol intake is considered primary prevention.

The nurse is educating a group of college students about cancer prevention and screening. Which secondary prevention actions should the nurse include? Select All That Apply a. Annual mamogram starting at age 45. b. Maintain normal body weight. c. Cancer support group. d. Colonoscopy beginning at age 45. e. Limit or eliminate alcohol intake.

c. Nagging cough c. CORRECT. The mnemonic "C-A-U-T-I-O-N" represents an easy way to recall the seven early warning signs and symptoms of potential cancer. Each letter indicates a specific body alteration that should be reported to the primary healthcare provider. 'N' stands for a nagging cough or hoarseness. a. INCORRECT. Though indigestion and difficulty swallowing are considered among the seven warning signs of cancer, nausea and vomiting are vague symptoms which can be attributed to a variety of disorders. These do not represent the "N" in 'CAUTION'. b. INCORRECT. While any type of drainage from the breast should be reported to the primary healthcare provider, drainage is represented under the "U" for unusual discharge or bleeding. This is not the correct interpretation for the "N". d. INCORRECT. A nose bleed could be the result of many factors, including clotting issues or even a dry environment. This symptom does not represent an early sign of cancer.

The nurse is educating a group of college students about early signs and symptoms of cancer. When explaining the mnemonic "C-A-U-T-I-O-N", the nurse explains the 'N' stands for what sign/symptom? Choose One a. Nausea b. Nipple drainage c. Nagging cough d. Nose bleeds

a. Rest cast on a soft pillow. b. Keep the cast uncovered until air dried. c. Mark the cast if there is breakthrough bleeding. d. Place ice packs on side of the cast for first 24 hours. a., b., c., and d. Correct: Until the cast has dried completely, the cast care instructions are to prevent indentations on the cast, reduce swelling, and evaluate any breakthrough bleeding. e. Incorrect: To prevent indentations in the plaster cast, the cast should be moved with the palms of hands for first 24 to 72 hours.

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

b. Mood alterations c. Lipolysis d. Trucnal obesity e. Hirsutism b., c., d., & e. Correct: The client will experience mood swings. Several of the clinical manifestations of Cushing's are related to significant physical changes which can result in periods of depression for the client. Another clinical manifestation is lipolysis which is the breakdown of adipose tissue and the thinning of the extremities. Truncal obesity (apple-shaped obesity) is the distribution of adipose tissue located in the abdominal area. Hirsutism is when a female develops male characteristics such as increased hair on the face. When the adrenal cortex is stimulated there is an increase production of adrenal androgen. This results in the increased production of testosterone, a sex hormone. a. Incorrect: The clinical manifestation of Cushing's is hyperglycemia not hypoglycemia. The increase adrenocortical activity in the adrenal cortex will result in hyperglycemia. f. Incorrect: Client's diagnosed with Cushing's disease will present with hypokalemia not hyperkalemia. This is the result from increased adrenocortical activity which results in a decrease in potassium levels, hypokalemia.

The nurse is initiating assessment. What signs and symptoms would validate the client's diagnosis of Cushing's disease? Select all that apply. a. Hypoglycemia b. Mood alterations c. Lipolysis d. Trucnal obesity e. Hirsutism f. Hyperkalemia

b. Place supplies for client in room. c. Limit nursing personnel in room. b. and c. Correct: They need their own cups; they need their own everything. You don't need to go to a general closet and get supplies for this client. They need their own blood pressure cuff and own stethoscope in the room. Their own stuff because you only want their bacteria in the room. Limit people in the room who could pass on an infection to the client. Limit visitors, nurses, and nursing personnel to only those necessary to care for the client. a. Incorrect: IV tubings should be changed daily, not every 2 days. d. Incorrect: Bathe warm moist areas like underarms, groin, and perineum twice a day. Moist areas are a great place for bacteria to grow. e. Incorrect: There is no indication that this client needs to be in isolation. A private room is acceptable at this time.

The nurse is planning care for a client admitted for chemotherapy. What interventions should the nurse initiate to prevent infection? Select All That Apply a. Change IV tubing every 48 hours. b. Place supplies for client in room. c. Limit nursing personnel in room. d. Bathe perineum once daily. e. Place in protective isolation.

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

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

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

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

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

The nurse is preparing a teaching plan for a client newly diagnosed with fluid retention and heart failure. What should the nurse advise the client to avoid? Select All That Apply a. Broiled, fresh fish b. Effervescent soluble medications c. Seasoning with lemon pepper d. Chicken noodle soup e. Deli-ham sandwiches

a. Squeeze tennis ball with right hand every 2-4 hours while awake. c. Wear gloves when gardening. d. Wear your watch on the left wrist. a., c., and d. Correct: Squeezing a tennis ball will help promote new circulation. Protect the hand and arm at all times. A tiny cut could turn into a major infection, so wearing gloves while gardening is a good idea. Since the mastectomy was on the right breast, the client can wear a watch on the left wrist. Do not wear anything constricting on the right wrist, or arm. b. Incorrect: No blood pressure reading in right arm ever. e. Incorrect: We want the client to use the affected arm when brushing hair. This will help promote new circulation and will help prevent frozen shoulder. So, this client should use the right hand to brush her hair.

The nurse is preparing discharge teaching instructions for a client post right radical mastectomy with reconstruction. What instruction should the nurse include? Select All That Apply a. Squeeze tennis ball with right hand every 2-4 hours while awake. b. No blood pressure readings in right arm for one year. c. Wear gloves when gardening. d. Wear your watch on the left wrist. e. Brush your hair with your left hand until pain free.

15 Dopamine 5 mcg/kg/min IV per infusion pump using the dopamine infusion protocol is the prescription. The protocol states that a mixture of 400 mg dopamine is put in 250 mL fluid to provide 1600 mcg/mL/ The table provides the mcg/kg/min infusion and weight in kg to yield the flow rate for the infusion pump. 5 mcg/kg/min for a client weight of 80 kg is 15 mL/hour. Always double check the chart to make sure it is correct. Step 1: Determine mcg/min. 5 mcg x 80 kg = 400 mcg/minute is required. Step 2: Determine the mL/min. D/H x Q = 400 mcg/min./1600 mcg x 1 mL = 0.25 mL/min. Step 3: Determine the flow rate (mL/H) 0.25 x 60 = 15 mL/H

The nurse is preparing to initiate a dopamine infusion per protocol. The primary HCP prescription is Dopamine 5 mcg/kg/min. IV per infusion pump. At what rate should the nurse set the pump? Use numbers only.

b. Asparagus, broccoli, cabbage, and cucumbers. b. Correct: A calorie is the unit of energy needed to raise the temperature of 1 kilogram of water 1 degree of Celsius. The recommended percentage of calories from carbohydrates is 50% of the daily diet. Nonstarchy vegetables are lower in carbohydrates, so they do not raise blood sugar very much. They are also high in vitamins, minerals, and fiber, making them an important part of a healthy diet. Filling half your plate with nonstarchy vegetables means you will get plenty of servings of these superfoods. Examples include asparagus, broccoli, cabbage, brussel sprouts, carrots, and cucumbers. a. Incorrect: The listed foods are high in protein. The intake of proteins will reduce appetite because protein takes longer to digest in the stomach. This results in a person feeling fuller for a extended period. The recommended percentage of daily calories from proteins is 20-25% for both a regular diet and a diabetic diet. Proteins are beneficial to build, repair, and maintain the body's tissues. Protein with high levels of fat can cause both a weight gain and an increase in the serum glucose levels. Also a high intake of protein has not proven to influence the level of serum glucose levels. c. Incorrect: The foods that are listed are high in protein, which should consist of 20-25% of the diabetic diet. The intake of various amounts of high protein foods will not affect the client's glucose level. d. Incorrect: The monounsaturated and polyunsaturated fats such as milk, cheese and chocolate in the diet function such as components of cell membranes, energy storage, energy storage, and fat-soluble vitamin A, D, E and K. The intake of fat does not cause an increase or decrease in serum glucose levels.

The nurse is providing dietary instructions to a client newly diagnosed with type 2 diabetes. Which food examples should make up the highest percentage of this client's recommended diet? Choose one. a. Pecans, eggs, pork chop b. Asparagus, broccoli, cabbage, and cucumbers. c. Lean hamburger, fish, skinless chicken d. Whole milk, cheese, dark chocolate

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

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

b. Attend classes such as guided imagery to reduce stress. c. Temperature extremes can precipitate an angina attack. b. and c. Correct: We want to teach clients who have angina to do whatever they can to decrease the workload of the heart. Stress can increase the workload on the heart, so learning ways to decrease or deal with stress is a positive step. This can be done through guided imagery or music therapy. Temperature extremes can precipitate an attack, so the client should dress warmly in cold weather and be cautious in extremely hot weather. a. Incorrect: The client should wait at least 2 hours after eating to exercise. During this time, more blood goes to the digestive system. We don't want the heart to have to compete with the gut. d. Incorrect: Weightlifting will increase the workload of the heart. We don't want to increase the workload of the heart in a client with a cardiac issue. e. Incorrect: Losing weight is often beneficial for the cardiac client, so we advise them to decrease calorie consumption and maintain a low fat, high fiber diet. f. Incorrect: We want to decrease the workload of the heart, not increase it. Medications are prescribed to prevent angina work to decrease the workload of the heart.

The nurse is providing teaching to a group of clients newly diagnosed with chronic stable angina. What points should the nurse include? Select All That Apply a. Wait 1/2-1 hour after eating to exercise. b. Attend classes such as guided imagery to reduce stress. c. Temperature extremes can precipitate an angina attack. d. Gradually increase weightlifting training to improve cardiac output. e. Eat a low fat, low fiber diet to lose weight. f. Medications prescribed to prevent angina work by increasing the workload of the heart.

b. 500 ml D5W at 100 mL per hour e. 100 mL O.45% sodium chloride (NaCL) with potassium chloride KCL 10mEq IV b. and e. Correct: The clinical manifestation of DKA is a serum glucose level of greater than 300mg/dL. The goal of the treatment for DKA is to reduce the serum glucose level. Prescribing D5W will increase the client's serum glucose level which is already elevated. The prescription should begin with 0.9% NaCL. to compensate for the effects of polyuria, IV normal saline, an isotonic solution. An isotonic solution is composed of equal concentrations of solutes and water which will increase vascular volume. Initially the potassium is normal or high and can decrease when treatment begins. This prescription should be questioned. a. Incorrect: The prescription for arterial blood gases is appropriate. The arterial blood gases will identify if the client is in metabolic acidosis. c. Incorrect: The goal of the treatment for DKA is to reduce the elevated glucose level. The glucose levels of the client are evaluated hourly to monitor the efficiency of the treatment and assess for hypoglycemia. As the serum glucose level reduces to 250 -300 mg/dL the IV prescription will change from normal saline to D5W. d. Incorrect: The glucose levels of the client are evaluated hourly to monitor the desired outcome of control of the serum glucose level. The Regular insulin prescription is adjusted according to the serum glucose levels. The objective of the Regular insulin prescription is to reduce the hyperglycemic episode without a hypoglycemic episode.

The nurse is reviewing the primary healthcare provider's (PHP) initial prescriptions for a client diagnosed with diabetic ketoacidosis (DKA)? Which prescription from the PHP would the nurse question? Select all that apply. a. Arterial blood gases b. 500 ml D5W at 100 mL per hour c. Serum glucose levels every hour d. Hourly adjustment of Regular insulin IV according to serum glucose level protocol e. 100 mL O.45% sodium chloride (NaCL) with potassium chloride KCL 10mEq IV

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

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

c. The right ventricle pumps the blood to the lungs via the pulmonary artery where the blood becomes oxygenated. d. From the lungs, oxygenated blood goes to the left atrium via the pulmonary vein, then to the left ventricle. c. and d. Correct: These are true statements. The right ventricle pumps the blood to the lungs via the pulmonary artery where the blood becomes oxygenated. From the lungs, oxygenated blood goes to the left atrium via the pulmonary vein, then to the left ventricle. a. Incorrect: Deoxygenated blood comes from the body to the heart via the superior and inferior vena cava. b. Incorrect: Blood flows from the right atrium through the tricuspid valve to the right ventricle. e. Incorrect: The left ventricle pumps the blood out through the aorta to the body.

The nurse is teaching a group of clients in cardiac rehabilitation how blood flows through the heart. What information should the nurse include? Select All That Apply a. Deoxygenated blood enters the heart through the pulmonary vein. b. Blood flows from the right atrium through the mitral valve to the right ventricle. c. The right ventricle pumps the blood to the lungs via the pulmonary artery where the blood becomes oxygenated. d. From the lungs, oxygenated blood goes to the left atrium via the pulmonary vein, then to the left ventricle. e. The right ventricle pumps the blood out through the aorta to the body.

c. "Self-breast exams may detect changes early enough for successful treatment." c. CORRECT. The nurse responds to this client's incorrect statement by presenting an accurate fact in a non-judgmental and open manner, allowing for further discussion about breast cancer facts. The nurse has a responsibility to provide the client important data about the topic of self-breast exams. a. INCORRECT. A breast exam completed only once a year is not often enough. Self-breast exams should be done monthly by both male and female clients. Some cancers are so aggressive that waiting a year could lead to a terminal diagnosis. b. INCORRECT. This comment by the nurse is totally false. A family history of cancer is not a precursor to the occurrence of breast cancer. d. INCORRECT. Though this closed-ended statement is accurate, the nurse has not provided the client with any information which could correct the client's misconceptions about breast-cancer.

The nurse is teaching a group of female clients how to perform a self-breast exam. One client reports no family history of breast cancer and indicates disinterest in learning the technique. What is the most appropriate response by the nurse? Choose One a. "You can ask your healthcare provider to do this with your yearly physical." b. "If you have no family history of cancer, you won't need to worry about this." c. "Self-breast exams may detect changes early enough for successful treatment." d. "You have the right to refuse anything related to health because of client rights."

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

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

a. Malaise b. Blood pressure - 16O/92 d. Costovertebral angle tenderness e. Urine specific gravity of 1.040 a., b., d., and e. Correct: A client with glomerulonephritis is retaining toxins. The result is the client has a overall sense of being ill with possible fatigue and decrease interest in activities. A client with glomerulonephritis is producing less and less urine. Due to the retention of fluid, the client's blood pressure is elevated. Costovertebral angle tenderness (CVAT) is elicited by percussing the flank area of the back over both the kidneys. If pain is present, the client would be assessed for a kidney infection. The normal range of urine specific gravity ranges from 1.010 to 1.030. An elevated urine specific gravity of 1.040 is reflective of highly concentrated urine. The client is not diuresing appropriately. The client's specific gravity of 1.040 supports glomerulonephritis. c. Incorrect: The normal range for a 24 urinary output is 800-2000 mL. The listed 24 hour urinary output of 960 is within the normal range. Urinary output on a client with glomerulonephritis is less than 800 mL per 24 hours.

The nurse on a medical unit is reviewing the data on a client admitted to a medical unit. Which data supports the diagnosis of glomerulonephritis? Select All That Apply a. Malaise b. Blood pressure - 16O/92 c. 24 hour urinary output - 960 mL d. Costovertebral angle tenderness e. Urine specific gravity of 1.040

b. Moist skin. d. Weak radial pulses. e. BP 90/50, HR 200, RR 22. f. Mild chest discomfort. b., d., e., and f. Correct: When cardiac output is inadequate, the vital organs are not being perfused properly. The skin will be cool and clammy (moist) because the skin is not being perfused. Radial pulses will be weak and thready, because less blood is pumping through the arteries. Less volume means less pressure, so BP is low. The heart rate is too fast, so blood does not have time to get into the ventricles before it is contracting again, which decreases cardiac output. Less blood is being pumped into the body. Chest pain means oxygenated blood is not reaching the heart muscles. a. Incorrect: Normal CVP is 2-6 mmHg, so this is a normal finding. c. Incorrect: Normal urinary output (UOP) should be at least 30 mL per hour. This client's UOP was 150 mL over 4 hours (37.5 mL per hour). So there is no concern here.

The nurse performs a rapid assessment on a client who states, "I feel really sick and my heart is beating so fast." What signs and symptoms would indicate to the nurse that the client's cardiac output is inadequate? Select All That Apply a. CVP 5 mm Hg. b. Moist skin. c. Urinary output 150 mL over 4 hours. d. Weak radial pulses. e. BP 90/50, HR 200, RR 22. f. Mild chest discomfort.

b. Pancreatitis b. Correct: These s/s point to pancreatitis. Look at the big clues: Cullen's sign, rigid abdomen with guarding, and fever. a. Incorrect: What are the classic s/s of cirrhosis that are different from pancreatitis? Firm, nodular liver, dyspepsia, change in bowel habits, splenomegaly, acites. c. Incorrect: Peptic ulcers typically do not present with severe pain, but with a burning pain in the mid-epigastric area and back. Dyspepsia is common as well, but no bruising around the flank area or umbilicus. d. Incorrect: Ulcerative colitis presents with diarrhea, rectal bleeding, vomiting, weight loss, cramping, rebound tenderness and fever.

The nurse performs an assessment on a client who reports abdominal pain. Based on the assessment findings, what problem does the nurse suspect? Choose One a. Cirrhosis b. Pancreatitis c. Peptic ulcer d. Ulcerative colitis

b. Nitroglycerin ointment 2% 0.5 inch to chest. c. Ceftriaxone 250 mg intramuscularly e. Humalog 8 units subcutaneously b, c, and e are correct. You do not want to get nitroglycerin on your hands. The medication would be absorbed into your skin. When giving a medication IM or SQ, there is a chance of being exposed to blood and you should wear gloves. "a" is incorrect. Gloves are not needed when administering oral medications unless contact with the client's mucous membranes is anticipated or the medication is hazardous. "d" is incorrect. Gloves are not needed when preparing ABX such as ceftriaxone by IV piggyback.

The nurse should wear gloves when administering which medication(s)? Select all that apply. a. Lorazepam 1 mg orally. b. Nitroglycerin ointment 2% 0.5 inch to chest. c. Ceftriaxone 250 mg intramuscularly d. Metronidazole 500 mg intravenous piggyback. e. Humalog 8 units subcutaneously

a. "deci" is the starting place on the metric line. c. Gram is the base unit of measurement. e. "milli" is the desired place. The metric symbol for the prefix "deci" is "d," the starting place on the metric line. The metric symbol for the prefix "milli" is "m," the desired place. To convert from the deci place to the milli place, the decimal point is moved two places. The answer is 25 mg. The "g" indicates mass and is the base unit of measurement in this problem.

To convert 0.25 decigram (dg) to milligram (mg), the nurse needs to understand what facts? Use the metric line to solve the problem. Select all that apply. a. "deci" is the starting place on the metric line. b. The base unit is the desired place. c. Gram is the base unit of measurement. d. "deka" is the starting place on the metric line. e. "milli" is the desired place.

c. Hangs platelets immediately upon arrival from blood bank refrigerator. c. Correct: The charge nurse needs to intervene here. NEVER infuse cold platelets, because the spleen will reject them if they are cold and not absorb them. So, room temperature for your platelets or they will do you no good. a. Incorrect: The charge nurse does not need to intervene here. The nurse should check for a prescription to administer platelets. b. Incorrect: This is also a correct action by the nurse, so there is no need for the charge nurse to intervene. d. Incorrect: Normal saline is the acceptable fluid to hang with blood and blood products, so the charge nurse does not need to stop the nurse.

What action by the nurse, who is administering platelets to a client, would require the charge nurse to intervene? Choose One a. Verifies prescription for platelet transfusion. b. Confirm client has provided informed consent. c. Hangs platelets immediately upon arrival from blood bank refrigerator. d. Infuse platelets with normal saline solution.

d. Notify the HCP Notify the HCP if diarrhea occurs. It can promote the development of C. diff. infection. Cephalosporin difficile is a toxin producing bacteria that causes antibiotics-associated colitis, and can occur with ABX therapy. Cephalosporin is one of the most common antibiotics that cause C. diff. "a" is incorrect. Taking a probiotic, stopping the ABX, or switching to another ABX are standard treatments for ABX induced diarrhea. Administering an anti-diarrheal is not recommended for ABX induced diarrhea. "b" is incorrect. Increasing fluid intake will healp with the associated dehydration seen with diarrhea, but will not correct the problem or decrease the risk of C. diff. "c" is incorrect. If the client has GI upset, then cephalosporin may be given with food. However, the most important thing to worry about is the development of C. diff. infection. Notifying the HCP is the most important action.

What action is most important for the nurse to take when a client receiving a cephalosporin develops abdominal cramping and diarrhea? a. Administer antidiarrheal medication b. Increase fluid intake c. Provide food with the medication d. Notify the HCP

a. Dialysate is warmed to body temperature by allowing it to sit out for a short period of time. c. Once infused, dialysate remains for prescribed dwell tiime. a. and c. Correct: These actions are correct. The dialysate should be warmed to body temperature by allowing it to sit out for a short period of time. The dwell time is the length of time that the dialysate stays in the peritoneal cavity. This allows for toxins to be drawn out of the blood and into the peritoneal cavity for removal. b. Incorrect: The dialysate is infused through the peritoneal catheter into the peritoneal cavity. d. Incorrect: Allow the dialysate to drain by gravity for 20-30 minutes. e. Incorrect: The nurse should turn the client from side to side if all the drainage does not come out of the peritoneum.

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

d. Wear film badge throughout assigned shift. e. Educate visitors to stay at least 6 feet from the client. d. and e. Correct. Wear a film badge at all times so that you know how much radiation you are getting.Visitors should stay at least 6 feet from the source to decrease exposure to radiation. The closer you get the more radiation exposure. a. Incorrect: Nursing assignments should be rotated daily, so that the nurse is not continuously exposed. b. Incorrect: The nurse should only care for one client with a radiation implant in a given shift. c. Incorrect: Visitors should be limited to 30 minutes per day in order to decrease exposure to radiation.

What does the nurse need to remember when caring for clients on the oncology unit who have a radiation implant? Select All That Apply a. Nursing assignments should be rotated weekly. b. The nurse should care for no more than 3 clients with a radiation implant per shift. c. Limit visitors to 60 minutes per day. d. Wear film badge throughout assigned shift. e. Educate visitors to stay at least 6 feet from the client.

d. Briefly soak burned area in cool water. d. Correct: Although all options are correct, the priority is to stop the burning process. Just putting out the flames is not enough to stop the burning process. You need to apply cool water briefly (no more than 10 minutes) to soak the burn area. Any longer can cause extensive heat loss. a. Incorrect: Removing jewelry is important but stop the burning process first. Swelling occurs with burns, so jewlrey must be removed or you will not get it off. This can result in constriction of the extemity. Additionally, metal burns. b. Incorrect: Wrapping the client in a clean or preferably a sterile blanket will help to hold in body heat. Remember, they have lost skin, the number one way to hold in body heat. c. Incorrect: Applying a clean, dry cloth to the burn area will help prevent infection, but the priority is to stop the burning process.

What immediate action should the occupational health nurse take once flames have been extinguished from a burned victim? Choose One a. Remove jewelry. b. Wrap in a clean blanket. c. Cover burns with clean, dry cloth. d. Briefly soak burned area in cool water.

b. Clean the lint trap on the clothes dryer after each use. d. Do not hold a child while holding a hot drink. e. Home hot water heater should be set at a maximum of 120°F (48.8°C). b., d., and e. Correct: Lint that accumulates in the lint trap of a dryer can cause a fire, so the lint trap should be cleaned after each use. A hot beverage can easily spill on a child by accident when trying to handle both the beverage and child at the same time. Home hot water heater should be set at a maximum of 120°F (48.8°C), especially when small children, the elderly, or diabetics are in the home. a. Incorrect: A chimney should be professionally inspected every year prior to use. It should also be cleaned if necessary. c. Incorrect: Space heaters need space at least three feet (0.91 meters) away from anything that can burn.

What information on burn prevention strategies should the nurse include when providing an education program at a community center? Select All That Apply a. Have chimney professionally inspected every 5 years. b. Clean the lint trap on the clothes dryer after each use. c. Keep anything that can burn at least 1 foot (0.30 meters) away from space heaters. d. Do not hold a child while holding a hot drink. e. Home hot water heater should be set at a maximum of 120°F (48.8°C).

c. Hepatitis B is more readily transmitted via needle sticks than HIV. Hepatitis B virus (HBV) and HIV can be transmitted in similar ways, but HBV is more infectious. Studies show HBV is more readily transmitted via needle sticks than HIV. More than 1 million people currently have HIV in the United States. HBV is 50-100 times more infectious than HIV. "a" is incorrect. Neither virus can be transmitted via toilet seats. Both are spread by contact with infected body fluids such as blood, semen, vaginal fluid, or from a mother to her baby during pregnancy or delivery. "b" and "d" are incorrect. Both can be transmitted though body fluids during sexual contact, so condoms should be worn to reduce the chances of spreading the viruses. standard precautions should be implemented for both. The CDC recommends HBV vaccination for people who are at risk for or living with HIV, including men who have sex with men (MSM); people who inject drugs; anyone with a sexually transmitted infection; people with diabetes; and health care and public safety workers who may be exposed to blood on the job.

What information should be included when a nurse is teaching a group of college students about the transmission of hepatitis B and human immunodeficiency virus (HIV)? a. HIV is transmitted via toilet seats whereas hepatitis B is not. b. HIV is transmitted by sexual contact whereas hepatitis B is not. c. Hepatitis B is more readily transmitted via needle sticks than HIV. d. Neither virus is transmitted via blody fluids.

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

What interventions should the nurse include when caring for a client who is receiving total parenteral nutrition (TPN)? Select All That Apply a. Change tubing and filter every 48 hours. b. Monitor IV drip rate hourly. c. Compare new bag with prescription prior to infusing. d. Weigh weekly. e. Cover TPN with dark bag. f. Check urine for protein.

a. Weigh daily b. Measure abdominal girth c. Provide skin care e. Intake and output a., b., c., and e. Correct: The client with nephrotic syndrome is producing less urine. Due to the decrease in urinary output the client is retaining fluid. The client should be weighed daily, and the girth would be measured to evaluate fluid retention. Edematous skin is prone to skin breakdown, so adequate skin care is necessary. Intake and output is required whenever there is a fluid volume problem. d. Incorrect: This client with nephrotic syndrome does not require positioning in a semifowlers position. Any position of comfort is acceptable.

What interventions would the nurse implement for a client diagnosed with nephrotic syndrome? Select All That Apply a. Weigh daily b. Measure abdominal girth c. Provide skin care d. Position in semifowlers e. Intake and output

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

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

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

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

c. Place the IV bag and tubing into a chemotherapy waste container. c. Correct: The disposable items such as the IV bag and tubing should remain intact and be disposed of in a securely sealed chemotherapy waste container. Tubing should never be disconnected from an IV bag containing a hazardous drug because of the risk of splashing. a. Incorrect: The IV line does not have to be flushed with that much fluid. Usually, a central venous access device (CVAD) is flushed with 10 mL NS and a heparin solution if appropriate for the client and the device . For a peripheral line 2-5 mL NS is sufficient. b. Incorrect: Shoe covers are not needed. Shoe covers are used when there is a chance of walking in contamination such as blood spilled on floor. d. Incorrect: PPE (including double gloves, goggles, and protective gown) should be worn for all activities associated with chemotherapeutic drug administration. PPE used in chemotherapy drug administration should be disposed of in chemotherapy—not biohazardous—waste receptacle.

What should the nurse do after administering a chemotherapeutic drug intravenously (IV) to a client in the outpatient infusion unit? Choose One a. Hang a 250 mL normal saline (NS) bag to flush the IV line. b. Wear shoe covers during disposal of the drug. c. Place the IV bag and tubing into a chemotherapy waste container. d. Disposal of personal protective equipment (PPE) in a biohazardous container.

a. stridor b. Swallowing difficulty c. Singed nasal hair e. Wheezing a., b., c., and e. Correct: Substernal/intercostal retraction and stridor are bad signs. Remember you will see difficulty swallowing, singed nasal and facial hair, and wheezing. d. Incorrect: Blisters found on the oral/pharyngeal mucosa is more likely to indicate a smoke or inhalation injury.

What sign/symptom would indictate to the nurse that a client has had an inhalation injury? Select All That Apply a. stridor b. Swallowing difficulty c. Singed nasal hair d. Blisters to upper arms e. Wheezing

a. Abdominal cramping c. Diarrhea d. Fever e. Rebound tenderness f. Rectal bleeding a., c., d., e., and f. Correct: Ulcerative colitis is an ulcerative inflammatory bowel disease in the large intestines. Common s/s include abdominal cramping, diarrhea, fever, rebound tenderness, and rectal bleeding. b. Incorrect: Hematemesis is seen with upper GI bleeding.

What signs/symptoms does the nurse expect to see in a client who has ulcerative colitis? Select All That Apply a. Abdominal cramping b. Hematemesis c. Diarrhea d. Fever e. Rebound tenderness f. Rectal bleeding

a. Conjunctival hemorrhage b. Petechiae on inside of mouth c. Purpura e. Blood oozing from IV site a., b., c., and e. Correct: The problem is a low platelet count, so we are looking for signs/symptoms of bleeding such as conjunctival hemorrhage, petechiae on the arms, legs or inside the mouth, and ecchymosis or purpura. d. Incorrect: Thrombocytopenia is a decrease in the number of circulating platelets in the blood. Fever is seen with neutropenia.

What signs/symptoms should the nurse assess for when caring for a client at risk for thrombocytopenia? Select All That Apply a. Conjunctival hemorrhage b. Petechiae on inside of mouth c. Purpura d. Fever e. Blood oozing from IV site

a. Asterixis b. Fetor e. Squiggly handwriting a., b., and e. Correct: Signs and symptoms that a client diagnosed with cirrhosis is getting worse and headed for hepatic coma include asterixis, fetor, and handwriting changes. c. Incorrect: Grey Turner's sign is seen with pancreatitis. d. Incorrect: With hepatic coma, the client is full of toxins, so reflexes will be decreased.

What signs/symptoms would lead the nurse to suspect that a client diagnosed with cirrhosis may be developing hepatic coma? Select All That Apply a. Asterixis b. Fetor c. Grey Turner's sign d. Hyperactive reflexes e. Squiggly handwriting

a. Swelling b. Deformity c. Crepitus d. Discoloration a., b., c., and d. Correct: Swelling, deformity, crepitus, and discoloration are signs of a fracture. The swelling is caused by fluids and blood that move into the soft tissues. The leaking of blood from the soft tissue or from the bone will result in a discoloration or bruising at the injury site. The most accurate sign of a broken bone is deformity of the bone. An example would be when a bone is bending in an inappropriate direction. e. Incorrect: Tenting of the skin is not a sign of a fracture. Tenting is the slow return of skin after the skin has been pinched. If tenting is present, this indicates that the client is possibly dehydrated.

Which assessment findings would indicate to the nurse that a client may have a fracture? Select All That Apply a. Swelling b. Deformity c. Crepitus d. Discoloration e. Tenting of skin

b. A 62 year old client who speaks only Spanish. d. A 17 year old client needing an emergency appendectomy whose parents cannot be reached. b and d are correct. The Spanish speaking client should have a trained medical interpreter, in person, by telephone, or by video conference, but the client can still consent. The 17 year old client is considered a minor. However, since the parents are not available, the emergency exception rule known as "implied consent" would be followed. The primary healthcare provider must document the nature of the emergencey, the reason why immediate treatment is required, and the attempts to obtain consent from the minor's parents or legal guardian. "a" is incorrect. Disoriented people are not considered capable of making an informed decision. "c" is incorrect. Midazolam is a benzodiazapin administered for preoperative sedation/amnesia. For a consent to be legally valid, the consent must be signed prior to its administration. "e" is incorrect. Clients with schizophrenia who are hallucinating do not have the ability to understand explanations or understand risks and benefits. For this reason, they cannot communicate a decision based on that understanding.

Which client is legally able to sign a consent form? Select all that apply. a. An 86 year old client who is disoriented. b. A 62 year old client who speaks only Spanish. c. A 41 year old client who just received midazolam. d. A 17 year old client needing an emergency appendectomy whose parents cannot be reached. e. A 44 year old with schizophrenia who is hallucinating.

a. Confusion c. Vitiligo d. Hyperkalemia a., c., & d. Correct: Clients with Addison's disease may present with nonspecific symptoms of confusion. As the continual reduced functioning of the adrenal medulla and adrenal cortex occurs, the client will present with cognitive impairment, delusions, and hallucinations. The reduced blood cortisol increases the adrenocorticotropic hormones (ACTH) and the melanocyte-stimulating activity. The feedback mechanism results in the hyperpigmentation of skin. A deficiency of mineralocorticoids will result in the decreased excretion of potassium which results in hyperkalemia. b. Incorrect: The client diagnosed with Addison's disease will present with hypotension. The decrease in the production of the adrenal cortex steroids results in the increased excretion of sodium. The sodium loss can cause severe dehydration, decreased circulation, and hypotension. e. Incorrect: The increased excretion of sodium is the feedback action of the decreased level of adrenal cortex steroid. This action will result in hyponatremia. f. Incorrect: The reduced glucocorticoid will result in weight loss not gain. This reduction is due to changes in the carbohydrate, fat, and protein metabolism.

Which clinical manifestation does the nurse expect to see in a client diagnosed with Addison's disease? Select all that apply. a. Confusion b. Hypertension c. Vitiligo d. Hyperkalemia e. Hypernatremia f. Weight gain

d. pH 7.48, PaCO2 30, PaO2 88, SaO2 92, HCO3 24 d. Correct: This ABG result indicates respiratory alkalosis. Initially, acetylsalicylic acid stimulates the respiratory center and causes an increase in respiratory rate and depth. This causes respiratory alkalosis by blowing off CO2 and causing the pH to increase. Losing CO2 (acid) makes the client more alkalotic, which is reflected with an increased pH, decreased PaCO​2 and normal HCO​3. a. Incorrect: This ABG result indicates metabolic alkalosis. The pH is high, PaCO​2 is normal and HCO​3 is high. Normal pH is 7.35-7.45, normal PaCO​2 is 35-45, normal HCO​3 is 22-26. b. Incorrect: The client with an initial aspirin overdose will have a respiratory alkalosis. This ABG result indicates metabolic acidosis. The pH is less than 7.35 (acidotic); the PaCO2 is within normal limits, and the bicarb is low (less than 22), which creates acidosis. c. Incorrect: This ABG indicates partially compensated metabolic acidosis. The problem in the stem would initially result in a respiratory problem. The pH is low (acidosis). The PaCO2 is low (alkalosis) as the body tries to compensate by decreasing the acid in the body. The metabolic chemical, bicarb, is low (acidosis) which matches the acidotic pH. Since the pH, PaCO2, and bicarb are all abnormal, we know that partial compensation has occurred.

Which initial arterial blood gas (ABG) results would the nurse likely see in a client who has overdosed on acetylsalicylic acid (ASA)? Choose One a. pH 7.50, PaCO2 42, PaO2 63, SaO2 91, HCO3 28 b. pH 7.32, PaCO2 36, PaO2 83, SaO2 95, HCO3 19 c. pH 7.28, PaCO2 28, PaO2 72, SaO2 90, HCO3 16 d. pH 7.48, PaCO2 30, PaO2 88, SaO2 92, HCO3 24

c. Position the feet with the toes pointed upward. d. Assess client's popliteal, dorsalis pedis, and posterior tibial pulses. c. and d. Correct: These are correct interventions. The feet should be placed in a neutral rotation position with the toes pointed to the ceiling. This positioning of the feet prevents the hips from rotating inwardly or outwardly. If the hips are not positioned appropriately, there is a postoperative risk for dislocation of the hip. The postoperative neurovascular assessment of the right leg includes evaluating the client's popliteal, dorsalis pedis, and posterior tibial pulses. The nurse should evaluate the peripheral pulses distal to the hip. The primary healthcare provider should be notified of any alterations in the peripheral pulses. a. Incorrect: The abduction pillow is not removed within 6 hours of a total hip arthroplasty. This is an inappropriate intervention. The abduction pillow is attached to the legs to prevent adduction of the hips to decrease the risk of a dislocation of the surgical hip. b. Incorrect: The nurse should not place a pillow under either knee. The pillows would decrease the circulation to the lower extremities and increase the risk factor for deep vein thrombosis (DVT). Also, an abduction pillow is attached to the lower extremities. e. Incorrect: The normal hemoglobin range for a male client is 14-15 g/dL (8.7-11.2 mmol/L). The client's hemoglobin level is 15g/dL (9.31mmol/L). Since the client's hemoglobin level is within normal range, the nurse will not notify the primary healthcare provider.

Which interventions would the nurse implement for a client with a right total hip arthroplasty performed 6 hours ago? Select All That Apply a. Remove the abductor pillow. b. Place a pillow under both knees. c. Position the feet with the toes pointed upward. d. Assess client's popliteal, dorsalis pedis, and posterior tibial pulses. e. Report to the healthcare provider the 15g/dL (9.31mmol/L) Hemoglobin.

c. Pregnancy test c. Correct: RAI crosses the placenta and will affect the development of the fetus. If RAI is administered to a client who is pregnant, the fetus can experience mental retardation, hypothyroidism, and develop increased cancer risk. It is imperative that a pregnancy test should be prescribed prior to administering RAI. RAI should not be administered to a client who has a positive pregnancy test. a. Incorrect: A thyroid scan is prescribed to evaluate the function and size and shape of the thyroid gland. This scan can identify the amount of thyroid hormone the thyroid is producing (hyperthyroidism) Also the thyroid scan will evaluated for the presence of thyroid nodules. Prior to the administration of RAI, the female client should have a pregnancy test prescribed. This test will not identify if the client is pregnant. b. Incorrect: A calcium test is prescribed to analyze the calcium level in conditions affecting nerves, parathyroid, kidney, and thyroid. Since this test does not identify whether a client is pregnant, a calcium test result is not related to whether the nurse administers the RAI. d. Incorrect: The metanephrine test measures the amount of metanephrine in urine. The breakdown of catecholamines results in metanephrine. The catecholamines are epinephrine, norepinephrine and dopamine. The female client should be evaluated for pregnancy prior to administrating RAI.

Which laboratory test should be assessed by the nurse prior to administering radioactive iodine (RAI) to a female client? Choose one. a. Thyroid Scan b. Serum calcium c. Pregnancy test d. Metanephrine test

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

Which medication prescription should the nurse question for a client diagnosed with nephrotic syndrome? Choose One a. Ibuprofen b. Enalapril c. Prednisone d. Cyclophosphamide

a. Milk d. Chicken a. and d. Correct: Milk intake will not alter the production of epinephrine or norepinephrine. The client can drink milk prior to a VMA test. The period prior to a VMA test which measures the amount of production of epinephrine and norepinephrine would not require the client to eliminate chicken. Eating chicken would not alter the production of epinephrine or norepinephrine. b. Incorrect: The client should not eat/consume caffeine as it will alter the test. c. Incorrect: Citrus fruit and fruit juices will alter the accuracy of the VMA test which measures the amount of production of epinephrine and norepinephrine. e. Incorrect: Vanilla ice cream contains vanilla, which can alter the vanillylmandelic acid (VMA) test.

Which selection by the client indicates to the nurse that the client understands food allowed during a vanillylmandelic acid (VMA) test? Select All That Apply a. Milk b. Caffeine c. Citrus fruit d. Chicken e. Vanilla ice cream

a. Auditory hallucinations b. Grandiose delusions c. Religious preaching all the time. d. Flat affect a., b., c., and d. Correct: Auditory hallucinations are commonly experienced by the client diagnosed with schizophrenia. Delusions of grandiosity like believing they are a famous person or religious figure is a false fixed belief experienced by the client. If the client is in the acute phase of schizophrenia, the person may be overwhelmed by anxiety and is not able to distinguish thoughts from reality. It is thought that delusions may develop to cope with the anxiety. Religiosity is common. The client may carry a bible all of the time and preach to everyone all of the time. The client may have an inappropriate affect, a flat affect, or a blunted affect. e. Incorrect: This client has concrete thinking which implies over emphasis on specific details and an impairment in the ability to use abstract concepts. For example, during the nursing history you may ask the client what brought them to the hospital and the answer will be "a cab."

Which signs/symptoms does the nurse expect to see in a client diagnosed with schizophrenia? Select All That Apply a. Auditory hallucinations b. Grandiose delusions c. Religious preaching all the time. d. Flat affect e. Abstract reasoning

c. Gently remove the debris and re-dress the wound. c. Correct: What likes to live in the scabs and dried blood? Bacteria. That is why it is important to remove the debris to prevent infection. a. Incorrect: This is not appropriate because bacteria is in the scabbing area and ointment would trap it, enhance reproduction of the germs, and increase infection. b. Incorrect: There is no need to notify primary healthcare provider at this time. This is not the best option for the nurse to fix the problem. d. Incorrect: We don't put lotion in the wound because this would cause infection of the wound.

While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and a dark collection of blood. What is the nurse's next action? Choose One a. Leave the scabbing area alone and apply extra ointment. b. Notify the primary healthcare provider. c. Gently remove the debris and re-dress the wound. d. Apply skin softening lotion for 3 hours and then re-dress.