NCLEX Prep: Foundations (Infection control, safety, communication, spirituality, sleep/rest, fluids/electrolytes, population, perioperative care, acid/bases, lab tests)

The nurse is providing orientation to a newly graduated nurse. During a discussion of isolation procedures, which statement by the graduate nurse indicates a need for further review of isolation guidelines?

"I can reuse a gown if it's not dirty, as long as I hang it up inside the client's room." Rationale:Guidelines from the Centers for Disease Control and Prevention (CDC) require that gowns used in isolation rooms be discarded after each use and not reused, even for the same client. The other options reflect correct isolation guidelines.

The nurse provides home care instructions to a client with hepatitis B. Which statement made by the client indicates the best understanding of how to prevent transmission of the disease?

"My partner needs to get the vaccine." Rationale:The vaccine is used as a preventive measure and is recommended for both sexual and household contacts of the person with hepatitis B. Hepatitis B can be transmitted through intimate contact, such as kissing. The vaccine is used for prevention. This disease is not transmitted through the use of towels.

The nurse is providing instructions to the assistive personnel (AP) who will be caring for a client with hand restraints. The nurse asks the AP to repeat the instructions to ensure that the AP understands the care. Which statement, if made by the AP, indicates an understanding of the care for this client?

"I need to remove the restraints at least every 2 hours to perform range-of-motion exercises." Rationale:The nurse would instruct the AP to check restraints, circulatory status, and skin integrity every 30 minutes. Additionally, restraints need to be removed at least every 2 hours to permit muscle exercise and promote circulation. Restraints are not to be secured to the bedrails because this could cause injury to the client if the rails are lowered. The responsibility of the client would not be placed on the family members. Agency guidelines regarding the use of restraints would always be followed.

A 7-year-old child is diagnosed with viral conjunctivitis. Antibiotic eye drops are prescribed for the child. When the parent asks the nurse when the child can return to school, what would the appropriate response be?

"The child usually needs to be kept home until the antibiotic eye drops have been administered for 24 hours." Rationale:Viral conjunctivitis is extremely contagious. The child usually needs to be kept home from school or day care until antibiotic eye drops have been administered for 24 hours. The pediatrician needs to be consulted on this time frame as well as the school because some schools may have different policies regarding when the child can return to school.

The nursing instructor determines that the nursing student understands the purposes of standard and transmission-based precautions if which statements are made? Select all that apply.

"They prevent transmission of organisms from client to client. They prevent transmission of organisms from primary health care providers to clients. They prevent transmission of organisms from clients to primary health care providers. They prevent transmission of organisms from primary health care providers and clients to people outside of the hospital. Rationale:The purpose of these precautions is to prevent the transmission of organisms from clients to primary health care providers (PHCPs), from PHCPs to clients, from client to client, and from PHCPs and clients to people outside of the hospital. Hospital visitors are not included in these infection-based precautions.

The nurse is transcribing a primary health care provider's prescription and notes that the client is to receive a medication at 1:00 p.m. Using the military time clock, the nurse documents which military time in the medication record for administration of the medication? Click on the image to indicate your answer.

1300

The nurse has administered diazepam 5 mg by the intravenous route to a client. The nurse would plan to maintain the client on bed rest for at least how long?

3 hours Rationale:The client would remain in bed for at least 3 hours after a parenteral dose of diazepam. The medication is a centrally acting skeletal muscle relaxant and has antianxiety, sedative-hypnotic, and anticonvulsant properties. Cardiopulmonary adverse effects of the medication include apnea, hypotension, bradycardia, and cardiac arrest. For this reason, resuscitative equipment also is kept nearby.

A registered nurse (RN) is providing instructions to an assistive personnel (AP) assigned to give a bed bath to a client who is on contact precautions. The RN instructs the AP to use which protective item when giving the bed bath?

A gown and gloves Rationale:Contact precautions require the use of gloves and a gown if direct client contact is anticipated. Goggles are not necessary unless it is anticipated that splashes of blood, bodily fluids, secretions, or excretions may occur. Shoe protectors are not necessary.

The nurse is preparing to care for a client with esophageal varices who needs a Sengstaken-Blakemore tube inserted because other treatments were unsuccessful. The nurse gathers supplies, knowing that which item must be kept at the bedside at all times?

A pair of scissors Rationale:The Sengstaken-Blakemore tube is a triple-lumen gastric tube that may be used to treat bleeding esophageal varices if other interventions are contraindicated or are ineffective. The tube has an inflatable esophageal balloon, an inflatable gastric balloon, and a gastric aspiration lumen. The gastric balloon applies pressure at the cardioesophageal junction to compress gastric varices directly and decrease blood flow to esophageal varices. Traction is applied to maintain the gastric balloon in place. When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. The client must be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures and the entire tube moves upward. If this occurs, the nurse immediately cuts all balloon lumens and removes the tube. An obturator and a Kelly clamp are kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside, but it is not the priority item.

The nurse is observing a second nurse perform hemodialysis on a client. The second nurse is drinking coffee and eating a doughnut next to the hemodialysis machine, while talking with the client about the events of his week. What is the nurse's most appropriate action regarding this observation?

Ask the nurse to refrain from eating and drinking in that area. Rationale:A potential complication with hemodialysis is the acquisition of dialysis-associated hepatitis B. This is a concern for clients (who may carry the virus), their families (at risk from contact with the client and with environmental surfaces), and staff (who may acquire the virus from contact with the client's blood). This risk is minimized by the use of standard precautions; appropriate handwashing and sterilization procedures; and the prohibition of eating, drinking, or other hand-to-mouth activities in the hemodialysis unit. The nurse would ask the second nurse to stop eating and drinking in the work area.

The ambulatory care nurse is working with a 22-year-old client who has been diagnosed with pelvic inflammatory disease (PID). The nurse incorporates which item in a teaching plan for this client?

Avoid frequent douching. Rationale:The client who has been diagnosed with PID would avoid frequent douching because it decreases the natural flora that controls the growth of infectious organisms. The client needs to wear cotton undergarments, and clothes should not fit tightly. Intrauterine devices increase the client's susceptibility to infection. Sanitary pads need to be changed at least every 4 hours. Tampons would not be used during the acute infection, and some primary health care providers may recommend avoiding them indefinitely. The client also needs to avoid strong soaps, sprays, powders, and similar products that will irritate the perineum.

The client seen in the health care clinic has tested positive for gonorrhea. The nurse anticipates that which medication will be prescribed based on this finding?

Ceftriaxone Rationale:Treatment for gonorrhea consists of antibiotic therapy, usually with ceftriaxone and doxycycline. Acyclovir is the treatment for genital herpes simplex virus; azithromycin is the treatment for Chlamydia infection, and penicillin G benzathine is the treatment for syphilis.

A client with active tuberculosis demonstrates less-than-expected interest in learning about the prescribed medication therapy. The nurse assesses that this client may ultimately need which intervention as a last resort?

Directly observed therapy Rationale:Tuberculosis is a highly communicable disease that is reportable to the local public health department. This agency has regulations that may be enforced to ensure compliance with tuberculosis therapy. Ultimately the client may be required to have directly observed therapy to reduce the risk to the public. This involves having a responsible person actually observe the client taking the medication each day.

The nurse employed on a medical unit in a hospital receives a telephone call from the admission office and is told that a client with a diagnosis of mycoplasmal pneumonia will be admitted to the unit. The nurse prepares for the admission and obtains the necessary supplies to place the client on which type of transmission-based precautions?

Droplet precautions Rationale:Droplet precautions are required for a client with mycoplasmal pneumonia because this type of pneumonia is transmitted by droplet nuclei larger than 5 mm. The nurse wears a mask while in the client's room. Enteric precautions are necessary when exposure from feces is likely; gloves are necessary and possibly a gown and face shield if splashes are expected to occur. Contact precautions are implemented when exposure to contaminated material, such as wound drainage, can occur and require the use of gloves and possibly a gown. Protective isolation is instituted when it is necessary to protect the client from others.

A client is receiving outpatient radiation treatments for carcinoma of the oropharynx and is experiencing dysphagia. The nurse would include which intervention in the plan of care?

Encourage the client to use artificial saliva to manage dryness. Rationale:Epithelial cells are destroyed by radiation involving the head and neck. Inflammation and ulceration occur because of the rapid cell destruction, impairing normal saliva excretion and distribution. Artificial saliva aids in preventing further damage by lubricating the affected area. A client with difficulty swallowing would avoid drinking thin liquids because of the increased risk of aspiration resulting from epiglottis dysfunction related to radiation therapy. Examining the oral mucosa is a preventive maintenance intervention to alert the client to changes in the mucosa, but this would be done daily, not monthly. The client with dysphagia has difficulty swallowing, not difficulty speaking; therefore, teaching the client to speak slowly and to enunciate clearly would provide no health benefit for the impairment in swallowing.

A client with pulmonary tuberculosis (TB) is on airborne isolation precautions. Which item(s) is essential for the nurse to wear?

High-efficiency particulate air (HEPA) filter mask Rationale:The hospitalized client with TB is placed on airborne isolation. A HEPA filter mask must be worn whenever the nurse enters the client's room because these masks can remove almost 100% of the small TB particles. This mask must fit snugly around the nose and mouth. Option 1 is an incorrect option; although gloves may be needed, the nurse must wear a HEPA mask. Option 2 is incorrect. The mask must be a HEPA mask. Option 3 is an incorrect choice. The mask must be a HEPA mask, and there is no need for gown and gloves unless a wound, body fluid, or blood is involved.

A female client seen in the ambulatory care clinic has a history of syphilis infection. The nurse assessing the client for reinfection would expect to observe a lesion on the labia that has which characteristic?

Is painless and indurated Rationale:The characteristic lesion of syphilis is painless and indurated. The lesion is referred to as a chancre. Genital warts are characterized by cauliflowerlike growths or growths that are soft and fleshy. Scabies is characterized by erythematous, papular eruptions. Genital herpes is accompanied by the presence of one or more vesicles that then rupture and heal.

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse would wear which items when performing this care?

Particulate respirator, gown, and gloves Rationale:The nurse who is in contact with a client with tuberculosis needs to wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath.

While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse would take which initial action?

Pick up the implant with long-handled forceps and place it in a lead container. Rationale:In the event that a radiation source becomes dislodged, the nurse would first encourage the client to lie still until the radioactive source has been placed in a safe, closed container. The nurse would use long-handled forceps to place the source in the lead container that would be in the client's room. The nurse would then call the radiation oncologist and document the event and the actions taken. It is not within the scope of nursing practice to insert a radiation implant.

The nurse is caring for an older client following surgical repair of a hip fracture. On assessment of the client, the nurse notes that the client is disoriented and is attempting to get out of bed. Which is the most appropriate initial nursing intervention?

Place a mattress sensor pad on the bed. Rationale:A client would not be placed in a physical restraint or sedated just because he or she is older and disoriented. Alternative methods would be used before applying any types of restraints. For example, a mattress sensor pad will alert the nursing staff of movement. Physical restraints may cause further disorientation and would not be applied unless specifically prescribed. Agency policies and procedures need to be followed before the application of restraints.

The nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for magnetic resonance imaging (MRI). Which nursing action is most appropriate in preparing the client for the test?

Place a surgical mask on the client for transport. Rationale:If the client is on airborne precautions, client movement and transport would be limited if possible. If transport or movement is necessary, client dispersal of droplet nuclei can be minimized by placing a surgical mask on the client. Options 1 and 2 are unnecessary. Option 4 is inappropriate. This leaves option 3, which is done to provide protection for the staff.

The nurse is teaching a client with acquired immunodeficiency syndrome (AIDS) how to avoid food-borne illnesses. The nurse would instruct the client that which food can cause a food-borne illness?

Raw oysters Rationale:The client is taught to avoid raw or undercooked seafood, meat, poultry, and eggs. The client also would avoid unpasteurized milk and dairy products. Fruits that the client peels are safe, as are bottled beverages. The client may be taught to avoid sorbitol, but this is to diminish diarrhea and has nothing to do with food-borne infections.

Which action by the parent of an infant with respiratory syncytial virus infection who is receiving ribavirin would indicate a need for further instruction regarding the management of the disease process?

Telling a family member, who is pregnant, that it is acceptable to visit the infant Rationale:When an infant is receiving ribavirin, exposure precautions need to be observed. Anyone entering the infant's room needs to wear a gown, mask, gloves, and hair covering. Anyone who is pregnant or considering pregnancy and anyone with a history of respiratory problems or airway disease would not care for or visit the infant who is receiving ribavirin. Handwashing is absolutely necessary before leaving the room to prevent the spread of germs.

The home health nurse is watching the caregiver change the sternotomy dressing on the postoperative client after teaching the caregiver about the procedure. Which action by the caregiver identifies correct principles of infection control?

The caregiver washes hands before removal of the soiled dressing and again before applying the clean dressing. Rationale:The single most effective technique to prevent the spread of germs and bacteria is hand washing. The initial step with all aseptic procedures is hand washing. Using previously opened gauze, not washing the hands after sneezing, and not applying new gloves after removing the old dressing increase the risk of wound contamination as a result of poor aseptic technique.

The charge nurse is assessing the nurse's knowledge about the use of an interpreter. Which statement made by the nurse requires a need for further teaching?

The use of an interpreter does not need to occur until the client requests one Rationale:The use of an interpreter would occur regularly and frequently while interacting with the client. Family members and friends would not be asked by a health care professional to be an interpreter. Confidentiality, conflict of interest, and the risk of relaying inaccurate information are all barriers to not using a designated health care agency interpreter.

A client with tuberculosis (TB), whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when which occurs?

Three sputum cultures are negative. Rationale:The client must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative because the client is considered noninfectious at that point. Therefore, the remaining options are incorrect. A negative chest x-ray does not mean that the client is noninfectious. A positive tuberculin skin test never reverts to negative.

The nurse participating in a health fair is setting up a booth on prevention of human immunodeficiency virus (HIV) transmission. A poster is planned that will list sexual behaviors in 1 of 2 columns, "safe" and "not safe." Which behavior would the nurse place in the "not safe" column?

Use of natural skin condoms Rationale:Abstinence is the safest way to avoid HIV infection. Another reliable method is participation in a mutually monogamous relationship. The use of latex condoms is considered safe because the latex prevents the transmission of HIV as long as the condom is used properly and remains in place. The use of natural skin condoms is not considered safe because the pores in the condom are large enough for the virus to pass through.

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client?

Wearing a gown and gloves Rationale:Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage or if the nurse is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

A nursing instructor asks a nursing student about a client admitted with tuberculosis (TB). What comment by the student indicates that there is a need for further teaching?

"It is a fast-growing infectious disease." Rationale:Mycobacterium tuberculosis is a nonmoving, slow-growing (not fast-growing), acid-fast rod transmitted via the airborne route. The other options are accurate statements.

The nurse teaches the parent of a child diagnosed with bacterial conjunctivitis about measures to prevent transmission of the infection. Which statement by the parent indicates a need for further teaching?

"It is all right to share towels and washcloths as long as they are bleached after use." Rationale:Bacterial conjunctivitis is highly contagious, and infection control measures need to be taught. These measures include frequent handwashing and not sharing towels and washcloths, regardless of the bleaching process. Options 2 and 4 are also correct treatment measures.

A client is diagnosed with conjunctivitis, and the nurse provides information to the client about the use of contact lenses. Which statement by the client would indicate the need for further information?

"My contact lenses can be worn if they are cleaned properly." Rationale:If the client wears contact lenses, the client needs to be instructed to discontinue wearing them until the infection has cleared completely. Securing new contact lenses will eliminate the chance of reinfection from contaminated contact lenses and will also lessen the risk of a corneal ulceration.

The nurse is caring for a client with acute viral hepatitis A who resides in a group home. Which outcome indicates that the most important goal has been achieved?

Avoids transmitting the virus to others in the group home Rationale:All of the options are expected outcomes of care for this client. However, because the disease is communicable to others, 1 of the most important goals in management of acute viral hepatitis is preventing the spread of infection.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?

Activate the fire alarm. Rationale:The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing all doors and, finally, the fire is extinguished.

The nurse is planning to teach a group of adolescents about the use of condoms as part of a risk reduction program for sexually transmitted infections (STIs). The nurse would plan to include which recommendation in the teaching plan?

Always apply the condom before inserting the penis into the vagina. Rationale:To be effective, condoms must be applied before any vaginal penetration occurs and must be used with every sexual encounter. A lubricated condom may be used to increase sensitivity of the glans. Natural membrane condoms are less effective than latex in preventing the spread of some STIs.

A client with right leg hemiplegia from a stroke has a problem with mobility. The nurse determines a need for reinforcement of teaching the client and the client's family if the nurse observes which action being done by the family?

Encouraging the client to stand unassisted on the leg Rationale:Depending on the client's functional ability, either passive or active range of motion is indicated to keep the joint moving freely. Application of a premolded splint also would keep the limb aligned and in good position. The client should not attempt to stand unsupported on a weak or paralyzed limb. The inability to bear weight will cause the client to fall.

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply.

Inhalation of bacterial spores Through a cut or abrasion in the skin Ingestion of contaminated undercooked meat Rationale:Anthrax is caused by Bacillus anthracis and can be contracted through the digestive system, through abrasions in the skin, or by inhalation through the lungs. It cannot be spread from person to person, and it is not contracted via bites from ticks or deerflies.

The nurse is inserting an indwelling urinary catheter into a client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What action would the nurse take next?

Insert the catheter 2.5 to 5 cm and inflate the balloon. Rationale:The balloon of the urinary catheter is behind the opening at the insertion tip. The catheter is inserted 2.5 to 5 cm after urine begins to flow to provide sufficient space to inflate the balloon. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. Inflating the balloon in the urethra could produce trauma.

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?

Placing the client in a semiprivate room at the end of the hallway Rationale:A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent accidental exposure of other clients to radiation. The remaining options identify accurate interventions for a client with an internal radiation implant and protect the nurse from exposure.

The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client?

Private room Rationale:Meningitis is transmitted by droplet infection. Precautions for this disease include a private room or cohort (as appropriate) client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis. When appropriate, a mask must be worn by the client and not the staff when the client leaves the room.

The nurse in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which action would the nurse take first?

Remove the client from the waiting room. Rationale:The first order of priority in the event of a fire is to rescue the clients in immediate danger. The next step is to activate the fire alarm. The fire is then confined by closing all doors, and last, the fire is extinguished.

A registered nurse (RN) asks a licensed practical nurse (LPN) to set up a hospital room for a client who is being admitted with a diagnosis of tonic-clonic seizures and asks the LPN to institute seizure precautions. The RN checks the client's room before the arrival of the client and determines that which item placed in the room by the LPN is unsafe?

Restraints Rationale:Seizure precautions include keeping side rails up and padded if the client has tonic-clonic seizures, ensuring that suction and oxygen equipment is available, and disabling the locks on the bathroom and room doors. Restraints are not used and can result in client injury.

The nurse is caring for an 18-month-old child with a fever who has been vomiting. Which is the most appropriate position for this child while sleeping?

Side-lying position Rationale:The vomiting child needs to be placed in an upright or side-lying position to prevent aspiration. Placing the child supine or prone will place the child at risk for aspiration if vomiting occurs.

The nurse is assessing the intravenous (IV) line of a client who is receiving a chemotherapy infusion. The assessment reveals coolness and swelling around the IV insertion site. What would the nurse do next?

Stop the IV infusion. Rationale:The assessment indicates that infiltration of the IV solution has occurred, and the infusion must be stopped immediately to prevent further infiltration of the chemotherapy fluid. The nurse next notifies the primary health care provider (PHCP) of the occurrence. The PHCP needs to prescribe the treatment for the insertion site. There is no useful reason for doing a chest x-ray.

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge to prevent infection of others. The nurse's response to the client's question is based on which correct understanding of TB transmission?

The disease is transmitted by droplet nuclei. Rationale:TB is spread by droplet nuclei or via the airborne route. The disease is not carried on objects such as clothing, eating utensils, linens, or furniture. It is unnecessary to remove carpeting from the home. Bleaching of clothing and linens is unnecessary, although the client and family members would use good handwashing technique.

The nursing student develops a plan of care for a client with a spinal cord injury with paraplegia who is at risk for injury related to spasticity of the leg muscles. On reviewing the student's plan, the nurse identifies which action as an incorrect intervention?

Using padded restraints to immobilize the limb Rationale:Use of limb restraints will not alleviate spasticity and could harm the client. Use of muscle relaxants is indicated if the spasms cause discomfort to the client or pose a risk to the client's safety. Range-of-motion exercises are beneficial in stretching muscles, which may diminish spasticity. Removing potentially harmful objects is a good safety measure.

The nurse is providing instructions to a client regarding the use of a walker. Which statement by the client would indicate the need for further instruction?

"The walker height needs to allow for about 45 degrees of flexion at my elbow so that the height of the walker will be safe." Rationale:In a standing position, there would be 15 to 30 degrees of flexion at the client's elbow. A walker of incorrect height will not allow the client's line of gravity to go through his or her base of support. The other options regarding the use of a walker are correct statements.

The nurse preceptor and the orientee note that the reticulocyte count for a client is increased. The preceptor determines that the orientee understands the significance of reticulocytes if the orientee makes which statement with regard to red blood cells (RBCs)?

"A reticulocyte is an immature RBC." Rationale:The reticulocyte is an immature RBC. The reticulocyte count is increased any time there is an accelerated production of RBCs. It is decreased when the bone marrow has slowed production of RBCs.

A nurse is educating prospective foster families on health care considerations for the foster child. Which statement made by a family member indicates a need for further teaching?

"All physicians will sign off on the child, so medical visits will not be necessary." Rationale:A foster child can often have complex health conditions. Frequent health visits will be needed during the transition from foster care to home to ensure that the child is acclimated well without any health concerns arising. Therefore option 3 is an incorrect statement by the family member, indicating the need for further teaching. Options 1, 2, and 4 are accurate statements.

A client preparing to go home 2 days following a right mastectomy with dissection of axillary lymph nodes to treat breast cancer asks the nurse, "What should I do to minimize my chance for complications from this surgery?" Which response would the nurse make?

"Avoid having blood pressures taken on your right arm." Rationale:Option 4 is the correct answer, as lymphedema (accumulation of lymph in soft tissue) can occur as a result of the excision of lymph nodes, and clients need to be taught measures to prevent and reduce lymphedema, including no blood pressure readings, venipunctures, or injections on the affected arm. Option 1 is incorrect, as it is important for clients to move the arm and promote lymphatic drainage. Clients need to be instructed on exercises that are designed to prevent contractures and muscle shortening, maintain muscle tone, and improve lymph and blood circulation. Option 2 is incorrect because the surgical incision needs to be examined daily, not just once a week. Option 3 is incorrect, as this could cause pressure and harm the surgical site.

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

"Can you share with me what you've been told about your surgery?" Rationale:Explanations would begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option 4 avoids the client's anxiety and is focused on postoperative care.

The client with a history of chronic lung disease is at risk for developing respiratory acidosis. The nurse asks this client about which symptoms that are characteristic of this disorder?

"Do you have a headache or become confused?" Rationale:When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache, restlessness, and mental status changes such as drowsiness and confusion, visual disturbances, diaphoresis, and cyanosis as the hypoxia becomes more acute, along with hyperkalemia, a rapid irregular pulse, and dysrhythmias.

The parent of a 2½-year-old child arrives at the hospital emergency department and reports to the nurse that the child has been complaining of a "tummy ache." The parent also reports that the child has been irritable and that it has been difficult to awaken the child. On further assessment, the nurse suspects lead poisoning. Which assessment question would elicit specific data related to this condition?

"Do you live in a house that is more than 25 years old?" Rationale:Homes that are older than 25 years may have lead paint and will most likely have lead pipes, which can contribute to lead poisoning. Pencil lead is made of graphite, so it does not present a hazard to the child. Crayons are not toxic. A sweet and fruity odor to the breath is a symptom of ketoacidosis. Rapid breathing and diaphoresis are signs of salicylate poisoning.

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep?

"I drink hot chocolate before bedtime." Rationale:Many nonpharmacological sleep aids can be used to influence sleep. However, the client needs to avoid caffeinated beverages and stimulants such as tea, cola, and chocolate. The client needs to exercise regularly because exercise promotes sleep by burning off tension that accumulates during the day. A 20- to 30-minute walk, swim, or bicycle ride 3 times a week is helpful. The client needs to sleep on a bed with a firm mattress. Smoking and alcohol need to be avoided. The client needs to avoid large meals; peanuts, beans, fruits, raw vegetables, and other foods that produce gas; and snacks that are high in fat because they are difficult to digest.

A client is being discharged to home after application of a plaster leg cast to treat a fracture. Which statement indicates to the nurse that the teaching has been effective?

"I need to avoid getting the cast wet." Rationale:A plaster cast must remain dry to keep its strength. The cast needs to be handled using the palms of the hands, not the fingertips, until fully dry. The client should never scratch under the cast. A hair dryer set at a cool setting may be used to relieve an itch. Air would circulate freely around the cast to help it dry. Also, the cast gives off heat as it dries.

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of rheumatoid arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement?

"I need to continue to take the aspirin until the day of surgery." Rationale:Antiplatelets alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter platelet aggregation and needs to be discontinued at least 48 hours before surgery. However, the client would always check with the surgeon regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements.

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement?

"I need to continue to take the aspirin until the day of surgery." Rationale:Antiplatelets alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter platelet aggregation and would be discontinued at least 48 hours before surgery. However, the client needs to check with the surgeon regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements.

The charge nurse is educating a new nurse on culturally competent communication techniques. Which response(s) made by the new nurse indicates a need for follow-up? Select all that apply.

"I would use a language interpreter for all culturally diverse groups. I need to recognize my own biases and address known stereotypes with the client." Rationale:Knowing and understanding the client's needs and their beliefs about health help to guide the plan of care. Health care providers need to know the client's perspectives and cultural preferences to create a treatment plan that is realistic, acceptable, and individualized for each client. Communicating in a professional and respectful manner will optimize client outcomes. A language interpreter may not be necessary for some ethnic groups that speak English. It is also important to have self-awareness about any biases or misconceptions regarding other ethnic groups. It is not appropriate to address these directly with the client.

The nurse has provided discharge instructions to a client after radical vulvectomy. Which statement by the client indicates a need for further instruction?

"It is all right to ride in a car as much as I want, as long as I am not driving the car." Rationale:The client needs to avoid activities such as sitting for long periods and doing heavy housework until approved by the primary health care provider (PHCP) because of pressure and trauma at the surgical site. The client needs to be instructed to avoid sexual activity for 4 to 6 weeks or as indicated by the PHCP. The client would keep the perineal area as clean and dry as possible and needs to wash the perineum with solutions such as peroxide and water or as prescribed after each urination or defecation to prevent infection. The client needs to be instructed to report any redness, swelling, drainage, odor, or increased soreness along the suture line because these are signs of infection.

The home care nurse visits a client who has been started on oxygen therapy. The nurse provides instructions to the client regarding safety measures for the use of oxygen in the home. Which statement, if made by the client, indicates a need for further instruction?

"It is all right to use an electric razor for shaving if I leave it plugged in for only a short time." Rationale:The use of small electric items, tools, or other equipment could emit sparks; these items need to be avoided while oxygen is in use. The use of this equipment could result in fire and injury to the client. The client also would be instructed not to allow smoking in the home and to stay at least 10 feet away from any type of flame. The oxygen concentrator is kept away from walls and corners to permit adequate airflow.

An 85-year-old client is hospitalized for a fractured right hip. During the postoperative period, the client's appetite is poor and the client refuses to get out of bed. Which nursing statement would be most appropriate to make to the client?

"It is important for you to get out of bed so that calcium will go back into the bone." Rationale:Early ambulation in the postoperative period is important because if a client does not increase activity, the bones will suffer from loss of calcium. Iron, not iodine, is recommended for hemoglobin synthesis because oxygen is necessary for wound healing. Increasing calcium intake would cause elevated amounts of calcium in the blood, which could lead to kidney stones. Clients who are not turned in bed will develop pressure ulcers. An 85-year-old who is immobile needs to be turned every 2 hours by the nursing staff; clients would not be expected to turn themselves.

The nurse educator asks a student to list the five main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories?

"Magnetic therapy and massage therapy are a focus of CAM." Rationale:The five main categories of CAM include whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine. Magnetic therapy and massage therapy are therapies within specific categories of CAM.

The primary nurse is caring for a client who is intellectually disabled. Another nurse states, "I hate when this client comes in." What response made by the primary nurse is best?

"The communication barriers present are frustrating, but we work through it." Rationale:Communication barriers between health care professionals and those with an intellectual disability present unique challenges in identifying and managing health care needs. These clients are often poor historians and may require more time for questioning and care. The nurse needs to recognize personal biases or misunderstandings about those in this population. Equitable and fair treatment for the client is expressed in option 4. The nurse recognizes an obstacle but does not hinder the care provided. Options 1 and 3 are nontherapeutic statements. Option 2, although correct, is not the best statement and minimizes the individualized needs of a person in this population.

The nurse manager is giving a staff in-service on providing culturally sensitive education to clients. Which statements indicate to the nurse manager that the staff understands providing culturally sensitive education? Select all that apply.

"The population served will determine the culturally sensitive resources to use for teaching. Assessment of a client's preferred learning approach is essential to facilitate the learning process. It is important to have an accurate translator when the nurse and client do not speak the same language." Rationale:Providing culturally competent care or education is an important aspect of nursing. Care or education must be emphatically based on the client's culture; otherwise, the care or education is not specific to the client. The correct options address culturally specific and individualized care. Options 1 and 2 are not individually focused.

A client is about to have arterial blood gases drawn, and the nurse explains what an Allen's test is. What comment shows that the client understands the nurse's explanation?

"This test is done to make sure my circulation is good." Rationale:The Allen's test is important because it ensures collateral circulation to the hand if thrombosis of the radial artery occurs after the puncture. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Options 1, 3, and 4 are incorrect.

The nurse is completing medication reconciliation with a client just before discharge to home. The client asks, "Why are you going over this list? They did that when I was admitted!" Which statement by the nurse is the best response?

"We do this to make sure you will be receiving the correct medications once you are at home." Rationale:Although medication reconciliation is a required procedure by The Joint Commission, the purpose is to reduce the risk of medication error and to ensure that the client receives the correct medication at home. Explanation of the purpose is a better answer than simply explaining that it is a required procedure.

The nurse provides home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further instruction?

"When I'm feeling better, I'm returning to the soccer team." Rationale:Clients with sickle cell anemia are advised to avoid strenuous activities. Quiet activities as tolerated are recommended when the client is feeling well. Increasing fluid intake is encouraged to assist in preventing sickle cell crisis.

The nurse cares for a client prior to surgery. The client asks the nurse, "What is the advantage of spinal anesthesia over general anesthesia for controlling my pain?" Which is the best response by the nurse?

"Your pain can be managed without making you as sleepy." Rationale:An advantage of spinal anesthesia (a regional anesthesia) is pain control without any accompanying cognitive dysfunction. Thus, option 3 is the correct option. With spinal anesthesia the local anesthetic is administered directly into the cerebrospinal fluid, producing an autonomic, sensory, and motor blockade. The autonomic blockade causes vasodilation that can result in hypotension, so option 1 is incorrect. Option 2 is incorrect, as itching is a common side effect with morphine. Option 4 is incorrect, as the autonomic, sensory, and motor blockade produced by the spinal anesthesia can result in lack of bladder control and either urinary incontinence or retention.

The nurse checks the laboratory results of a serum medication level assay for a newly admitted client with a history of heart failure taking digoxin 0.125 mg orally daily. The nurse determines that which value indicates a therapeutic level?

0.6 ng/mL (0.76 nmol/L) Rationale:The normal therapeutic range for digoxin is 0.5 to 2.0 ng/mL (0.6 to 2.4 nmol/L). A value of 0.6 ng/mL (0.76 nmol/L) falls within the therapeutic range. A value of 0.1 ng/mL (0.13 nmol/L) is lower than the therapeutic range and would require additional medication to be given. A value of 2.4 ng/mL (2.30 nmol/L) or 2.8 ng/mL (3.07 nmol/L) exceeds the therapeutic range, could be toxic to the client, and would indicate the need to withhold the medication and contact the physician.

The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution would the nurse use to irrigate the NG tube?

0.9% sodium chloride Rationale:Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. Tap water, sterile water, and 0.45% sodium chloride are hypotonic solutions.

The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse determines that the urine specific gravity is normal if which value is noted on the laboratory results?

1.019 Rationale:The normal range for urine specific gravity is between 1.005 and 1.030. Values of 1.001 and 1.003 represent low values, and 1.036 reflects an elevated value.

A client has a prescription to have blood drawn to measure peak and trough vancomycin levels to determine the effectiveness of therapy with this medication. The nurse arranges with the laboratory to have the peak level specimen drawn at which time?

1.5 hours after completion of the scheduled infusion Rationale:Peak serum medication levels would be monitored to ensure that the dosage is appropriate and would be drawn 1.5 to 2.5 hours after the intravenous infusion is completed. Peak levels of 30 to 40 mcg/mL generally are acceptable. Options 1, 3, and 4 are incorrect.

The nurse is preparing to administer an intramuscular injection to a 4-year-old child. The nurse plans to administer the injection in the ventral gluteal muscle, knowing that which indicates the maximum amount of medication volume that can be safely injected?

1.5 mL Rationale:In a young child, ages 3 to 6 years, the maximum volume of medication that can be tolerated into the ventral gluteal muscle is 1.5 mL.

The nurse is evaluating the laboratory test results for a client with diabetes mellitus seen in the health care clinic. The nurse determines that which glycosylated hemoglobin level value shows poor adherence to therapy?

10% Rationale:The normal glycosylated hemoglobin in an adult without diabetes is <6%. Levels >8% indicate poor diabetic control and need for adherence to regimen or changes in therapy. The results in the remaining options indicate adequate control.

The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? Select all that apply.

10% dextrose in water 5% dextrose in 0.9% saline 5% dextrose in 0.45% saline 5% dextrose in lactated Ringer's solution Rationale:Hypertonic fluids include 10% dextrose in water, 5% dextrose in 0.9% saline, 5% dextrose in 0.45% saline, and 5% dextrose in lactated Ringer's solution. The solutions of 0.45% sodium chloride and 5% dextrose in 0.225% saline are not hypertonic solutions

The nurse is reviewing the laboratory test results for a client who was treated for pancreatitis who reports to the health care clinic for a follow-up visit. The nurse determines that the serum lipase level is normal if which value is noted on the laboratory report?

100 U/L (100 U/L) Rationale:The normal serum lipase level is 0 to 160 U/L (0 to 160 U/L). The remaining options reflect either low or elevated serum lipase levels.

The nurse just completed an assessment and reviewed the laboratory test results for an adult adult client client seen in the clinic. The client complains of being tired. The nurse determines that the hemoglobin level is normal if which value is noted on the laboratory report?

14 g/dL (140 mmol/L) Rationale:The normal hemoglobin level for an adult ranges from 12 to 16 g/dL (120 to 160 mmol/L). A hemoglobin level of 8 g/dL (80 mmol/L) is low, while 22 and 32 g/dL (220 and 320 mmol/L) are extremely elevated.

The nurse is reviewing the results of the electrolyte panel for a client seen in the clinic. The nurse determines that the client's sodium level is normal if which value is noted?

142 mEq/L (142 mmol/L) Rationale:The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A sodium level of 120 mEq/L (120 mmol/L) is low, while sodium levels of 148 and 152 mEq/L (148 and 152 mmol/L) are high.

The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse reports to the client that the total cholesterol level is within the recommended guidelines if which value is noted on the laboratory report?

146 mg/dL (4 mmol/L) Rationale:The client needs to be counseled to keep the total cholesterol level under 200 mg/dL (under 5 mmol/L) or even lower as recommended by the primary health care provider. Controlling cholesterol levels will aid in prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life.

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?

15 mg/dL (5.25 mmol/L) Rationale:The normal BUN level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Values of 29 mg/dL (10.15 mmol/L) and 35 mg/dL (12.25 mmol/L) reflect continued dehydration. A value of 3 mg/dL (1.05 mmol/L) reflects a lower than normal value, which may occur with fluid volume overload, among other conditions.

A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?

15 mg/dL (5.4 mmol/L) Rationale:The normal BUN level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Values of 29 mg/dL (10.44 mmol/L) and 35 mg/dL (12.6 mmol/L) reflect continued dehydration. A value of 3 mg/dL (1.08 mmol/L) reflects a lower-than-normal value, which may occur with fluid volume overload, among other conditions.

An adult client with a history of seizure disorder is having a routine serum phenytoin level drawn. Which serum phenytoin result indicates that the client is having a therapeutic effect of the medication?

16 mcg/mL (63.4 mcmol/L) Rationale:The therapeutic range for serum phenytoin level is 10 to 20 mcg/mL (39.6 to 79.2 mcmol/L). A level below the therapeutic range could place the client at risk for seizures. If a level is too high, the client is at risk for toxicity. At levels above 20 mcg/mL (79.2 mcmol/L), toxicity can occur with nystagmus, sedation, ataxia (staggering gait), diplopia (double vision), and cognitive impairment.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's platelet level is normal if which value is noted?

160,000 mm3 (160 × 109/L) Rationale:A normal platelet count ranges from 150,000 to 400,000 mm3 (150 to 400 × 109/L). Values of 70,000 and 110,000 mm3 (70 and 110 × 109/L) identify decreased values. A value of 500,000 mm3 (500 × 109/L) is an elevated value.

The nurse in the respiratory care unit completes a lung assessment and reviews the laboratory results of a serum medication level assay for a client with obstructive pulmonary disease receiving theophylline. The nurse determines that a therapeutic medication level has been achieved by indication of which value?

18 mcg/mL (100 mcmol/L) Rationale:The therapeutic range for serum theophylline is 10 to 20 mcg/mL (55.5 to 111 mcmol/L). If the level is less than the therapeutic range, the client may experience frequent exacerbations of the respiratory disorder. If the level is too high, the medication may need to be stopped or the dose may need to be lowered. Values of 8 and 9 mcg/dL (44 and 50 mcmol/L) indicate low values although some physicians may consider these levels acceptable for certain clients, while 26 mcg/dL (144 mcmol/L) indicates an elevated value, which can be harmful.

The nurse is administering an acetaminophen suppository to a child with a fever. The nurse inserts the suppository into the rectum a distance of no more than how many centimeters?

2 Rationale:The child's rectal vault is not as long as that of an adult, and the distance required to place medications is approximately 1 to 2 cm. After insertion, the buttocks would be held together until the urge to expel the suppository has passed.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the blood urea nitrogen (BUN) level is normal if which value is noted on the laboratory report?

20 mg/dL (7.1 mmol/L) Rationale:The normal BUN level ranges from 10 to 20 mg/dL (3.6 to 7.1 mmol/L). A BUN of 30 or 39 mg/dL (10.7 or 14.0 mmol/L) reflects an elevated value, while 4 mg/dL (1.4 mmol/L) reflects a lower than normal value.

After completing an assessment and reviewing the laboratory test results of a client admitted to the hospital with acute left side abdominal pain, the nurse would take action for which noted serum amylase level?

200 Somogyi units/dL (100 U/L) Rationale:The normal serum amylase level ranges from 60 to 120 Somogyi units/dL (30 to 220 U/L), depending on the laboratory running the test. Option 4 is out of range for a serum amylase level and would require action by the nurse. The values in the remaining options are normal serum amylase levels and would not require any action.

The nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. The nurse would implement neutropenic precautions if the client's white blood cell count was which value?

2000 mm3 (2.0 × 109/L) Rationale:The normal WBC count ranges from 5000 to 10,000 mm3 (5 to 10 × 109/L). The client who has a decrease in the number of circulating WBCs is immunosuppressed. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values.

The nurse is caring for a client with a diagnosis of lung cancer who is immunosuppressed. The nurse would plan to implement neutropenic precautions if the client's white blood cell count was which value?

2000 mm3 (2.0 × 109/L) Rationale:The normal WBC count ranges from 5000 to 10,000 mm3 (5 to 10 × 109/L). The client who has a decrease in the number of circulating WBCs is immunosuppressed. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values.

The nurse is reviewing the laboratory results of a serum medication level assay for a client seen in the health care clinic who has been taking phenytoin for the control of seizures. The nurse determines that a subtherapeutic level of phenytoin is present and that additional medication is required if which level is found?

3 mcg/mL (12 mcmol/L) Rationale:The therapeutic range for a serum phenytoin level is 10 to 20 mcg/mL (40 to 79 mcmol/L). A level of 3 mcg/dL (12 mcmol/L) is subtherapeutic and would indicate the need for additional medication. If the level is less than the therapeutic range, the client may continue to experience seizure activity. The level in option 4 is high. If the level is too high, the client could experience phenytoin toxicity.

A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, would be reported before administering the dose of furosemide?

3.2 mEq/L (3.2 mmol/L) Rationale:The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range.

A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, would the nurse report before administering the dose of furosemide?

3.2 mEq/L (3.2 mmol/L) Rationale:The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range.

The nurse is reviewing the electrolyte panel results for an assigned client who is taking a potassium supplement. The nurse would determine that a therapeutic effect is present if which value is noted?

4.0 mEq/L (4.0 mmol/L) Rationale:The normal serum potassium level for an adult client is approximately 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The values in options 1, 2, and 3 are incorrect because they are low.

The nurse is providing instructions to a client who will be self-administering eye drops. To minimize systemic absorption of the eye drops, the nurse would instruct the client to take which action?

Occlude the nasolacrimal duct with a finger after instilling the drops. Rationale:Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication. Options 1, 2, and 3 will not prevent systemic absorption.

The nurse is calculating a client's fluid intake for a 24-hour period. The client suffers from chronic kidney disease, is on hemodialysis, and urinates about 100 mL a day. The client is on a fluid restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his medications, and 4 oz of iced tea at lunch and dinner. At 0800 and again at 1400, the client received his intravenous antibiotics in 50 mL of normal saline. How many mL of fluid does the client have left to drink for the day? Fill in the blank.

30mL Rationale:The hemodialysis client has severe renal insufficiency and requires fluid restriction. Clients receiving hemodialysis are limited to a fluid intake resulting in a gain of no more than 0.45 kg (1 lb) per day on the days between dialysis and a daily intake of 500 to 750 mL plus the volume lost in urine. The client consumed a total of 24 oz of fluid (8 oz at breakfast, 8 oz with medications, and 4 oz at lunch and 4 oz at dinner). This equals 720 mL (1 oz = 30 mL). The client also received a total of 100 mL of intravenous fluid (50 mL at 0800 and 50 mL at 1400). The total fluid intake is 820 mL. The client voids approximately 100 mL of urine a day so add that to the prescribed daily intake (750 plus 100 equals 850 allowable daily fluid intake). So if the client took in 820 mL and is allowed 850 mL, subtract 820 from 850. The client may drink 30 mL more fluid on this day.

The nurse is reviewing the results of the electrolyte panel for a client seen in the health care clinic. The nurse determines that the client's potassium level is normal if which value is noted?

4.0 mEq/L (4.0 mmol/L) Rationale:The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium level of 2.0 mEq/L (2.0 mmol/L) identifies a low level, while 5.3 and 6.0 mEq/L (5.3 and 6.0 mmol/L) identify elevated levels.

The nurse is reviewing the laboratory test results for an adult client who is being treated for anemia. The nurse determines that the hematocrit level is normal if which value is noted on the laboratory report?

50% (0.50) Rationale:The normal hematocrit level for an adult ranges from 37% to 52% (0.37 to 0.52 volume fraction). A hematocrit of 58% (0.58) is a high level, whereas 40% and 32% are low hematocrit levels.

A client with a diagnosis of hyperphosphatemia has been treated with dietary management and phosphate binding gels. The client reports to the clinic, and the nurse is reviewing the laboratory results. Which reported serum phosphate level would indicate improvement in the client's condition?

4.0 mg/dL (1.3 mmol/L) Rationale:The normal range of serum phosphate is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The only option that indicates improvement in the client's condition is the serum phosphate level of 4.0 mg/dL (1.3 mmol/L). The values in the remaining options represent elevated serum phosphate values.

A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse determines that which fibrinogen level is normal?

400 mg/dL (4.0 g/L) Rationale:The normal fibrinogen level is 200 to 400 mg/dL (2 to 4 g/L). With DIC, the fibrinogen level drops because fibrinogen is used up in the clotting process. The correct option is the only one that identifies a normal level.

An adult male client admitted to the hospital with shock has received fluid volume replacement. The nurse would determine that the client has had adequate fluid resuscitation if the client's repeat hematocrit level has decreased to which value in the normal range?

48% (0.48) Rationale:The normal hematocrit level for an adult male is 42% to 52% (0.42 to 0.52). The client who is in shock has an elevated level because of hemoconcentration. The client's level may be expected to drift back down to within the normal range once fluid volume has been adequately restored. Thus, 48% (0.48) is the only correct choice; 56% (0.56) is too high, and 34% (0.34) and 37% (0.37) are low.

A client with diabetes mellitus reports to the clinic for determination of the glycosylated hemoglobin (HbA1c) level. Which value on this laboratory test indicates client compliance with the prescribed diabetic regimen?

6% Rationale:The HbA1c measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Depending on the primary health care provider preference, the level should be <6% for an adult without diabetes. Elevations in blood glucose will cause elevations in the amount of glycosylation. Elevations indicate a continued need for teaching related to prevention of hyperglycemic episodes.

The nurse instructs a client with diabetes mellitus who takes insulin about blood glucose monitoring and monitoring for signs of hypoglycemia. The nurse would inform the client that a blood glucose level of which value indicates hypoglycemia?

60 mg/dL (3.3 mmol/L) Rationale:The principal adverse effect of insulin therapy is hypoglycemia, a blood glucose level of 60 mg/dL (3.3 mmol/L) or lower. The remaining options identify values that are in the normal blood glucose range.

The nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The nurse would expect the hematocrit level for this client to be noted at which level?

60% (0.60) Rationale:The normal hematocrit level is approximately 42% to 52% (0.42 to 0.52) in a male and 37% to 47% (0.37 to 0.47) in a female. Because hematocrit is measured as a proportion of red blood cells to a volume of blood, a decrease in fluids that make up the blood can cause an increase in hematocrit level. In a client with dehydration, the nurse would expect to note that the hematocrit level is increased. Conversely, an increase in fluid can cause a decrease in the hematocrit level.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the serum protein level is normal if which value is noted on the laboratory report?

7.0 g/dL (70 g/L) Rationale:The normal range for the serum protein level in the adult client is 6.4 to 8.3 g/dL (64 to 83 g/L). Values of 0.9 and 2.7 g/dL (9 and 27 g/L) identify low protein levels, while a value of 9.2 g/dL (92 g/L) identifies an elevated protein level.

The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse determines that the white blood cell (WBC) count is normal if which value is noted on the laboratory report?

8600 mm3 (8.6 × 109/L) Rationale:The normal WBC count ranges from 5000 to 10,000 mm3 (5 to 10 × 109/L). Values of 2000 mm3 (2 × 109/L) and 3600 mm3 (3.6 × 109/L) indicate low values, while 13,500 mm3 (13.5 × 109/L) indicates an elevated value.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's fasting serum glucose level is normal if which value is noted?

99 mg/dL (5.5 mmol/L) Rationale:The normal fasting blood glucose is 70 to 99 mg/dL (4 to 5.65 mmol/L) in the adult client. The results in the remaining options indicate elevated fasting serum glucose levels.

The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client would the nurse monitor closely for signs of hyperkalemia?

A client admitted 6 hours ago with a 40% burn injury Rationale:Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium caused by early massive cell destruction, such as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.

The nurse is working at a Veterans Affairs clinic that provides services for homeless veterans. Which client would the nurse attend to first?

A client with a plan to harm themself Rationale:Mental health is common among veterans. Post-traumatic stress disorder (PTSD) is one of the most prevalent problems and can easily lead to suicide, which occurs commonly in this population. A client with a plan to harm themself or others is a safety risk and need to be addressed first. Options 1 and 3 may or may not compete for priority, depending on other presenting factors. An infected wound can lead to a life-threatening situation, but the client with a persistent cough may have tuberculosis and this is a communicable disease. The client with a history of substance abuse can be attended to last.

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

A client with an ileostomy Rationale:A fluid volume deficit occurs when the fluid intake is insufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.

Considering the primary health risks associated with a military veteran who has just been discharged from active duty, which community resources are most appropriate for the nurse to suggest? Select all that apply.

A counseling center An employment agency Veterans Affairs services Rationale:Mental health is a prevalent issue in this population. Providing assistance to identify and treat mental disorders is important. Veterans who may be experiencing health issues can find management assistance through community services designed specifically for them. Resources for mental health, preparation to reenter the civilian workforce, and a service center such as Veterans Affairs services would be specifically recommended to this population. A public health clinic is not needed because the veteran will be cared for by Veterans Affairs services. Tuition assistance is not a primary concern; in addition, the Veterans Affair services will address this if the veteran expresses a desire to pursue his or her education.

The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care. A staff member asks the nurse educator to provide an example of the concept of acculturation. The nurse educator would make which most appropriate response?

A person who moves from China to the United States (U.S.) and learns about and adapts to the U.S. culture." Rationale:Acculturation is a process of learning a different culture to adapt to a new or changing environment. Options 1 and 3 describe a subculture. Option 4 describes ethnic identity.

The nurse is teaching a graduate nurse in the operating room about the components of Universal Protocol, one of The Joint Commission's National Patient Safety Goals. What specific component would the nurse include in the instructions?

A time-out needs to be performed in the operating room before the procedure. Rationale:Universal Protocol is one of The Joint Commission's National Patient Safety Goals. It is a protocol that is followed to prevent wrong site, wrong procedure, and wrong surgery. Option 3 is the correct option because part of Universal Protocol involves performing a time-out in the operating room to identify the correct client, the correct surgical site, and the correct procedure. Although options 1, 2, and 4 are also safety procedures, they are not specific components of Universal Protocol.

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved?

A urine specific gravity of 1.043 Rationale:The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.003 to 1.030. A temperature of 98.8° F (37.1° C) is only 0.2 of a point above the normal temperature and would not be as specific an indicator of hydration status as the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range.

The nurse caring for a refugee considers which health care need a priority for this client?

Access to mental health care services Rationale:Mental health problems are the primary concern for this population as a result of difficult events. While all other options are important for all clients, they do not address the specific needs of this population.

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse would take which initial action?

Activate the emergency response plan specific to the facility. Rationale:In an external disaster (a disaster that occurs outside of the institution or agency), many victims may be brought to the ED for treatment. The initial nursing action must be to activate the emergency response plan specific to the facility. Once the emergency response plan is activated, the actions in the other options will occur.

The nurse purchases a cup of coffee, a bottle of water, and a bagel in the hospital cafeteria and then returns to the nursing unit to take a morning break in the staff lounge. On entering the lounge, the nurse notes that the cushion of a chair is on fire. What would the nurse's first action be?

Activate the fire alarm. Rationale:The initial nursing action in the event of a fire would be to remove any clients from the vicinity of the fire. The next step would be to activate the fire alarm. The nurse would then contain the fire, followed by extinguishing the fire. In the situation described in the question, the initial nursing action would be to activate the fire alarm. Pouring water or coffee onto the fire or attempting to extinguish the fire with the use of a fire extinguisher can delay obtaining lifesaving assistance from the fire department.

The nurse is reviewing the laboratory test results for a client and notes that the serum potassium level is 5.5 mEq/L (5.5 mmol/L). The nurse understands that this value would be noted in which condition?

Addison's disease Rationale:The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Many pathological conditions, including Addison's disease, adrenocortical insufficiency, anemia, burns, and ketoacidosis, result in an increased potassium level. Hyperkalemia can also cause abdominal cramping and diarrhea. The conditions in the remaining options would result in a decreased serum potassium level.

Which most essential element would the nurse consider to promote client adherence to care recommendations?

Adhering to the client's cultural preferences Rationale:The client's care would encompass their perspective and beliefs about health. Understanding the client's cultural preferences will allow the nurse to create a plan of care that is realistic and acceptable to the client. Although options 1, 3, and 4 are important, they are not the most essential.

The nurse is caring for a pediatric client who is recovering from abuse and neglect. Place in order of priority the interventions that the nurse performs. All options must be used.

Administer pain medications Clean and dress wounds Ensure environmental safety Provide emotional support Rationale:Interventions that may be performed by the nurse when caring for a client who is a victim of abuse or neglect include administering pain medications, providing wound care, using assistive devices to support sprains or fractures, and educating the client and family about self-care, as well as education on support programs that provide awareness and emotional support. Also, ensuring that the victim is in a safe environment both in the hospital and when the victim is discharged is a priority. Administering pain medications and cleaning and dressing wounds need to be done first, followed by ensuring environmental safety and providing emotional support.

A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse would plan to carry out which prescribed measure as the most effective means to treat the problem?

Administer prescribed antibiotics. Rationale:The most effective way to treat an acid-base disorder is to treat the underlying cause of the disorder. In this case, the problem is sepsis, which is most effectively treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis but do nothing to treat the acid-base balance. The paper bag and partial rebreather mask will assist the client in rebreathing exhaled carbon dioxide, but again, these do not treat the primary cause of the imbalance.

The nurse is instructing a client to perform a 2-point gait for crutch walking. The nurse would tell the client to perform which action?

Advance the right crutch and the left foot forward, followed by advancing the right foot and the left crutch forward. Rationale:The 2-point gait is used when weight bearing is allowed on both feet. Only 2 points are in contact with the floor. The 2-point gait closely resembles normal walking. Options 1 and 2 describe 3 points of contact. Option 3 describes 4 points of contact.

A client has been taught to use a walker to aid in mobility after internal fixation of a hip fracture. The nurse determines that further teaching is required if the client performs which action?

Advances the walker with reciprocal motion Rationale:A disadvantage of the walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks; thus the client would not be supporting the weaker leg with the walker during ambulation. The client would use the walker by placing the hands on the hand grips for stability. The client lifts the walker to advance it and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg.

The nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates will take which action?

After maximal inspiration, hold the breath for 10 seconds and then exhale. Rationale:For optimal lung expansion with the incentive spirometer, the client would assume a semi-Fowler's or high-Fowler's position. The mouthpiece would be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client would hold the breath for 2 or 3 seconds and then exhale slowly.

Which nursing actions would indicate a need for further teaching as it applies to fire safety? Select all that apply.

Aims the fire extinguisher at the top of the fire Sweeps the fire extinguisher in an upward and downward motion Rationale:Use the mnemonic RACE to prioritize in the event of a fire. R is rescue clients in immediate danger, A is alarm (sound the alarm), C is confine the fire by closing all doors, and E is extinguish. To properly use the fire extinguisher, remember the mnemonic PASS to prioritize in the use of a fire extinguisher. P is pull the pin, A is aim at the base of the fire, S is squeeze the handle, and S is sweep from side to side to coat the area evenly.

The nurse is assessing a client who had abdominal surgery earlier in the day. Which preexisting medical condition would place the client at most risk for postoperative complications?

Alcohol abuse Rationale:A client with a history of alcohol abuse is at risk for liver disease, including altered metabolism and elimination of medications, impaired wound healing, and clotting and bleeding abnormalities. A client with this risk factor also would be at risk for experiencing alcohol withdrawal during the postoperative period. Clients with a pacemaker, osteoporosis, and peptic ulcer disease need to be monitored closely but are not at risk for major complications, as is the client with alcohol abuse and liver disease.

The nurse is assigned to care for a client who is experiencing episodes of postural hypotension. Which action would the nurse take to ensure safety while transferring the client from the bed to the chair?

Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair. Rationale:Having the client sit on the side of the bed before transfer allows the body to adjust to position changes, thereby avoiding a fall resulting from postural hypotension. The nurse would remain with the client and assist in the transfer to the chair. Options 1 and 2 are not necessary. Although option 3 is an important measure, it is not related to preventing postural hypotension.

A client with cirrhosis is admitted with possible hepatic encephalopathy. The nurse determines that which noted serum laboratory abnormality supports this suspicion?

Ammonia level of 98 mcg/dL (60 mcmol/L) Rationale:The normal serum ammonia level ranges from 10 to 80 mcg/dL (6 to 47 mcmol/L). High levels of ammonia can result in encephalopathy and coma. The other blood levels are unrelated to hepatic encephalopathy and are also normal values.

A client is admitted to the ambulatory surgery center for elective surgery. The nurse asks the client whether any food, fluid, or medication was taken today. Which medication, if taken by the client, would indicate to the nurse the need to contact the surgeon?

An anticoagulant Rationale:An anticoagulant suppresses coagulation by inhibiting clotting factors. A client admitted for elective surgery would have been instructed to discontinue the anticoagulant 7 to 10 days preoperatively. Even if this were unscheduled surgery, the nurse needs to notify the surgeon. Vitamin K can be given for reversal of its action, but the client may still have an increased risk of bleeding. The other medications listed are commonly taken and do not constitute an increased risk for the client.

The clinic nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests for thyroxine (T4) and thyroid-stimulating hormone (TSH). Which laboratory finding indicates a diagnosis of primary hypothyroidism?

An elevated TSH level Rationale:Diagnostic findings in primary hypothyroidism include a low T4 level and a high TSH level. The remaining options are not diagnostic findings of this condition.

A client is being transferred to the nursing unit after receiving a radiation implant for bladder cancer. The nurse would take which priority action in the care of this client?

Assign the client to a private room. Rationale:The client who has a radiation implant is placed in a private room and has limited visitors. This reduces the exposure of others to the radiation. Protective isolation is unnecessary. Frequent rest periods are a helpful general intervention but are not a priority for the client in this situation.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

An increase in blood pressure and increased respirations Rationale:A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

A client with a 3-day history of nausea and vomiting and suspected gastroenteritis presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn, and the nurse reviews the results, expecting to note which finding?

An increased pH and an increased HCO3- Rationale:Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include a decrease in the respiratory rate and depth, and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

An increased pH and an increased HCO3- Rationale:Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.

The nurse is reviewing the medication list for a client seen in the health care clinic. The nurse determines that which medications will increase the sodium level? Select all that apply.

Anabolic steroids Oral contraceptives Nonsteroidal anti-inflammatory drugs Rationale:The normal sodium level for an adult client is 135 to 145 mEq/L (135 to 145 mmol/L). Some medications are known to increase sodium levels, and these medications include anabolic steroids, oral contraceptives, and nonsteroidal anti-inflammatory drugs.

A client is recovering well 24 hours after cranial surgery but is fatigued. The surgeon advances the client from nothing-by-mouth status to clear liquids. The nurse knows that which information is least reliable in determining the client's readiness to take in fluids?

Appetite Rationale:To begin to tolerate oral intake after cranial or any other type of surgery, the client must have bowel sounds. The client also must have intact swallow and gag reflexes and would be free of nausea and vomiting. The client is likely to be easily fatigued, which may decrease appetite. Thus, appetite is the least reliable indicator regarding when intake would be started.

The nurse is developing a plan of care for a preoperative client who has a latex allergy. Which intervention would be included in the plan?

Apply a cloth barrier to the client's arm under a blood pressure cuff when taking the blood pressure. Rationale:If a client has a latex allergy, a cloth barrier needs to be applied to the arm under a blood pressure cuff to prevent skin contact with the cuff. Medications from glass ampules are safe to use, and medications from ampules with rubber stoppers are unsafe to use. Latex-safe intravenous tubing made of polyvinyl chloride would be used for a client with a latex allergy. Additionally, agency procedures would be followed for a client with a latex allergy; usually, a latex allergy cart containing latex-free supplies is kept in the client's room.

The nurse is assigned to change the surgical dressing on a client who has undergone abdominal surgery. After removing the old dressing, the nurse assesses the surgical site. Which would be the nurse's initial action if the appearance shown in the figure is observed? Refer to figure.

Apply a sterile nonadherent dressing. Rationale:Wound dehiscence is a partial or complete separation of the outer layers of the wound, sometimes described as splitting open of the wound. If this is noted, the nurse applies a sterile nonadherent dressing, such as a Telfa dressing or a saline dressing, to the wound and notifies the surgeon. The nurse would document the findings, but this would not be the initial action. A dry dressing could disrupt the integrity of the underlying tissues. Asking the client to cough could cause an extension of the separation of the outer layers of the wound

The nurse is performing a change-of-shift assessment on a client. The client had an arterial blood gas specimen drawn during an admission workup on the previous day and has a hematoma at the puncture site. What is the priority nursing intervention?

Apply a warm compress. Rationale:If a hematoma develops, ice packs, wrapped in a cloth, can be applied to the affected site for approximately 20 minutes one or more times during the first 24 hours. Then, warm, moist compresses are applied to the site for 20 minutes one or more times during the second 24 hours after the collection. Since the arterial blood gas was drawn on the previous day, warm compresses would be applied. Allen's test is performed before the collection of the specimen to assess collateral blood flow. Heparinized syringes are used for the collection of an arterial blood gas, but no heparin is administered to a client. The antidote for heparin is not administered at this time unless prescribed. The laboratory department is not responsible for collecting the arterial blood gas specimen. Additionally, there is no useful reason to notify the hospital laboratory supervisor.

A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply.

Blood transfusions Bleeding or hemorrhage Ingestion of potassium in medications Failure to restrict dietary potassium Rationale:With CKD, factors other than tissue breakdown that can cause hyperkalemia include blood transfusions, bleeding or hemorrhage, ingestion of potassium in medications, and failure to restrict dietary potassium. Metabolic alkalosis and decreased sodium excretion are not contributing factors.

The nurse is preparing to administer an intramuscular (IM) injection to a client receiving a continuous heparin infusion. Which action would the nurse prepare to do?

Apply prolonged pressure to the IM site after the injection. Rationale:Heparin is an anticoagulant that increases the risk of bleeding. Prolonged pressure over the site of an IM injection will lessen the chance of having an increase of bleeding into the tissue. It is not necessary to apply a pressure dressing to the IM site of injection. A ⅝-inch needle is not an appropriate size needle for an IM injection. The heparin infusion is not decreased before an injection, and the rate is not adjusted unless specifically prescribed by a primary health care provider (PHCP).

The nurse is planning to obtain blood for arterial blood gas analysis from a client with chronic obstructive pulmonary disease. The nurse would plan time for which activity after the arterial blood specimen is drawn?

Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes Rationale:Applying pressure over the puncture site reduces the risk of hematoma formation and damage to the artery. A cold (not warm) compress would aid in limiting blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.

A nursing student is caring for a client with a stroke who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which strategy to help the client adapt to this deficit?

Approaching the client from the unaffected side Rationale:Unilateral neglect is an unawareness of the paralyzed side of the body, which increases a client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. The nurse moves personal care items and belongings to the affected side, as well as the bedside chair and commode. The nurse teaches the client to scan the environment so as to become aware of the affected half of the body. The nurse approaches the client from the affected side to increase awareness further.

The nurse is assessing the extremities of a client who had wrist restraints applied 2 hours ago. Which findings noted by the nurse are indicative of impaired circulation? Select all that apply.

Areas of pallor Decreased movement Decreased temperature Reports of pain or tingling Rationale:When assessing the skin of a client with bandages, cast, restraints, or other restrictive devices, assessment findings indicating impaired circulation include the following: areas of pallor, decreased movement, decreased temperature, and reports of pain or tingling. Areas of erythema and heightened sensation are not appropriate findings.

The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse would determine that the client's status is returning to normal if which is no longer exhibited?

Areflexia Rationale:Signs and symptoms of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany, muscular excitability, and tremors are seen with hypomagnesemia.

Which assessment finding indicates that a client who had a mastectomy is experiencing a complication related to the surgery?

Arm edema on the operative side Rationale:Arm edema on the operative side (lymphedema) is a complication after mastectomy. It can occur immediately postoperatively or months to even years after surgery. The remaining options are expected occurrences after mastectomy and do not indicate a complication

When communicating with a client who speaks a different language, which best practice would the nurse implement?

Arrange for an interpreter to translate. Rationale:Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options 1 and 4 are inappropriate and ineffective ways to communicate. Option 3 is inappropriate because it violates privacy and does not ensure correct translation.

Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness?

Arranging for home health care Rationale:Nursing follow-up visits are important in promoting health for individuals with chronic illness; therefore, arranging for home health care is an important strategy. Focusing on a single illness does not effectively manage an individual with multiple chronic diseases—rather, the "big picture" needs to be understood in managing these clients. Interprofessional collaboration is important in safely managing individuals with chronic diseases and often involves consulting with specialist providers. Nurses play a key role in facilitating communication between providers and specialists. Inclusion of the client and support persons in health care decisions helps to increase adherence to a complex health care regimen. The nurse should be the facilitator of this communication.

A client is experiencing anxiety about being hospitalized. What therapeutic communication techniques would the nurse use while interacting with the client? Select all that apply.

Ask the client to identify how they feel. Help the client identify the cause of the anxiety. Observe for expressions of helplessness and hopelessness. Rationale:If a client experiences anxiety, immediate actions are to provide a calm environment, decrease environmental stimuli, and stay with the client. Excess stimulation would escalate the anxiety. Next, asking the client to identify what and how they are feeling and helping the client to identify the causes of the feelings increase the client's awareness of the connection between behaviors and feelings. This awareness helps to decrease the anxiety. While listening to the client, the nurse observes for expressions of helplessness and hopelessness that could indicate self-harm intentions. The nurse provides follow-up care as needed, based on observations and assessments. Finally, the nurse documents the event, significant information, actions taken and follow-up actions, and the client's response. Turning the TV on ignores the client's feelings and increases stimuli. Leaning casually against the wall with the arms crossed presents a defensive stance.

A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry for a preoperative client. The nurse would perform which best action to ensure accurate readings on the oximeter?

Ask the client to limit motion in the hand attached to the pulse oximeter. Rationale:Several factors can interfere with the reading of accurate oxygen saturation levels on a pulse oximeter. To ensure accurate readings, the nurse would ask the client to limit motion of the area attached to the sensor. The nurse needs to apply the device to a warm area because hypotension, hypothermia, and vasoconstriction interfere with blood flow to the area. The nurse needs to know that very dark nail polish (black, brown-red, blue, green) interferes with accurate measurement. The nurse also would avoid placing the sensor distal to any invasive arterial or venous catheters, pressure dressings, or blood pressure cuffs.

A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed?

Asks the athletes to take a salt tablet before football practice Rationale:Salt tablets would not be taken because they can contribute to dehydration. Frequent fluid breaks need to be taken to prevent dehydration. Early detection of decreased body weight alerts the athlete to drink fluids before becoming dehydrated. To prevent dehydration, 16 oz of fluid needs to be consumed for every pound lost.

The nurse is inserting an indwelling urinary catheter. As the nurse inflates the balloon, the client complains of discomfort. The nurse would take which appropriate action?

Aspirate the fluid, advance the catheter farther, and reinflate the balloon. Rationale:If the balloon is positioned in the urethra, inflating the balloon could produce trauma, and pain will occur. If pain occurs, the fluid would be aspirated and the catheter inserted a little farther into the bladder to provide sufficient space to inflate the balloon. The balloon of the catheter is behind the opening at the insertion tip. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. There is no need to remove the catheter and insert a new one. Pain when the balloon is inflated is not normal.

The nurse is developing a plan of care for a client receiving a nasogastric (NG) tube feeding. When formulating the plan of care, what would the nurse consider?

Aspiration is a concern with an NG tube feeding. Rationale:NG tube feedings are beneficial for some clients but present several significant possible complications such as diarrhea, lactose intolerance, dumping syndrome, or excess fluid volume. Another serious complication is aspiration pneumonia, which is caused by regurgitation of formula contents from the stomach into the respiratory tract. Keeping the head of the bed elevated to 30 degrees at all times assists in the prevention of this complication. NG tubes may be left in place from weeks to months, depending on the type of tube inserted. The rate of the feedings would not be increased unless prescribed. A rate that is too rapid also may cause diarrhea, fluid overload, or aspiration.

In preparation for ambulation, the nurse is planning to assist a postoperative client to progress from a lying position to a sitting position. Which nursing action is appropriate to maintain the safety of the client?

Assess the client for signs of dizziness and hypotension. Rationale:Early ambulation would not exceed the client's tolerance. The client would be assessed before sitting. The client is assisted to rise from the lying position to the sitting position gradually until any evidence of dizziness, if present, has subsided. This position can be achieved by raising the head of the bed slowly. After sitting, the client may be assisted to a standing position. The nurse needs to be at the client's side to provide physical support and encouragement.

The nurse receives a telephone call from the postanesthesia care unit stating that a client who had abdominal surgery is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?

Assess the patency of the airway. Rationale:The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions would be performed after a patent airway has been established.

The nurse receives a telephone call from the postanesthesia care unit, stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?

Assess the patency of the airway. Rationale:The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions would be performed after a patent airway has been established.

The nurse is caring for a postoperative client who has just returned from the postanesthesia care unit after having nasal surgery. What priority action is essential for the nurse to perform?

Assessing how often the client swallows Rationale:Assessing how often the client swallows after nasal surgery is a priority action because this is a sign of bleeding. Checking vital signs and looking at the external packing for bleeding are important but not a priority for nasal surgery clients. Ensuring that intravenous fluids are infusing at a prescribed rate are important but not the priority.

What elements are essential for the nurse to plan to address to be able to deliver culturally competent care? Select all that apply.

Assessing the client's health preferences Having knowledge of various racial and ethnic groups Acknowledging personal misconceptions of various ethnic groups Recognizing that subcultures exist and that not every characteristic of the cultural group is present Rationale:The nurse always determines the client's health preferences to create an individualized plan of care. Health care providers must have awareness of their own beliefs and values, as well as being aware that others hold different values and beliefs based on personal preferences or ethnic, cultural, and racial backgrounds. Recognizing one's own biases and respecting all people despite differences can influence satisfaction in care. It is imperative for health care providers to understand that cultural groups share dominant characteristics; however, subcultures exist and stereotyping must be avoided. It is not within the nurse's role to diagnose health conditions.

The nurse is caring for a client who is scheduled for abdominal surgery and administers the preoperative medications as prescribed. The nurse then raises the side rails on the stretcher, places the safety strap across the client, places the call bell near the client, and instructs the client to call for assistance as needed. Shortly thereafter the client calls the nurse and reports the need to urinate. Which action would the nurse take to meet this client's need?

Assist the client onto a bedpan. Rationale:Because preoperative medications cause sedation, the client would not be allowed to leave the bed or stretcher after the medications are administered. To ensure safety, the nurse would assist the client in using a bedpan. There is no need for a Foley catheter; in addition, a Foley catheter places the client at risk for infection. Option 4 is inappropriate; if the client verbalizes a need to void, the nurse would assist in meeting this need.

The nurse is preparing a client for surgery scheduled in 2 hours. Which interventions are appropriate in the preoperative period? Select all that apply.

Assist the client to void before transfer to the operating room. Check all surgeon's prescriptions to ensure that they have been carried out. Review the client's record for a history and physical report and laboratory reports. Rationale:The nurse would assist the client to void before transfer to the operating room, if a Foley catheter is not in place. The nurse also checks the surgeon's prescriptions to ensure that they have been carried out; if a prescription has not been carried out, the nurse would have the time to ensure that it is. Two hours before the scheduled surgery time is not the time to teach breathing exercises. This would have been accomplished earlier. A history and physical needs to be in the record so that all primary health care providers involved in the surgical procedure will be familiar with the client's health status. Additionally, the results of any laboratory tests prescribed need to be documented. The nurse does not administer all daily medications. Rather, the primary health care provider writes a specific prescription outlining which medications may be given with a sip of water.

A homeless parent brings their 1-year-old child to an emergency clinic. The nurse caring for this child understands that children affected by homelessness are most at risk for which problems? Select all that apply.

Asthma Anemia Ear infections Rationale:Homeless children will often be victims of malnourishment, leading to anemia, and while they may be diabetic, being homeless does not put them at greater risk for having diabetes. Typically, homeless children are underweight, not obese. Environmental exposures increase their risk of being asthmatics or getting ear infections. This pediatric population is sick more often and will have an increased incidence of mental health and behavioral problems.

The nurse is reviewing the surgeon's prescription sheet for a preoperative client, which states that the client must be NPO (nothing by mouth) after midnight. Which medication would the nurse clarify to be given and not withheld?

Atenolol Rationale:Atenolol is a beta blocker. Beta blockers would not be stopped abruptly, and the health care provider needs to be contacted about the administration of this medication before surgery. If a beta blocker is stopped abruptly, the myocardial need for oxygen is increased. Atorvastatin is a cholesterol-lowering medication used to treat high cholesterol. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal clients. The other three medications may be withheld before surgery without undue effects on the client.

The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan would be included?

Bed rest with elevation of the affected extremity Rationale:For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. A flat or dependent position of the leg would not achieve this goal. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking.

The nurse is caring for a client who is receiving immunosuppressant therapy, including corticosteroids, after renal transplantation. The nurse would plan to carefully monitor results of which laboratory test for this client?

Blood glucose level Rationale:Corticosteroid therapy can result in glucose intolerance, leading to elevated blood glucose levels. The nurse monitors these levels to detect this side effect of therapy. With successful transplantation, the client's serum electrolyte levels would be better regulated, although corticosteroids also could cause sodium retention and potassium depletion. The serum albumin, magnesium, and calcium will not be affected.

Which finding in a postoperative client would be of concern to the nurse?

Blood pressure of 88/52 mm Hg Rationale:The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A falling systolic blood pressure, under 90 mm Hg, is considered reportable because it could be an indication of bleeding and potential shock. Urine output needs to be maintained at a minimum of 30 mL/hr for an adult, so 40 mL per hour is adequate. An output of less than 30 mL/hr for each of 2 consecutive hours needs to be reported to the surgeon. A temperature above 37.7° C (100° F) or below 36.1° C (97° F) is a concern and would be reportable. Moderate or light serous drainage from the surgical site is considered normal.

A filled blood specimen tube was dropped and broken in the client's room. The nurse intervenes if the assistive personnel (AP) performs which action to clean up the blood spill?

Blots up the spill with a face cloth or cloth towel Rationale:The AP would blot the spill with an absorbent disposable material, such as paper towels or terry wipes but not with a face cloth or cloth towel. Gloves are worn for the procedure, and tongs are used to pick up any broken glass. The area is disinfected with a dilute bleach solution or an agency-approved product.

The nurse is caring for a client with diabetic ketoacidosis whose respirations are abnormally deep, regular, and increased in rate. The nurse monitors the client, expecting that which occurs with this type of respiration? Select all that apply.

Blowing off carbon dioxide Correction of metabolic acidosis Correction of an acid-base imbalance Respiratory compensation Rationale:Abnormally deep, regular respirations that are increased in rate enable respiratory compensation to help correct metabolic acidosis. These respirations are called Kussmaul's respirations, and they occur by exhaling excess carbon dioxide. Bradypnea is abnormally slow but regular respirations. Cheyne-Stokes respirations have rhythmic crescendo and decrescendo of rate and depth, including brief periods of apnea. Kussmaul's respirations do not stimulate Cheyne-Stokes respirations.

Which car safety device would be used for a child who is 8 years old and 4 feet tall?

Booster seat Rationale:All children whose weight or height is above the forward-facing limit for their car safety seat need to use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached a height of 4 ft, 9 in (145 cm) and are between 8 and 12 years of age. Infants would ride in a car in a semireclined, rear-facing position in an infant-only seat or a convertible seat until they weigh at least 20 lb (9 kg) and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 20 lb (9 kg) and 1 year of age.

Which car safety device should be used for a child who is 8 years old and 4 feet tall?

Booster seat Rationale:All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 feet, 9 inches in height (145 cm) and are between 8 and 12 years of age. Infants should ride in a car in a semireclined, rear-facing position in an infant-only seat or a convertible seat until they weigh at least 20 pounds (9 kg) and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kilograms (20 pounds) and 1 year of age.

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply.

Bounding pulse Difficulty breathing Presence of dependent edema Neck vein distention in the upright position Rationale:Care of a client with HF and fluid overload includes monitoring for bounding pulses, difficulty breathing, neck vein distention in the upright position, and dependent edema. Increased urine output is not associated with HF and fluid overload.

The nurse is caring for a client who is postoperative following a pelvic exenteration, and the surgeon changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse would check which priority item before administering the diet?

Bowel sounds Rationale:The client is kept NPO until peristalsis returns, usually in 4 to 6 days. When signs of bowel function return, clear fluids are given to the client. If no distention occurs, the diet is advanced as tolerated. The most important assessment is to assess bowel sounds before feeding the client. Options 2, 3, and 4 are unrelated to the data in the question.

The nurse has a prescription to remove the nasogastric (NG) tube from a client on the first postoperative day after cardiac surgery. The nurse would question the prescription if which finding was noted on assessment of the client?

Bowel sounds are absent. Rationale:The NG tube would remain in place until the client has bowel sounds. If NG suction is being used, the nurse needs to turn off the suction before listening to bowel sounds to prevent mistaking the sound of the suction for bowel sounds. If bowel sounds do not return, the client could have a paralytic ileus, which could result in distention and vomiting if the NG tube is discontinued. It is likely that the client would be drowsy after experiencing a stressor such as cardiac surgery. The abdomen is likely to be slightly distended after surgery, and it is normal for NG tube drainage to be Hematest negative.

The nurse is caring for a client with a nasogastric tube connected to continuous suction. During assessment the nurse observes that the client is mouth-breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which intervention would be most appropriate to maintain the integrity of this client's oral mucosa?

Brush the teeth frequently; use mouthwash and water. Rationale:After a nasogastric (NG) tube is in place, mouth care is extremely important. With one naris occluded, the client tends to mouth-breathe, drying the mucous membranes. Small sips of water are contraindicated when the client is on gastric suction. Hard candy would increase the salivation but would not be useful in cleaning the oral cavity. Lemon glycerin swabs have a drying and irritating effect on the mucous membranes.

The nurse is caring for a client with Paget's disease who has a serum calcium level of 12.3 mg/dL (3.1 mmol/L). The nurse would check to see that which medication is available in the stock medication supply for possible use to reverse this elevation?

Calcitonin Rationale:The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus keeping it out of the serum. In hypercalcemia, large doses of vitamin D need to be avoided. Calcium gluconate and calcium chloride would be used to treat tetany that results from acute hypocalcemia.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that which level indicates the need for immediate notification of the primary health care provider (PHCP)?

Calcium 4.0 mg/dL (1.0 mmol/L) Rationale:The normal reference level for calcium is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). The reported level is low, requiring immediate notification of the PHCP. The normal electrolyte levels for an adult client are sodium, 135 to 145 mEq/L (135 to 145 mmol/L); potassium, 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L); and magnesium, 1.8-2.6 mEq/L (0.74-1.07 mmol/L).

At a local school, a community health nurse is providing an educational session on childhood poisoning. The topic of the discussion is preventive measures to avoid accidental poisoning. The nurse would include taking which action first if an accidental poisoning occurs?

Call the poison control center. Rationale:If a poisoning occurs, the poison control center would be contacted immediately. Vomiting would not be induced if the victim is unconscious or the substance ingested is a strong corrosive or petroleum product. Bringing the child to the urgent care or calling an ambulance would not be the immediate action because either of these would delay treatment. The poison control center may advise the caregiver to bring the child to the emergency department. If this is the case, the caregiver would call an ambulance.

The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action would the nurse take at this time?

Call the primary health care provider to request a prescription for a chest radiograph. Rationale:If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates have acidic pH values. A pH of 1.0-4.0 is a good indicator of gastric placement. A pH of 7.35 indicates a neutral pH, which may indicate that the tube is no longer in the stomach. Based on this information, the nurse would call the primary health care provider to request a prescription for a chest radiograph to determine if placement is accurate. Retesting the pH using another strip is unnecessary, and checking for placement by auscultating for air injected into the tube is not a definitive method of checking for tube placement. The nurse would not document that the tube is in the correct place because the data indicate this may not be the case.

The nurse is caring for a client with metabolic alkalosis. The nurse plans care, knowing that most problems of metabolic alkalosis are related to increased stimulation of what systems? Select all that apply.

Cardiac Nervous Neuromuscular Rationale:Most problems of alkalosis are related to increased stimulation of the cardiac, nervous, and neuromuscular systems. Chemical reactions are also called buffer systems and are not related to most problems of alkalosis. The respiratory system is related to respiratory alkalosis and not metabolic alkalosis.

The nurse has administered an injection to a client. After the injection, the nurse accidentally drops the syringe on the floor. What is the safe nursing action in this situation?

Carefully pick up the syringe from the floor and dispose of it in a sharps container. Rationale:Used syringes would always be placed in a sharps container immediately after use to avoid injury to anyone. A syringe would not be swept up because this action poses an additional risk of needle stick. It is not the responsibility of the housekeeping department to pick up the syringe. Syringes would not be recapped because of the risk of getting pricked with a contaminated needle.

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding would the nurse expect to note?

Changes in mental status Rationale:A client with dehydration is likely to be lethargic or complain of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.

A client returns to the nursing unit following a pyelolithotomy for removal of a kidney stone. A Penrose drain is in place. Which action would the nurse include in the client's postoperative plan of care?

Changing dressings frequently around the Penrose drain Rationale:Frequent dressing changes around the Penrose drain are required to protect the skin against breakdown from the urinary drainage. If urinary drainage is excessive, an ostomy pouch may be placed over the drain to protect the skin. Placing the client on the affected side will prevent a free flow of urine through the drain. A Penrose drain is not irrigated. Weighing the dressings is not necessary.

The nurse is administering enteral feedings via a nasogastric (NG) tube. The nurse would take which action when caring for the client to maintain client safety?

Check for tube placement and residual amount at least every 4 hours. Rationale:NG tube feedings are beneficial but present possible complications, such as diarrhea, lactose intolerance, dumping syndrome, or excess fluid volume. The most common complication is aspiration pneumonia caused by regurgitation of formula contents from the stomach into the respiratory tract. This risk can be minimized by checking the tube placement, the pH and color of aspirate, and the residual amount, and by keeping the head of the bed elevated to 30 degrees at all times. Problems with diarrhea may be caused by infusing a formula that is cold, contaminated, or of the wrong consistency, or by infusing a formula too rapidly. Nasogastric tubes may be left in place from weeks to months, depending on the type of tube inserted. The feeding bag itself would be changed daily.

During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What would the nurse do next?

Check skin turgor over the client's sternum. Rationale:In an older adult, skin turgor needs to be checked by pinching the skin over the sternum or even the forehead, instead of the back of the hand or forearm. As a client gets older, the skin loses elasticity and can tent over the hands and arms, even when the client is adequately hydrated. Therefore, the next nursing action would be to obtain additional assessment data.

The nurse is preparing medications when a pill pops out of the medication container and falls onto the countertop. What action would the nurse take?

Promptly pick up the pill, dispose of it properly, and obtain a new one from the pharmacy. Rationale:Medication that is dropped on any surface is considered contaminated and would not be administered; therefore, the remaining options are incorrect.

A client has returned to the nursing unit after an abdominal hysterectomy. The client is lying supine. To thoroughly assess the client for postoperative bleeding, what is the primary nursing action?

Check the client's perineal pad; then roll the client to one side to check for further bleeding. Rationale:The nurse would roll the client to one side after checking the perineal pad and the abdominal dressing. This client position allows the nurse to check the rectal area, where blood may pool by gravity if the client is lying supine. Asking the client about a sensation of moistness is not a complete assessment. Vital signs will change with hemorrhage; they are a compensatory mechanism of change. Assess for external or most likely signs of bleeding first.

A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions would the nurse take in the care of the drain? Select all that apply.

Check the drain for patency. Observe for bright red bloody drainage. Maintain aseptic technique when emptying the drain. Rationale:The nurse would check the tube or drain for patency to provide an exit for the fluid or blood to promote healing. The nurse would monitor the drainage characteristics. Usually the drainage from the wound is pale, red, and watery. Active bleeding will be bright red. The nurse must use aseptic technique for emptying the drainage container or changing the dressing to avoid contamination of the wound. A postoperative drain would not be curled tightly or obstructed in any way, such as with clamping. This could prevent the drain from functioning properly.

The nurse is reviewing the laboratory test results for a client and notes that the albumin level is 3.0 g/dL (30 g/L). The nurse understands that this laboratory value would be noted in which condition?

Cirrhosis of the liver Rationale:The normal albumin level ranges from 3.5 to 5 g/dL (35 to 50 g/L). The albumin level is decreased in many conditions, such as acute infection, ascites, alcoholism, burns, and cirrhosis. The remaining options identify conditions in which the albumin level is increased

A client has a risk for infection following radical vulvectomy. Therefore, the nurse would avoid which action when giving perineal care to this client?

Cleansing with warm tap water Rationale:A sterile solution such as normal saline would be used for perineal care using an aseptic syringe. This needs to be done regularly at least twice a day and after each voiding and bowel movement. The wound is intermittently exposed to air to permit drying and to prevent maceration. Once sutures are removed, sitz baths may be prescribed to stimulate healing and for the soothing effect.

A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium. The client's prothrombin time is 20 seconds, with a control of 11 seconds. How would the nurse interpret these results?

Client results are within the therapeutic range. Rationale:The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at high risk for thrombus. Based on the client's control value, the therapeutic range for this individual would be 16.5 to 22 seconds; therefore, the result is within the therapeutic range.

The nurse is caring for a group of clients on the clinical nursing unit. Which client would the nurse plan to monitor for signs of fluid volume deficit?

Client with an ileostomy Rationale:The client with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output such as diabetes insipidus, insufficient intravenous fluid replacement, and draining fistulas. Clients who have heart failure or kidney disease are at risk for fluid volume excess. Hypertension may be associated with fluid volume excess.

The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid?

Client with an ischemic stroke Rationale:Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include the pleural and peritoneal cavities and pericardial sac. Risk factors include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. The client who has suffered a stroke is not at risk for third spacing.

A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and IV tubing. Arrange the actions in the order that they would be performed. All options must be used.

Close the roller clamp on the IV tubing. Spike the IV bag and half-fill the drip chamber. Open the roller clamp and fill the tubing. Uncap the distal end of the tubing. Attach the distal end of the tubing to the client. Rationale:The nurse would close the roller clamp on the IV tubing to prevent the solution from running freely through the tubing once it is attached to the IV bag. The nurse would next uncap the proximal (spike) end of the tubing, attach it to the IV bag, and then squeeze the drip chamber to half-fill it. Next, the roller clamp is opened slowly, and the fluid is allowed to flow through the tubing in a controlled fashion to prevent air from remaining in parts of the tubing. Finally, the distal end of the tubing is uncapped and attached to the client.

The nurse discovers a fire in the trash basket in a client's bathroom. The nurse assists the client out of the hospital room to a safe place, activates the fire alarm, and takes which action next?

Closes the doors to the other clients' rooms Rationale:In the event of a fire, the first priority is to rescue the client and protect the client from injury. The next priority is to activate the fire alarm and report the exact location of the fire to emergency personnel to aid in the rescue process. Next, the nurse would contain the fire by closing doors and placing towels under the doorways to prevent the spread of smoke. The nurse then would obtain the fire extinguisher, pull the pin, and extinguish the fire by sweeping side to side.

The nurse is reviewing the blood tests of a generally healthy client who is scheduled for orthopedic surgery under general anesthesia. Besides a complete blood count (CBC), what preadmission blood tests would the preoperative nurse expect to be prescribed? Select all that apply.

Clotting studies Glucose fasting Electrolyte levels Serum creatinine and blood urea nitrogen (BUN) levels Rationale:The most common blood tests prescribed preoperatively include CBC, clotting studies, glucose fasting, electrolyte levels, and serum creatinine and BUN levels. A urinalysis is also prescribed. Preoperative blood tests do not include ABG and D-dimer assay. Clotting studies must be prescribed to determine whether the surgical client may experience major hemorrhage from prolonged bleeding or clotting times. Glucose fasting must be done because many forms of stress such as general anesthesia can cause increased serum glucose levels. Electrolyte imbalances such as potassium levels (both increased and decreased) can affect the cardiac system, leading to dysrhythmias, especially with the use of anesthesia. Any potassium imbalance—hypokalemia or hyperkalemia—must be corrected before surgery. Serum creatinine and BUN levels must be assessed to determine any underlying renal disease that could be compounded with surgery.

The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, must be addressed first?

Complaints of pain associated with numbness and tingling in both feet Rationale:The nurse needs to address the complaints of pain and numbness and tingling in both feet first with this population. If the client perceives value to the service provided and the complaint is addressed, the client will be more likely to return for follow-up care. While the blood pressure, blood glucose, and vision results need follow-up, the client's stated concern must be addressed first.

A client with acute glomerulonephritis has had a urinalysis sample sent to the laboratory. The report reveals the presence of hematuria and proteinuria. The nurse interprets these results as which condition?

Consistent with glomerulonephritis Rationale:Gross hematuria and proteinuria are the classic signs of glomerulonephritis. The urine may be small in volume, dark or smoky from the hematuria, and foamy from the proteinuria. Concurrent serum studies would reveal an elevated level of blood urea nitrogen, creatinine, C-reactive protein, and antistreptolysin O titer.

The nurse is reviewing the plan of care with a non-American client who does not speak English. The client frequently nods the head during the review. Based upon this behavior, what would be the nurse's next action?

Contact a qualified medical interpreter. Rationale:The nurse must contact a qualified medical interpreter to correctly provide the information to the client. The nurse needs to be alert to nonverbal communication and have a professional interpreter discover the language that the client understands. In some cultures, head nodding does not necessarily mean that the client is in agreement with what is being presented, agrees with the plan, or is anxious.

The nurse caring for a newly admitted client is reviewing the medication prescription sheet in preparation for administering medications to the client. The nurse notes that the primary health care provider (PHCP) has prescribed a dose that is twice the amount that the client has reported taking before admission. What is the most appropriate nursing action?

Contact the PHCP directly. Rationale:If the nurse determines that an PHCP prescription is unclear, or if the nurse has a question about a prescription, the nurse would contact the PHCP before implementing it. Under no circumstances would the nurse carry out the prescription unless the prescription is clarified. Questioning the client whether the reported dosage is accurate may seem like a viable option, but this action may also cause the client to become upset. The nurse would not call the hospital pharmacist to clarify the prescription

The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride and plans to use an IV infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse would take which action?

Contact the electrical maintenance department for assistance. Rationale:Electrical equipment must be maintained in good working order and needs to be grounded; otherwise, it presents a physical hazard. An IV line that contains a dose of potassium chloride needs to be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord would not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard.

The nurse is preparing to initiate an intravenous (IV) line containing potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no outlet is available in the wall socket. The nurse would take which action?

Contact the electrical maintenance department for assistance. Rationale:Electrical equipment must be maintained in good working order and needs to be grounded; otherwise, it presents an electrical hazard. An IV line that contains potassium chloride would be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord would not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard.

The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action would the nurse take first?

Contact the primary health care provider (PHCP). Rationale:The nurse must contact the PHCP before administering the solution. Fluid and electrolyte replacement solutions such as lactated Ringer's are contraindicated for clients with kidney and liver disease or lactic acidosis.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions would the nurse take? Select all that apply.

Contact the surgeon Instruct the client to remain quiet. Prepare the client for wound closure. Document the findings and actions taken. Rationale:Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse would call for help, stay with the client, ask another nurse to contact the surgeon, and obtain needed supplies to care for the client. The nurse places the client in a low-Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions would the nurse take? Select all that apply.

Contact the surgeon. Instruct the client to remain quiet. Prepare the client for wound closure. Document the findings and actions taken. Rationale:Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse would call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low-Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit who is receiving nasal oxygen and notes a pH of 7.38, Paco2 of 38 mm Hg, Pao2 of 86 mm Hg, and HCO3 of 23 mEq/L. What action would the nurse take in response to these results?

Continue to monitor the client. Rationale:The client's results fall in the normal range for pH (7.35 to 7.45), Paco2 (35 to 45 mm Hg), and bicarbonate level (21 to 28 mEq/L). With acidosis, the pH would be less than 7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be high with respiratory acidosis, whereas bicarbonate levels would be low if metabolic acidosis were present.

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse would take which most appropriate action?

Continue to monitor the drainage. Rationale:Following gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours postoperatively, changes to brown-tinged, and is then yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse needs to continue to monitor the drainage. The nurse does not need to notify the surgeon at this time. Abdominal girth is measured to detect the development of distention. Following gastrectomy, a nasogastric tube would not be irrigated unless there are specific surgeon prescriptions to do so.

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse would take which most appropriate action?

Continue to monitor the drainage. Rationale:Following gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours postoperatively, changes to brown-tinged, and is then yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse would continue to monitor the drainage. The nurse does not need to notify the surgeon at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, a nasogastric tube would not be irrigated unless there are specific surgeon prescriptions to do so.

The nurse is providing discharge instructions to a non-American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. Which nursing action is most appropriate?

Continue with the instructions, verifying client understanding. Rationale:In some non-American cultures, individuals maintain a formal distance with each other, which is a form of respect. Many are uncomfortable with face-to-face communications, especially when there is direct eye contact. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Walking around to the client so that the nurse faces the client is in direct conflict with some cultural practices. Identifying the importance of the instructions for the maintenance of health care may be viewed as degrading. Returning later to continue with the explanation may be viewed as a rude gesture.

The nurse is providing discharge instructions to a client from a different culture than the nurse's regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse would implement which best action?

Continue with the instructions, verifying client understanding. Rationale:Some clients from some cultures prefer to maintain a formal distance with others, which is a form of respect. Many are uncomfortable with face-to-face communications, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Walking around the client so that the nurse faces the client is in direct conflict with some cultural practices. The client may consider it a rude gesture if the nurse returns later to continue with the explanation. Telling the client about the importance of the instructions for the maintenance of health care may be viewed as degrading.

The nurse is caring for a client with suspected hepatitis. What diagnostic test results will assist in confirming this client's diagnosis? Select all that apply.

Leukopenia Elevated liver enzymes Elevated serum bilirubin level Elevated serum erythrocyte sedimentation rate (ESR) Rationale:Laboratory indicators of hepatitis include leukopenia, elevated liver enzyme levels, elevated serum bilirubin levels, and elevated ESR. An elevated BUN level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

The pediatric nurse educator provides a teaching session to parents regarding the substances that cause lead poisoning. Which item, if identified by a parent as a known environmental substance that can cause lead poisoning, indicates a need for further education?

Properly glazed pottery Rationale:Paint chips, soil contaminated with lead, lead solder used in plumbing, vinyl blinds, and improperly glazed pottery can be the source of toxic exposure in lead poisoning.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse notes that the red blood cell (RBC) count is increased. The nurse interprets that this finding may be related to which condition or treatment?

Corticosteroid therapy Rationale:Increased RBCs are seen with decreased cardiac output, impaired pulmonary gas exchange, corticosteroid therapy, polycythemia vera, severe diarrhea, and dehydration. The conditions in the remaining options are not associated with an increased RBC count.

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?

The client who is taking diuretics Rationale:The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

The nurse is providing instructions to a client regarding the use of ice packs to treat an eye injury. What would the nurse instruct the client to do?

Cover the ice pack with a pillowcase and place it on the eye. Rationale:If an ice pack is placed directly against the skin or left in place for an extended period, it carries a risk of tissue damage similar to that of a hot water bottle. To prevent tissue damage from excessive cold exposure, the ice pack needs to be removed in most cases after 20 minutes and may be reapplied after a short time. An ice pack would never be placed directly against the skin but needs to be covered with a pillowcase or towel. Commercially prepared ice bags are appropriate for use as an ice pack.

The nurse prepares a client 1 hour prior to surgery. Which assessment finding does the nurse need to communicate to the surgeon at this time?

Daily garlic capsules, last dose yesterday morning Rationale:Option 4 is the correct answer, as garlic can increase bleeding and would be discontinued for 2 to 3 weeks before surgery. Options 1 and 3 are incorrect, as they are not findings that the surgeon needs to be immediately notified of because neither warrants a delay or cancellation of the surgery. Option 2 is incorrect because it is a normal potassium level.

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator?

Daily weight Rationale:Daily weight is the best indicator of fluid balance. Options 2, 3, and 4 are related to intake or output but are incomplete indicators of fluid balance.

Which outcome would the nurse expect to observe in the client who is recovering from viral hepatitis without complications?

Decrease in aspartate aminotransferase (AST) Rationale:Complications from viral hepatitis include bleeding tendencies with increasing prothrombin time values and abnormalities of liver function. Clients also can develop encephalopathy. A characteristic sign of encephalopathy is asterixis. Serum transaminase levels such as AST decrease, and vitamin K becomes absorbed as liver cells heal and regenerate.

The nurse is caring for a client with a diagnosis of fluid volume overload. The nurse reviews the laboratory test results and would expect to note which finding about the hematocrit level?

Decreased Rationale:Because the hematocrit is measured as a proportion of red blood cells to the volume of blood, a decrease in fluids that make up the blood can cause an increase in hematocrit levels. Conversely, an increase in fluids can cause a decrease in the hematocrit level. A client with a diagnosis of fluid volume overload would have a decreased hematocrit level.

The nurse is reviewing the laboratory test results for a client with a diagnosis of thrombocytopenia purpura. The nurse would expect the results for platelet aggregation to be at which level?

Decreased Rationale:The adherence of platelets to one another is defined as platelet aggregation. Platelets usually aggregate in less than 5 minutes. This test determines abnormalities in the rate and percentages of platelet aggregation. Decreased platelet aggregation may occur in persons with infectious mononucleosis, idiopathic thrombocytopenia purpura, acute leukemia, or von Willebrand's disease.

A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse monitoring this client would expect to note which signs/symptoms?

Decreased respiratory rate and depth Rationale:A client with metabolic alkalosis is likely to exhibit decreased respiratory rate and depth as a compensatory mechanism. A client with metabolic acidosis would display the symptoms noted in option 3. The client with respiratory acidosis and the client with respiratory alkalosis would display the symptoms noted in options 1 and 4, respectively.

The nurse is reviewing the laboratory test results and notes that the prothrombin time (PT) is 7.0 seconds. The nurse understands that this PT value would be noted in which condition?

Deep vein thrombosis Rationale:The normal PT for an adult ranges from 11 to 12.5 seconds. A decreased PT may be noted in many conditions, including arterial occlusion, deep vein thrombosis, edema, myocardial infarction, peripheral vascular disease, and pulmonary embolism. An increased PT would be noted in the conditions identified in the remaining options.

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/min, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, pastelike coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition?

Dehydration Rationale:When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the client stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.

A client is undergoing a series of diagnostic tests. The laboratory results indicate an increased blood urea nitrogen (BUN) to creatinine ratio. The nurse determines that which potential conditions could contribute to these results? Select all that apply

Dehydration Catabolic state High-protein diet Obstructive uropathy Rationale:Causes of an increased BUN to creatinine ratio include dehydration, a catabolic state, a high-protein diet, and obstructive uropathy. A decreased ratio is caused by fluid volume excess or acute renal tubular acidosis.

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply.

Dehydration Physiological stress Decreased blood volume Rationale:ADH, or vasopressin, is produced in the brain and stored in the posterior pituitary gland. Its release from the posterior pituitary gland is controlled by the hypothalamus in response to changes in blood osmolarity. Stimuli for ADH release are increased plasma osmolality; decreased blood volume; hypotension; pain; dehydration from nausea, vomiting, or diarrhea; and stress.

The nurse is explaining a preoperative teaching plan to an English-speaking client. What are some other aspects of verbal communication the nurse would employ? Select all that apply.

Timing Volume Voice tone Ability to share thoughts and feelings Rationale:Verbal communication includes not only one's language or dialect but also voice tone, volume, timing, and ability to share thoughts and feelings. It does not include eye contact or hand gestures.

The home care nurse visits a client to perform a dressing change on a leg ulcer. The client has diabetes mellitus and a history of cardiac disease and is taking 1 aspirin daily in addition to other medications as prescribed. The client tells the nurse that dental surgery is scheduled and asks the nurse whether the aspirin would be discontinued. The nurse would make which statement to the client?

Dental surgery can safely be done usually 10 days after stopping the aspirin, depending on the physician's preference." Rationale:Aspirin is an antiplatelet agent that affects the platelet for its life, which is 7 to 10 days. For an elective procedure such as dental surgery, aspirin therapy would be stopped approximately 10 days before the procedure (or as prescribed by the physician) to prevent bleeding complications. Option 1 is not an appropriate response and places the client's issue on hold. Options 2 and 3 are incorrect.

The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which electrocardiographic change would the nurse expect to observe based on the client's magnesium level?

Depressed ST segment Rationale:The normal serum magnesium level is 1.8-2.6 mEq/L (0.74-1.07 mmol/L). A magnesium level of 1.0 mEq/L (0.5 mmol/L) indicates hypomagnesemia. In hypomagnesemia, tall T waves and a depressed ST segment would be observed. Options 2 and 4 would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia.

What health effects best describe a client who is the victim of abuse or negligence? Select all that apply.

Depression Chronic fatigue Involuntary shaking Interrupted sleeping patterns Rationale:Clients who are victims of abuse or neglect are prone to certain health effects; these effects may be physical, such as bruises, broken bones, chronic fatigue, or involuntary shaking. The victim may also experience mental effects, such as nightmares, anxiety, post-traumatic stress disorder (PTSD), depression, interrupted sleep patterns, and low self-esteem. Motivation to persevere is not a direct effect and can be a positive characteristic.

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which action would the nurse take first?

Determine whether there are medication duplications. Rationale:Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined because the nurse needs to know what the client is taking. Asking about medication administration supervision may be part of the assessment but is not a first action. The phone call to the PHCP is the intervention after all other information has been collected.

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention would the nurse take first?

Determine whether there are medication duplications. Rationale:Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined, because the nurse needs to know what the client is taking. Asking about medication administration supervision may be part of the assessment but is not a first action. The phone call to the PHCP is the intervention after all other information has been collected.

A client is visiting a new primary health care provider (PHCP) office. The client is filling out the paperwork and doesn't know if the conditions they have are considered chronic illnesses. Which conditions, if present, should the client mark down under that section? Select all that apply.

Diabetes Osteoarthritis Cardiovascular disease Vision/hearing impairment Chronic obstructive pulmonary disease Rationale:Chronic illness is a leading cause of death and disability in the United States; prevalence increases with age and is a major cause of disability. Chronic illnesses include, but are not limited to, cardiovascular disease, cancer, respiratory disease, diabetes, mental disorders, vision and hearing impairment, oral diseases, bone and joint disorders, and genetic disorders. Gastroenteritis is an acute and short-term problem rather than a chronic illness.

The nurse is providing care to a client with the following arterial blood gas results: pH of 7.50, Pao2 of 90 mm Hg, Paco2 of 40 mm Hg, and bicarbonate of 35 mEq/L. When the nurse notifies the primary health care provider about these levels, the nurse would anticipate receiving from the PHCP which prescription for this client?

Discontinue nasogastric suctioning. Rationale:The arterial blood gas (ABG) results indicate metabolic alkalosis, as the pH and bicarbonate are elevated. Nasogastric suctioning may cause metabolic alkalosis by decreasing the acid components in the stomach. Excess alcohol ingestion and salicylate toxicity may cause metabolic acidosis. Fentanyl (an opioid) may cause respiratory acidosis.

A client with a history of atrial fibrillation brought to the emergency department has accidentally been taking two times the prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?

Draw a sample for prothrombin time (PT) and international normalized ratio (INR). Rationale:The nurse would plan to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy.

The nurse is reviewing the laboratory test results for a client and notes that the serum sodium level is 150 mEq/L (150 mmol/L). The nurse understands that this value would be noted in which condition?

Heart failure Rationale:The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A level of 150 mEq/L (150 mmol/L) would indicate hypernatremia. Hypernatremia is noted in such conditions as heart failure, Cushing's disease, dehydration, diabetes insipidus, diaphoresis, diarrhea, and hypovolemia. Hyponatremia would be noted in the conditions identified in the remaining options.

A client with a history of atrial fibrillation is brought to the emergency department after accidentally taking 2 times the prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse takes which action?

Draws a sample for prothrombin time (PT) and international normalized ratio (INR). Rationale:The action that the nurse would take is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy.

A client has a problem with sleeping at night. The nurse encourages the client to do which measure to best enhance nighttime sleep?

Drink a glass of milk. Rationale:Milk contains the essential amino acid tryptophan, which can enhance sleep by promoting production of the neurotransmitter serotonin in the brain. The client needs to avoid spicy foods and a large intake just before bedtime. The client needs to also avoid caffeine after noon.

A client scheduled for surgery receives a dose of scopolamine. The nurse expects to note which side effects of the medication? Select all that apply.

Dry mouth Pupillary dilation Rationale:Scopolamine is an anticholinergic medication that causes frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options are incorrect and are not side effects of this medication.

A preoperative client has received a dose of scopolamine as prescribed by the anesthesiologist. The nurse would assess the client for which anticipated side effect of this medication?

Dry oral mucous membranes Rationale:Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options are incorrect.

Which is the best nursing intervention regarding complementary and alternative medicine?

Educating the client about therapies currently being used or is interested in using Rationale:Complementary and alternative therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies currently being used or is interested in using is the nurse's role. Options 1, 2, and 4 are inappropriate actions for the nurse to take because they provide advice to the client.

The nurse has admitted a client to the clinical nursing unit following a right-sided mastectomy. The nurse would plan to place the right-sided arm in which position?

Elevated on one or two pillows Rationale:The client's operative arm needs to be positioned so that it is elevated on one or two pillows and does not exceed shoulder elevation. This promotes optimal drainage from the limb without impairing the circulation to the arm. If the arm is positioned flat (option 3) or dependent (option 4), this could increase the edema in the arm, which is contraindicated because of lymphatic disruption caused by surgery.

The nurse is reviewing the laboratory results from a lumbar puncture performed in a client with a diagnosis of meningitis. Which laboratory findings are expected to be noted with bacterial meningitis? Select all that apply.

Elevated protein level Elevated CSF pressure Increased white blood cells (WBCs) Rationale:If a bacterial infection of CSF is present, findings include reduced glucose level, an elevated protein level, increased WBCs, a cloudy appearance of CSF, and an elevated CSF pressure.

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status would avoid which action?

Encouraging the client to breathe slowly and shallowly Rationale:The client with respiratory acidosis is experiencing elevated carbon dioxide levels caused by insufficient ventilation. The nurse would encourage the client to breathe slowly and deeply to expand alveoli and to promote better gas exchange. The actions listed in options 1, 2, and 3 are helpful actions on the part of the nurse.

The nurse is creating a plan of care for a client with hypokalemia. Which interventions would be included in the plan of care? Select all that apply.

Ensure adequate fluid intake. Implement safety measures to prevent falls. Instruct the client about foods that contain potassium. Encourage the client to obtain assistance to ambulate. Rationale:Clients with hypokalemia will need instruction on potassium-rich foods, and all clients need to maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness, resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis.

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care would the nurse include? Select all that apply.

Ensure adequate oxygenation. Provide assistance to prevent falls. Monitor medication administration of diuretics. Prevent complications during potassium administration. Rationale:The priorities for nursing care of a client with hypokalemia are to ensure adequate oxygenation, to assure client safety in fall prevention and potassium administration, and to monitor for complications related to diuretic therapy and client response to therapy. Option 4 is related to hypocalcemia.

The nurse is reviewing the client's results of preadmission laboratory studies for a complete blood count, electrolytes, coagulation studies, and creatinine before a surgical procedure. Which laboratory result would the nurse report immediately to the surgeon?

Hemoglobin (Hgb) level 8.9 g/dL (89 mmol/L) Rationale:Routine screening tests include a complete blood count, coagulation studies, and serum electrolyte and creatinine levels. The complete blood count includes the Hgb analysis. All of these values are within normal range except for the Hgb level. If a client has a low Hgb level, the surgery could likely be postponed by the surgeon.

Which nursing actions are most appropriate for medication administration to a client at risk for aspiration? Select all that apply.

Ensure that all medications can be crushed. Assess for the presence of a gag reflex. Assess the client's level of consciousness. Assess the client's ability to swallow and cough on command. Rationale:If a client is determined to be at risk for aspiration, there are specific actions the nurse would take to ensure client safety when administering oral medications. As with the administration of any medication, the nurse checks the medication prescription and compares it against the medical record, clarifying any incomplete prescriptions; checks the rights of medication administration; reviews any pertinent information related to medication administration, such as the international normalized ratio for the client taking warfarin; and assesses for any contraindications for administration of oral medications, such as NPO status. Next, the nurse places the client in a high-Fowler's position (before, not after, medication administration) and assesses for the client's aspiration risk using the agency-approved screening tool to determine whether it is safe to administer oral medications, checking for the ability to swallow and cough on command and checking for the presence of a gag reflex. If the client is unable to swallow or does not have a gag reflex, then the nurse would not administer the medications and would collaborate with the primary health care provider. If the client is able to swallow and cough and has a gag reflex, then the nurse checks the rights of medication administration again and prepares the medications and any liquids used in the most appropriate form based on the outcome of the swallow screen. Next, the nurse checks the rights of medication administration immediately before administration for the last time, administers the medications one at a time in the prepared form, and ensures that the client has eff

A client is in extreme pain from scrotal swelling that is caused by epididymitis. The nurse providing care for the client administers an opioid analgesic to relieve the pain, as prescribed. What is the next nursing action for this client?

Ensure that the call bell is within the client's reach. Rationale:The nurse would ensure that the call bell is within reach for the client who receives an opioid analgesic. The nurse also instructs the client to call for assistance if it is necessary to get out of bed to prevent injury once the medication has taken effect. Dimming the light in the room is the next most helpful action. The name bracelet would have been checked before administering the medication. It is unnecessary to do range of motion at the site of injection.

The nurse is preparing a preoperative client for transfer to the operating room. The nurse would take which action in the care of this client at this time?

Ensure that the client has voided Rationale:The nurse needs to ensure that the client has voided if a Foley catheter is not in place. The nurse does not administer all daily medications just before sending a client to the operating room. Rather, the primary health care provider writes a specific prescription outlining which medications may be given with a sip of water. The time of transfer to the operating room is not the time to practice breathing exercises; this would have been done earlier. The client has nothing by mouth for 6 to 8 hours before surgery, not 24 hours.

To prevent postoperative atelectasis in a client recovering from an open cholecystectomy, what would the nurse do first?

Ensure that the client is experiencing adequate pain control. Rationale:Coughing is one of the protective reflexes. Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways and prevent atelectasis. The client with an abdominal incision is hesitant to cough unless pain control is adequate. The incision in an open cholecystectomy is just under the diaphragm in the right upper quadrant of the abdomen, making coughing and deep breathing painful. The nurse would first ensure that pain control is adequate so that pulmonary hygiene measures are maximally effective. A cardiopulmonary consult is requested for clients with preexisting risk caused by lung pathology or for clients already experiencing postoperative respiratory complications. Splinting the incision is an effective postoperative strategy for assisting with effective coughing and deep breathing, but it would follow pain control. Huff coughing, although it can be used in the postoperative client, is an effective coughing strategy that is most often recommended for clients with chronic obstructive airway disorders.

The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. How often would the nurse plan to check the IV infusions and IV sites of these clients?

Every 1 to 2 hours Rationale:Safe nursing practice includes monitoring an IV infusion at least every 1 to 2 hours in an adult client. The IV site may be checked even more frequently, depending on agency policy and whether medication also is being infused. Options 2, 3, and 4 are incorrect.

The nurse in a surgical unit receives a postoperative client from the postanesthesia care unit. After the initial assessment of the client, the nurse would plan to continue with postoperative assessment activities how often?

Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed Rationale:When the postoperative client arrives from the postanesthesia care unit, the nurse performs an initial assessment. Common time frames for continuing postoperative assessment activities are every 15 minutes the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed. However, agency policies would always be followed. Options 1 and 2 identify time frames that are too infrequent and that will not provide adequate assessment of the postoperative client. Option 4 identifies close time frames that are unnecessary.

A client is undergoing a 2-hour glucose tolerance test. The nurse assesses for which client factors that can interfere with the test period results? Select all that apply.

Experiencing stress Eating a small snack or candy during the test period Being unable to eat the entire test meal or vomiting some or all of the meal Rationale:Some interfering factors that can result in inaccurate test findings include experiencing stress, being unable to eat the entire test meal or vomiting during the test period, and eating a small snack or candy during the test period. Voiding during the test period, fasting for 4 hours before the test period, and having an episode of diarrhea before the test period would not interfere with the test results.

The nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen's test on the client. The nurse would perform the steps in which order to conduct an Allen's test? Arrange the actions in the order that they would be performed. All options must be used.

Explain the procedure to the client Apply pressure over the ulnar and radial arteries. Ask the client to open and close the hand repeatedly. Release pressure from the ulnar artery Assess the color of the extremity distal to the pressure point. Document the findings. Rationale:The Allen's test is performed before an arterial blood gas specimen is obtained from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse would first explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client's ulnar and radial arteries simultaneously. While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while continuing to compress the radial artery and then assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery would not be used for obtaining a blood specimen. Finally, the nurse documents the findings.

The nurse has a prescription to obtain an arterial blood sample from a client. Prior to the procedure the nurse assesses the adequacy of the client's radial artery by performing the Allen's test. In which order would the Allen's test be performed? Place in correct order of priority. All options must be used.

Explain the procedure to the client. Apply pressure over the ulnar and radial arteries simultaneously. Ask the client to open and close the hand repeatedly. Release pressure from the ulnar artery while compressing the radial artery. Assess the color of the extremity distal to the pressure point. Document the findings. Rationale:The Allen's test is performed before obtaining an arterial blood specimen from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse first would explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client's ulnar and radial arteries simultaneously. While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand would blanch. The nurse then releases pressure from the ulnar artery while compressing the radial artery and assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 to 7 seconds, the ulnar artery is insufficient, indicating that the radial artery would not be used for obtaining a blood specimen. Finally, the nurse documents the findings. Other sites, such as the brachial or femoral artery, can be used if the radial artery is deemed inadequate.

The nurse has a prescription to obtain a urinalysis specimen from a client with an indwelling urinary catheter. Which actions would the nurse plan to include in performing this procedure? Select all that apply.

Explaining the procedure to the client Clamping the tubing of the drainage bag Aspirating a sample from the port on the drainage tubing Wiping the port with an alcohol swab before inserting the syringe Rationale:A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag, so its properties do not necessarily reflect current client status. In addition, it may become contaminated with bacteria from opening the system. The remaining options are correct interventions for obtaining the specimen.

Which essential role does the nurse play in the health care team with multiple primary health care providers and specialists?

Facilitates communication among the team Rationale:Nurses play a key role in facilitating communication among primary health care providers and specialists. The nurse is the center of collaboration for the client. It is necessary to communicate and share the client's information where and with whom it is needed most. The nurse does not diagnose. Options 3 and 4 may be actions that the nurse takes, but these are not associated with the essential role the nurse plays in the health care team with multiple primary health care providers and specialists.

Which factors are most likely to affect health care access and health outcomes? Select all that apply.

Familial support Access to education Environmental safety Access to transportation Rationale:Socioeconomic status, education level, familial and social support, community safety, and access to transportation are factors that influence health care access and health outcomes. Living in a populated city is not specifically associated with health access and outcomes.

A homeless client is being seen at a local outreach clinic. What action(s) taken by the nurse is best to help ensure the client's adherence and follow-up to the new treatment plan? Select all that apply.

Focusing on reported symptoms Being nonjudgmental and nonthreatening Setting a follow-up appointment for the client Rationale:Health visits for clients in the homeless population would be nonjudgmental and nonthreatening; this will build trust between the caregiver and the client and is more likely to promote adherence to the plan of care. Also, the nurse would focus on reported symptoms first and not what the nurse thinks is a problem, based on subjective findings. Additionally, close monitoring and follow-up may be needed, so helping set up future appointments may help the client have better adherence to the treatment plan and follow-up. Focusing on the obvious health abnormalities and expecting the client to bathe before receiving health care is demeaning.

The nurse is developing a plan of care for a client with a diagnosis of early-stage Alzheimer's disease. The plan of care would include nursing interventions that address which early characteristic of Alzheimer's disease?

Forgetfulness interferes with the daily routine. Rationale:In early Alzheimer's disease, forgetfulness begins to interfere with daily routines. The client has difficulty concentrating and difficulty learning new material. Options 1, 2, and 3 are characteristics of this disorder but occur later as the disease progresses.

A client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?

Iron-deficiency anemia Rationale:The normal hemoglobin level for an adult ranges from 12 to 18 g/dL (120 to 180 g/L). Iron-deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity.

The long-term care nurse about to give a daily dose of digoxin to a client with atrial fibrillation is told that a serum digoxin level drawn earlier in the day measured 2.4 ng/mL (2.7 nmol/L). Which action would the nurse take first?

Gather data from the client related to signs of toxicity. Rationale:The normal therapeutic range for digoxin is 0.5 to 2.0 ng/mL (0.6 to 2.4 nmol/L). A value of 2.4 ng/mL (2.88 nmol/L) exceeds the therapeutic range and could be toxic to the client. The nurse needs to gather data about signs of digoxin toxicity first and then notify the cardiologist. Option 2 is incorrect because the next dose would not be administered automatically. Recording the value on the intershift report sheet is incorrect because the value is high, not normal, and dismisses the subject at hand.

A client has a urine specific gravity level of 1.034. The nurse determines that which causes or conditions can be related to this level? Select all that apply.

Glycosuria Albuminuria Dehydration Rationale:Specific gravity evaluates the kidneys' ability to regulate fluid balance and the hydration status of the body. A specific gravity level of 1.034 is high. Some causes for high specific gravity levels are dehydration, albuminuria, and glycosuria. BUN and creatinine levels do not evaluate hydration status. Diabetes insipidus is related to low specific gravity levels.

A home care nurse provides medication instructions to a client. What is the appropriate nursing action to ensure safe administration of medication in the home?

Have the client verbalize and demonstrate the correct administration procedures. Rationale:To ensure safe administration of medication, the nurse allows the client to verbalize and demonstrate correct procedure and administration of medications. Demonstrating the proper procedure for the client does not ensure that the client can safely perform this procedure. It is not acceptable to double up on medication, and conducting a pill count on each visit is not realistic or appropriate.

The nurse is creating a plan of care for a client scheduled for surgery. The nurse would include which activity in the nursing care plan for the client on the day of surgery?

Have the client void immediately before going into surgery. Rationale:The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours (or longer depending on the procedure and as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.

The nurse is creating a plan of care for a client scheduled for surgery. The nurse would include which activity in the nursing care plan for the client on the day of surgery?

Have the client void immediately before going into surgery. Rationale:The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client would not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours (or longer as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder?

Headache, restlessness, and confusion Rationale:When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result would be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed?

Hemoglobin, 8.0 g/dL (80 mmol/L) Rationale:Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All of these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery is likely to be postponed by the surgeon.

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolyte and creatinine levels. Which laboratory result would be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed?

Hemoglobin, 8.0 g/dL (80 mmol/L) Rationale:Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All of these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.

The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed?

Heparin Rationale:During the early phase of DIC, anticoagulants (especially heparin) are given to limit clotting and prevent the rapid consumption of circulating clotting factors and platelets. Antibiotics are given when sepsis is suspected in an attempt to prevent DIC from occurring.

To detect the development of a chronic carrier state in a client with hepatitis, which laboratory test would the nurse assess?

Hepatitis B surface antigen (HBsAg) Rationale:HBsAg is present in chronic carriers. Hepatitis B virus DNA indicates viral replication. A prolonged prothrombin time is caused by decreased absorption of vitamin K in the intestine with decreased production of prothrombin by the liver. Anti-HBs is a marker for the response to the vaccine and indicates immunity to hepatitis B.

The nurse is instructing a client who had a stroke and has weakness on one side how to ambulate with the use of a cane. Which instruction would the nurse provide to the client?

Hold the cane on the unaffected (strong) side. Rationale:The cane is kept on the strong side of the body. It would be hard to hold the cane on the weak side. The cane is assisting the weakened leg, so the weakened leg moves with the cane, or right after it, in ambulating or in going down stairs.

The nurse is preparing to test a client's blood glucose level with a glucometer. Which steps would facilitate obtaining an accurate result? Select all that apply.

Hold the finger in a dependent position during the test. Use gentle pressure to obtain an adequate amount of blood. Obtain the blood specimen by puncturing the lateral side of the finger. Rationale:When obtaining a droplet of blood for a blood glucose monitor, the site needs to be cleaned with an antiseptic swab and then allowed to dry completely. The puncture site would be the lateral side of the finger because the central tip contains more nerves and may be more painful. Holding the finger in a dependent position improves blood flow to the puncture site. Gentle pressure may be needed to obtain an adequate amount of blood for the test strip.

A client with a history of atrial fibrillation is receiving oral anticoagulant therapy with warfarin. The result of a newly drawn prothrombin time (PT) is 40 seconds. The nurse would anticipate which prescription to be prescribed for this client?

Hold the next dose of warfarin. Rationale:The normal PT is 11 to 12.5 seconds for adults. Appropriate therapy for full anticoagulation would prolong the PT by 1.5 to 2 times. Because the value stated is extremely high, the nurse would anticipate that the client would not receive further doses at this time. If the level was too high, the antidote (vitamin K) could also be prescribed. It would be dangerous to add a different anticoagulant to the client's regimen at this time, as in option 4.

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription?

Holding the next dose of warfarin Rationale:The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the value of 35 seconds is high, the nurse would anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect.

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription?

Holding the next dose of warfarin Rationale:The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). The normal INR is 2 to 3 for standard warfarin therapy, which is used for the treatment of atrial fibrillation, and 3 to 4.5 for high-dose warfarin therapy, which is used for clients with mechanical heart valves. A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the values of 35 seconds and 3.5 are high, the nurse would anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect.

A client's blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see? Select all that apply.

Lethargy Headache Weakness Confusion Rationale:In both respiratory and metabolic acidosis, the central nervous system (CNS) is depressed. Headache, lethargy, weakness, and confusion develop, leading eventually to coma and death. Therefore, seizures and hyperactivity would not be noted.

The nurse has instructed a client with a continuous passive motion device applied to the leg about the device and its use. The nurse determines that the client has misunderstood one of the teaching points if the client asks which question?

How to reset the degrees of flexion or extension according to comfort Rationale:The client would not adjust the flexion and extension settings. These settings are determined by the orthopedic surgeon and are maintained as prescribed. The client is instructed about how to stop and start the machine and about the need to notify the nurse if the client experiences knee discomfort. The client also would be aware of proper positioning so that the nurse can be notified if the leg slips. Other important actions by the nurse with use of this device are to assess the neurovascular status of the extremity and to ensure that the device is padded with manufactured disposable padding before the client's leg is placed in the device.

The nurse is preparing the morning medications to be administered to assigned clients and is reviewing the primary health care provider's prescriptions. Which medication prescription would the nurse question?

Hydrochlorothiazide orally twice daily Rationale:The prescription for the hydrochlorothiazide is incomplete because the dosage is missing. The prescriptions in the other options are complete prescriptions.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional sign would the nurse expect to note in a client with hyponatremia?

Hyperactive bowel sounds Rationale:The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted

A client is determined by blood gas analysis to be in respiratory alkalosis. Which electrolyte disorder would the nurse monitor for that could accompany the acid-base imbalance?

Hypokalemia Rationale:Clinical manifestations of respiratory alkalosis include tachypnea, hyperpnea, weakness, paresthesias, tetany, dizziness, convulsions, coma, hypokalemia, and hypocalcemia. The clinical picture does not include hypercalcemia, hypochloremia, or hypernatremia.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note?

Hypotension Rationale:Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the ECG, the nurse would note a prolonged ST interval and a prolonged QT interval.

The nurse in a health care clinic is preparing to conduct a nutritional session with a group of culturally diverse pregnant women. At the first session the nurse will be meeting with each client individually. The nurse prepares a list of items to be included in the session and lists which item as the priority?

Identify the food preferences and methods of food preparation for each client. Rationale:To determine each client's nutritional status and needs, the first priority of the nurse is to identify each client's food preferences. Cultural background and knowledge about nutrition are important factors influencing food choices and nutritional status. Although the remaining options may be a component of the sessions, the correct option is the first priority.

The nurse has given a client with a leg cast instructions on cast care at home. The nurse determines that the client needs further instruction if the client makes which statement?

If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting." Rationale:Client instructions would include avoiding walking on wet, slippery floors to prevent falls. The client would never scratch under a cast because of the risk of skin breakdown and ulcer formation. Surface soil on a cast can be removed with a damp cloth. If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it.

A client who has undergone radical neck dissection is experiencing problems with verbal communication related to postoperative hoarseness. The nurse would formulate which outcome as the most appropriate goal for this client problem?

Incorporates nonverbal forms of communication as needed Rationale:The client may experience temporary hoarseness after neck dissection. Goals for the client include using nonverbal forms of communication as needed, expressing willingness to ring the call bell for assistance, and using the services of a speech pathologist if prescribed. Options 1, 2, and 3 are incorrect.

The nurse is reviewing the laboratory results of a client admitted to the hospital with a diagnosis of venous thrombosis. The nurse expects the platelet aggregation to be reported as which level in this client?

Increased Rationale:The adherence of platelets to one another is defined as platelet aggregation. Platelets usually aggregate in less than 5 minutes. This test determines abnormalities in the rate and percentage of platelet aggregation. Increased platelet aggregation may occur after surgery or with acute illness, venous thrombosis, and pulmonary embolism.

The nurse is caring for a non-English-speaking client and is attempting to integrate the client's cultural practices into Western medicine. What are some other aspects of culturally competent care the nurse can employ? Select all that apply.

Increasing client safety Using spiritual practices Reducing health disparities Increasing client satisfaction Preventing misunderstandings between the nurse and the client Rationale:Besides integrating cultural practices into Western medicine, other aspects of culturally competent care include the following: increasing client safety, reducing health disparities, increasing client satisfaction, and preventing misunderstandings between the nurse and the client. Incorporating spiritual practices as appropriate to the client's culture is also important. Maintaining eye contact when having a conversation with a client is not always part of culturally competent practices.

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?

Increasing restlessness Rationale:Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats per minute is within normal limits. Hypoactive bowel sounds heard in all four quadrants are a normal occurrence in the immediate postoperative period.

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?

Increasing restlessness Rationale:Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/min is within normal limits. The presence of hypoactive bowel sounds heard in all four quadrants is a normal occurrence in the immediate postoperative period.

The nurse would recognize that some minority groups are hesitant to seek health care because of which most likely factor?

Ineffective communication with the primary health care provider (PHCP) Rationale:Some ethnic minorities report hesitancy in seeking health care due to a language barrier. Effective communication is essential to understand and treat the client. Ineffective communication affects the client's safety or willingness to comply with treatment or follow-up care. A low household income and a lack of insurance coverage may be factors but are less likely than the communication problem.

The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia. The nurse notes that the granulocyte count is decreased. The nurse interprets that the client is at risk for which condition?

Infection Rationale:Granulocytes are blood cells that destroy bacteria. When granulocytes are decreased from normal, the risk of infection increases significantly. A decreased granulocyte count is not associated with anemia, bleeding, or dehydration.

The nurse is reviewing the laboratory results for a client with a diagnosis of leukemia and notes that the absolute neutrophil count is decreased. The nurse interprets this to mean that the client is at risk for which problem?

Infection Rationale:Neutrophils arise from stem cells and complete the maturation process in the bone marrow. They belong to a class of leukocytes known as granulocytes because of the large number of granules present inside each cell. Neutrophils provide the first internal line of defense, via phagocytosis, against foreign invaders (especially bacteria) in blood and extracellular fluid. If the neutrophil count is low, the client is at risk for infection. The remaining options are not associated with the function of neutrophils.

The nurse notes that a client's lithium level is 3.9 mEq/L (3.9 mmol/L). What is the nurse's priority action in response to this finding?

Instituting seizure precautions Rationale:A therapeutic regimen aims at a serum lithium level of 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L). A toxic level is greater than 1.5 mEq/L (1.5 mmol/L). A level of 3.9 mEq/L (3.9 mmol/L) is in the toxic range, and seizures may occur at levels of 3.5 mEq/L (3.5 mmol/L) and higher. Options 1, 2, and 3 are indicated, but none of these is the priority intervention.

The nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse plans to monitor the client, knowing that insensible fluid loss occurs through which type of excretion?

Integumentary output Rationale:Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse plans to make a notation that insensible fluid loss occurs through which type of excretion?

Integumentary output Rationale:Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic and notes that the red blood cell (RBC) count is decreased. The nurse recognizes that this finding occurs in which condition?

Iron deficiency Rationale:Decreased RBC counts occur in clients with vitamin B6 and B12 deficiencies, iron deficiency, chronic infection, bone marrow depression, multiple myeloma, leukemia, hemolytic anemia, and pernicious anemia. A decrease in the RBC count also may be noted in the older client. Increased RBC counts are noted in clients with the disorders in the remaining options.

A client's laboratory test results reveal an increased transferrin level and a decreased iron-binding capacity. The nurse interprets that these laboratory results are compatible with anemia because of which problem?

Iron deficiency Rationale:Iron-deficiency anemia usually is characterized by decreased iron-binding capacity and increased transferrin saturation. Infection is not associated with these laboratory values. Malnutrition can cause reductions in both iron-binding capacity and transferrin saturation. Sickle cell anemia is diagnosed by determining that the client has hemoglobin S.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic and notes that the hematocrit value is 30% (0.30). The nurse determines that this hematocrit value is most likely to be associated with which condition?

Iron-deficiency anemia Rationale:A hematocrit of 30% (0.30) or less indicates iron-deficiency anemia. Decreased values occur in leukemia, acute hemorrhage, iron-deficiency anemia, and hemolytic anemia. The conditions in the remaining options represent conditions in which an elevated hematocrit would be noted.

The nurse is monitoring the client with a serum calcium level of 6.2 mg/dL (1.55 mmol/L). Which findings would the nurse assess for in the client? Select all that apply.

Irritability Muscle cramps Tingling sensations Hyperactive reflexes Memory impairment Rationale:Begin by recalling that the normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L) to determine that the client is experiencing hypocalcemia. Signs of hypocalcemia include tingling sensations, hyperactive reflexes, and a positive Trousseau's or Chvostek's sign. Other signs include increased neuromuscular excitability, muscle cramps, tetany, seizures, insomnia, irritability, memory impairment, and anxiety. Severe muscle weakness is seen in hypercalcemia, not hypocalcemia.

The nurse provides instructions to the parent of a newborn to bring the infant to the well-baby clinic for a phenylketonuria rescreening blood test. The nurse determines that the parent understands the need for the test when which statement is made?

It will allow me to institute measures to prevent complications if the level is elevated." Rationale:Phenylketonuria is a genetic disorder that is characterized by an inability of the body to use the essential amino acid phenylalanine. The phenylalanine level is checked to screen for this disorder. Newborn screening tests are mandatory in all 50 states and are most reliable if the blood sample is taken after the infant has ingested a source of protein. The objective in diagnosing or treating phenylketonuria is to prevent cognitive impairment. Minimal or absent phenylalanine hydroxylase activity results in profound cognitive impairment if not treated early with dietary restriction of phenylalanine. The phenylketonuria test is not used to detect cardiac disease, discover the presence of cancer, or check for the presence of a genetic condition.

The nurse is caring for a child who will require the use of an apnea monitor when discharged from the hospital. Which information would the nurse provide to the child's caregiver about the use of an apnea monitor? Select all that apply.

Keep pets and children away from the monitor. Keep emergency rescue numbers near the telephone. Rationale:An apnea monitor would not be adjusted to eliminate false alarms; adjustments could compromise the monitor's effectiveness. The monitor needs to be placed on a firm surface away from the crib and drapes. The caregiver would not sleep in the same bed as a monitored infant. Pets and children need to be kept away from the monitor and infant. Emergency rescue numbers would be kept near phones in the home. Leads needs to be removed when the infant is not attached to the monitor.

A client who had a brain attack (stroke) has an impairment of cranial nerve II. To maintain safety in the home, the nurse would plan to teach the spouse to implement which measure?

Keep traveled paths in the home free of clutter. Rationale:Cranial nerve II is the optic nerve, which governs vision. The nurse can promote safety by encouraging the family to keep pathways free of clutter to prevent falls. Speaking to the client in a loud voice may help compensate for a deficit of cranial nerve VIII (vestibulocochlear). Cranial nerves VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior one third of the tongue, respectively. Lowering the temperature of the hot water heater would be useful if the client had peripheral nerve damage.

When caring for a client with cervical cancer who has an internal radiation implant, the nurse would observe which principles? Select all that apply.

Keeping pregnant persons out of the client's room. Placing the client in a private room with a private bath. Wearing a lead shield when providing direct client care. Rationale:The time that the nurse spends in the room of a client with an internal radiation implant is 30 minutes per shift. The client must be placed in a private room with a private bath. Lead shielding can be used to reduce the transmission of radiation. The dosimeter film badge must be worn when in the client's room. Children younger than 16 years of age and pregnant individuals are not allowed in the client's room.

A client experiencing metabolic acidosis is to be admitted to the nursing unit. The nurse plans care, knowing that what reaction is the most powerful regulator of acid-base balance?

Kidney Rationale:The renal reaction is the most powerful regulator of acid-base balance. Renal tubules secrete hydrogen ions and potassium effectively, and in lesser amounts they secrete ammonia and uric acid. They respond to large or chronic fluctuations in hydrogen ion production or elimination and also reabsorb carbon dioxide molecules. However, the kidney tubules have the slowest response (hours to days).

The registered nurse is observing a newly hired nurse perform a dressing change on a client with a leg ulcer. An enzymatic agent is being used to treat the ulcer. Which observation, if made by the registered nurse, would indicate a need for further teaching with the newly hired nurse?

Leaves the ulcer open to the air after the enzymatic agent is applied Rationale:The wound needs to be cleansed with a sterile solution, such as normal saline, before applying the enzymatic agent. The nurse then applies a thin film of the enzymatic agent on the necrotic areas only and applies a loose, thin dressing taped securely in place.

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed?

Leaving the rate of the heparin infusion as is Rationale:The normal aPTT varies between 28 and 35 seconds (28 and 35 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 times normal (42 to 52.5 seconds) and 2.5 times normal (70 to 87.5 seconds) . This means that the client's value should not be less than 42 seconds or greater than 87.5 seconds. Thus the client's aPTT is within the therapeutic range and the dose should remain unchanged.

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed?

Leaving the rate of the heparin infusion as is Rationale:The normal aPTT varies between 30 and 40 seconds (30 and 40 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 times (45 to 60) and 2.5 times (75 to 100) normal. This means that the client's value should not be less than 45 seconds or greater than 100 seconds. Thus, the client's aPTT is within the therapeutic range and the dose should remain unchanged.

An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder?

Light-headedness and paresthesias Rationale:Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth, headache, light-headedness, vertigo, mental status changes, paresthesias such as tingling of the fingers and toes, hypokalemia, hypocalcemia, tetany, and convulsions. The remaining three options are not clinical manifestations of respiratory alkalosis.

The nurse is caring for a minority client. When assessing for social inequities, which social determinants would be most appropriate for the nurse to consider? Select all that apply.

Living conditions Working conditions Access to health care Rationale:Age and gender are not social determinants. Age is biological, and gender may also be considered biological. Gender is a term also used more broadly to denote a range of identities that do not correspond to established ideas of male and female. Where minority clients live and work and their access to health care play a major role in managing health care maintenance. Without adequate living or working conditions, or with little to no access to health care, health inequities and disparities are created.

The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How would the nurse respond?

Living in a prison can predispose a person to different health conditions." Rationale:The environment of a prison predisposes a person to different health conditions, such as tuberculosis, sexually transmitted infections, or other infectious diseases. Option 1 does not address the client's question. Options 2 and 4 convey incorrect information.

The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding would the nurse most likely expect to note in the client based on this magnesium level?

Loss of deep tendon reflexes Rationale:The normal serum magnesium level is 1.8-2.6 mEq/L (0.74-1.07 mmol/L). A client with a magnesium level of 3.5 mEq/L (1.75 mmol/L) is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau's sign are seen in a client with hypomagnesemia.

The client is suspected of having a skeletal muscle disorder. Which isoenzyme value reported with the creatine kinase (CK) level would the nurse assess for elevation?

MM Rationale:CK is a cellular enzyme that can be fractionated into three isoenzymes. The MM band reflects CK from skeletal muscle. This band would be elevated in skeletal muscle disease. The MB band reflects CK from myocardial muscle. The BB band reflects CK from the brain. There is no MS band.

The nurse has instructed a preoperative client using an incentive spirometer to sustain the inhaled breath for 3 seconds. When the client asks about the rationale for this action, the nurse explains that this action achieves which function?

Maintains inflation of the alveoli Rationale:Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk for these conditions. Options 1, 2, and 4 are incorrect.

The nurse is caring for an abdominal surgical client who has a Jackson-Pratt drain in place. Which interventions would the nurse include in the plan of care for this drain? Select all that apply.

Make sure suction is maintained. Check that the drains are sutured in place. Compress the reservoir to restore suction after emptying. Record the amount and color of drainage according to agency protocol or surgeon's prescription. Rationale:Interventions include making sure suction is maintained, checking that the drains are sutured in place, compressing the reservoir to restore suction after emptying, and recording the amount and color of drainage according to agency protocol or surgeon's prescription. The other interventions are not appropriate.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level?

Malnutrition Rationale:The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level?

Malnutrition Rationale:The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

A client has a prescription for an injection to be administered by the intradermal route. The nurse would avoid which action when administering this medication?

Massaging the area after removing the needle Rationale:An intradermal injection is administered with the needle bevel facing upward at a 10- to 15-degree angle. The medication is injected slowly, and a bleb would form under the skin with injection. After withdrawal of the needle, the area may be patted dry with a 2 × 2 sterile gauze. The area would not be rubbed, to prevent the spread of the medication beyond the area of injection. All equipment is then disposed of, and the area of injection is outlined (circled) for later reference.

The nurse working in a community health clinic for refugees plans care knowing that which health condition(s) are common in this population? Select all that apply.

Measles Tuberculosis Poor nutrition Pregnancy complications Rationale:Refugees and immigrants are at risk for many health conditions that are associated with acculturation, the process of migration, and little to no access to health care. Communicable diseases, poor nutrition, and pregnancy complications are some associated risks. Obesity and asthma are not directly associated with refugees or immigrants.

The nurse receives a telephone laboratory report indicating that a client with diabetes mellitus has a glycosylated hemoglobin (HgbA1c) level of 7.6%. In which priority area would the nurse plan to provide diabetic teaching?

Measures to prevent hyperglycemia Rationale:The normal level for HgbA1c is <6% in an adult without diabetes. Regardless, a level of 7.6% is elevated. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation, helping to detect otherwise unknown episodes of hyperglycemia. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes because the results are reflective of the blood glucose levels over the preceding 2- to 3-month period.

What health issue is essential to address in a prisoner to decrease repeated criminal behavior once released?

Mental health Rationale:Mental illness is a prevalent risk factor among this population. The correctional facility is the only means for this population to get properly screened prior to release. Consistent protocols need to be in place to address mental illness. This may be a leading factor that contributes to repeated criminal activity. Living situation, educational level, and gang-related crimes are not health related.

A client with diabetes mellitus is most likely to experience which type of acid-base imbalance as a complication of the disorder?

Metabolic acidosis Rationale:Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises while the cells of the body use all available glucose and then break down glycogen and fat for fuel. The by-products of fat metabolism are acidotic, leading to the complication called diabetic ketoacidosis. The acid-base disorders in the remaining options are unlikely to occur in diabetes mellitus unless there is another existing disorder.

A client with diabetes mellitus has a blood glucose level of 644 mg/dL (35.7 mmol/L). The nurse plans care, knowing that the client is at risk for the development of which type of acid-base imbalance?

Metabolic acidosis Rationale:Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic, potentially leading to the condition known as diabetic ketoacidosis. The remaining options are incorrect.

The nurse is caring for a client with hyperglycemia and diabetic ketoacidosis (DKA) who now has developed Kussmaul's respirations. The nurse plans care, understanding that the purpose of this type of breathing is to correct what imbalance?

Metabolic acidosis Rationale:Kussmaul's respirations cause respiratory compensation in an attempt to correct metabolic acidosis by exhaling carbon dioxide. This breathing pattern is very deep and rapid and is the respiratory system's attempt to correct metabolic acidosis by exhaling carbon dioxide.

A client reports ingesting large amounts of oral antacids on a daily basis because of a gastric ulcer. The nurse plans care, knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?

Metabolic alkalosis Rationale:Increases in base components occur as a result of oral or parenteral intake of bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing bicarbonate can cause a metabolic alkalosis. The remaining acid-base disturbances are incorrect.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

Metabolic alkalosis Rationale:Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations.

A child is hospitalized because of persistent vomiting. The nurse would monitor the child closely for which priority problem?

Metabolic alkalosis Rationale:Vomiting causes the loss of hydrochloric acid and subsequent metabolic alkalosis. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Diarrhea might or might not accompany vomiting. Hyperactive bowel sounds are not associated with vomiting.

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client?

Monitor the client for dysrhythmias. Rationale:The normal serum magnesium level is 1.8-2.6 mEq/L (0.74-1.07 mmol/L). Cardiac monitoring is indicated because this client is at risk for ventricular dysrhythmias. Phosphate use needs to be limited in the presence of hypomagnesemia because it worsens the condition. It is not necessary to discontinue magnesium products. Ground beef, eggs, and chicken breast are low in magnesium.

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present?

Muscle weakness Rationale:Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness. Mental status changes and confusion are most likely to be noted in the client experiencing hypocalcemia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia.

When a client is transferred from the postanesthesia care unit and arrives on the surgical unit, which would be the first action taken by the nurse?

Obtain the client's vital signs. Rationale:When a client arrives on the nursing unit from the postanesthesia care unit (PACU), the nurse receives the client and immediately checks the client's airway status. The nurse next performs an initial assessment consisting of vital signs. The results must be compared with the vital signs last obtained in the PACU. Once this has been done, the intravenous infusion is checked, and a pain, respiratory, neurological, wound, urinary, and safety assessment is performed. Oxygen is not needed for every postoperative client but may be administered to those who may have a compromised respiratory status. The nurse documents the findings, including the time that the client arrived from the PACU.

The client is being seen by the primary health care provider (PHCP). During the visit, the client states that being a single parent who works is stressful, and because of this, feels chronically fatigued. The client also states feeling anxious because the client cannot find consistent day care for the child. The nurse wants to help the client with community resources. Which resource would be best for the client?

Names of child care facilities Rationale:Access to community organizations and resources can help alleviate some burdens the single parent may encounter. Services such as child care, wellness clinics for access to screenings, and employment opportunities can set the single parent up for success. There are no data in the question indicating that the client needs the names of food banks or the names of psychologists. Although the client is chronically fatigued, there are no data indicating a sleep study is warranted.

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply

Nausea Confusion Tachycardia Light-headedness Rationale:Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, light-headedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.

Nausea Confusion Tachycardia Light-headedness Rationale:Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, light-headedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.

An operating room nurse is positioning a client on the operating room table to prevent the client's extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to prevent which condition?

Nerve and muscle damage Rationale:Part of the operating room nurse's role is to ensure that the safety needs of the client are met, which includes proper positioning. The client's extremities would not be allowed to dangle over the sides of the table because this may impair circulation to the local area or cause nerve and muscle damage. Options 1, 2, and 4 are unrelated to client positioning in this situation.

The nurse is assessing an older adult who was just admitted to the emergency department with a possible hip fracture. What typical complaints of types and/or locations of pain might the nurse expect? Select all that apply.

No pain Groin pain Pain referred to the lower back Pain referred to the back of the knee Rationale:Clients with a fractured hip may have no pain, groin pain, pain referred to the lower back, or pain referred to the back of the knee. Sciatic pain and pain referred to the lower leg are not examples of complaints of pain related to hip fracture.

The nurse assesses a client with an admitting diagnosis of bipolar affective disorder, mania. Which symptom presented by the client would require the nurse's immediate intervention?

Nonstop physical activity and poor nutritional intake Rationale:Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. It is a period during which the mood is predominantly elevated, expansive, or irritable. All options reflect the client's possible symptomatology. Option 2, however, clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse would take which most appropriate action in the care of this client?

Obtain a telephone consent from a family member, following agency policy. Rationale:Every effort would be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may be unavailable. In this situation, a surgeon is permitted legally to perform surgery without consent, but the data in the question do not indicate an emergency. Options 1, 2, and 3 are inappropriate in this situation. Also, agency policies regarding informed consent would always be followed.

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse would take which most appropriate action in the care of this client?

Obtain a telephone consent from a family member, following agency policy. Rationale:Every effort would be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a primary health care provider is permitted legally to perform surgery without consent, but the data in the question do not indicate an emergency. Options 1, 2, and 3 are inappropriate in this situation. Also, agency policies regarding informed consent would always be followed.

The nurse is working at an immigration clinic that provides health checks and health education for immigrants and refugees. What need(s) are essential for the nurse to focus on when caring for this population of clients? Select all that apply.

Offering vaccinations Educating on acculturation and health promotion Rationale:Immigrant and refugee clients need health care regardless of insurance status. Acculturation puts this population at risk because they begin to pick up American culture practices that may be unhealthy in an attempt to fit in. Vaccinations need to be offered to provide protection and build immunity to a new environment. Educating clients about what migration means to them does not offer any health benefits to the client. Immigrant clients do not always experience health conditions through the migration process. Finally, clients with known communicable health conditions would be treated prior to entering a new country of residence.

The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse would place the client?

On the nonoperative side with the legs abducted Rationale:Positioning following a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the surgeon's preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or side-lying on the operative side (unless specifically prescribed by the surgeon) is avoided to prevent displacement of the prosthesis.

When administering an intramuscular injection in the ventrogluteal muscle, how would the nurse position the client to best relax the muscle?

On the side with the hip and knee of the uppermost leg flexed Rationale:The client can be placed in the supine or lateral position. Side-lying (lateral) with the uppermost hip and knee flexed will help to relax the muscle to be injected. Options 1, 2, and 4 will not best relax the muscle and are improper positioning for this injection site.

A client who does not speak English arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take?

Page an interpreter from the hospital's interpreter services. Rationale:The best action is to have a professional hospital-based interpreter translate for the client. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality as well as accurate information may be compromised when a family member or a non-health care provider acts as interpreter.

The evening shift nurse is reviewing the laboratory results of a client's urine culture showing 100,000 bacterial units/mL of urine. What would be the nurse's action?

Page the primary health care provider (PHCP) with the results. Rationale:The PHCP needs to be notified. A colony count of 100,000 is considered a positive culture and could be indicative of pyelonephritis if accompanied by fever and flank pain. A positive culture that is accompanied by dysuria, frequency, and urgency is indicative of cystitis. The other options are incorrect and delay necessary intervention.

The nurse is reviewing the laboratory test results for a client and notes that the differential white blood cell (WBC) count indicates a shift to the right. The nurse suspects that the client's diagnosis is most likely to be which one?

Pernicious anemia Rationale:A differential WBC count is the leukocyte count broken down (differentiated) according to the cell type. A right shift represents an increased number of mature neutrophils, which is seen with pernicious anemia and after tissue breakdown. The conditions in the remaining options are not associated with this finding.

The ambulatory care nurse is reviewing an adult client's laboratory test results and notes that the hematocrit level is 60% (0.60). The nurse recognizes that this level is most likely to be found in clients with which diagnosis?

Pernicious anemia Rationale:The normal hematocrit level is approximately 42% to 52% (0.42 to 0.52) in a male and 37% to 47% (0.37 to 0.47) in a female. The hematocrit level measures the percentage of red blood cells in whole blood. Elevated hematocrit levels are seen in persons with dehydration, pernicious anemia, or polycythemia. Therefore, the conditions in the remaining options are incorrect.

While giving care to a client with cervical cancer who has an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse would take which initial action?

Pick up the implant with long-handled forceps and place it in a lead container. Rationale:In the event that a radiation source becomes dislodged, the nurse would first encourage the client to lie still until the radioactive source has been placed in a safe, closed container. The nurse would use long-handled forceps to place the source in the lead container that should be in the client's room. The nurse would then call the radiation oncologist and document the event and the actions taken. It is not within the scope of nursing practice to insert a radiation implant.

The nurse creates a plan of care for a client with a cervical-uterine radiation implant. Which intervention would be appropriate for the nurse to include in the plan?

Place a lead shield at the client's room. Rationale:The external radiation level associated with an implant necessitates that exposure to staff, other clients, and visitors be minimized. A lead shield is kept at the client's room for use when providing direct care to prevent exposure to radiation. Visitors are limited, and women who are pregnant or who may be pregnant would not enter the room. Visitation is allowed for clients older than 16 years of age. A client with a radiation implant must have a warning sign posted on a closed door and on the chart (per agency policy) to alert staff and visitors that radiation therapy is in process. The client undergoing internal radiation needs to be in a private room.

The nurse cares for a client who is at risk for wound dehiscence after abdominal surgery. Which action is the priority to minimize this risk?

Place a pillow over the incision site during deep breathing and coughing. Rationale:Wound dehiscence occurs most frequently in the postoperative client after coughing, sneezing, vomiting, or getting up from a sitting position. Clients would be instructed to use caution during these activities and to use a pillow to splint the incision. Therefore, option 4 is the correct option. Although wound infection can delay healing and contribute to dehiscence, options 1 and 2 are not priorities, and option 3 is appropriate to treat an evisceration but not to minimize the risk for dehiscence.

A client with peptic ulcer disease and a history of upper gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse would plan to take which action after seeing the laboratory results?

Place the normal report in the client's medical record. Rationale:A normal platelet count ranges from 150,000 to 400,000 mm3 (150 to 400 × 109/L). The nurse should place the report containing the normal laboratory value in the client's medical record. A platelet count of 300,000 mm3 (300 × 109/L) is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed.

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse would take which action after seeing the laboratory results?

Place the normal report in the client's medical record. Rationale:A normal platelet count ranges from 150,000 to 400,000 mm3 (150 to 400 × 109/L). The nurse would place the report containing the normal laboratory value in the client's medical record. A platelet count of 300,000 mm3 (300 × 109/L) is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed.

The primary health care provider writes a prescription to apply a heating pad to a client's back. The nurse plans care, knowing that which intervention is contraindicated and is unsafe?

Placing the heating pad under the client Rationale:The heating pad would never be placed under the client, but it needs to be placed lightly against or on top of the involved area. Burns to the skin can occur when the client lies on the pad. Options 1, 2, and 4 are appropriate measures for the use of a heating pad.

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results would the nurse report? Select all that apply.

Platelets 35,000 mm3 (35 × 109/L) Sodium 150 mEq/L (150 mmol/L) Segmented neutrophils 40% (0.40) White blood cells, 3000 mm3 (3.0 × 109/L) Rationale:The normal values include the following: platelets 150,000 to 400,000 mm3 (150 to 400 × 109/L); sodium 135 to 145 mEq/L (135 to 145 mmol/L); potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L); segmented neutrophils 62% to 68% (0.62 to 0.68); serum creatinine male: 0.6 to 1.2 mg/dL (53 to 106 mcmol/L); female: 0.5 to 1.1 mg/dL (44 to 97 mcmol/L); and white blood cells 5000 to 10,000 mm3 (5.0 to 10.0 × 109/L). The platelet level noted is low; the sodium level noted is high; the potassium level noted is normal; the segmented neutrophil level noted is low; the serum creatinine level noted is normal; and the white blood cell level is low.

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results would the nurse report? Select all that apply.

Platelets, 35,000 mm3 (35 × 109/L) Sodium, 150 mEq/L (150 mmol/L) Segmented neutrophils, 40% (0.40) White blood cells, 3000 mm3 (3.0 × 109/L) Rationale:The normal values include the following: platelets, 150,000 to 400,000 mm3 (150 to 400 × 109/L); sodium, 135 to 145 mEq/L (135 to 145 mmol/L); potassium, 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L); segmented neutrophils, 60% to 70% (0.60 to 0.70); serum creatinine, 0.6 to 1.3 mg/dL (53 to 115 mmol/L); and white blood cells, 5000 to 10,000 mm3 (5.0 to 10.0 × 109/L). The platelet level noted is low; the sodium level noted is high; the potassium level noted is normal; the segmented neutrophil level noted is low; the serum creatinine level noted is normal; and the white blood cell level is low.

The nurse is implementing the complementary therapy of therapeutic touch when caring for clients. The nurse would implement which action when performing therapeutic touch?

Position hands 2 to 4 in (5 to 10 cm) from the body. Rationale:During therapeutic touch, nurses use their hands to assess the client's energy field. Hands are positioned 2 to 4 in (5 to 10 cm) from the body. The energy field is assessed for bilateral similarities or differences in the flow of energy. The next step is clearing and balancing the energy field. Nurses then redirect energy through their own intentionality. The session ends with a smoothing of the energy. Therefore, the remaining options are incorrect.

A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse would plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis?

Potassium Rationale:The serum potassium level tends to rise with metabolic acidosis. This is because potassium moves out of the cells and into the bloodstream. When acidosis is corrected with treatment, the potassium will shift back into the cellular compartment. This can cause a rapid drop in the serum potassium level. Because of the effects of potassium on the heart, this electrolyte needs to be monitored closely while the client is treated.

The nurse is monitoring a client on telemetry notes the presence of prominent U waves. The nurse assesses the client and checks the most recent electrolyte results. The nurse expects to note which electrolyte value?

Potassium 3.0 mEq/L (3.0 mmol/L) Rationale:The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) is indicative of hypokalemia. In hypokalemia, the electrocardiographic (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves.

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

Potassium level of 3.0 mEq/L (3.0 mmol/L) Rationale:Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Some clinical manifestations of respiratory alkalosis include light-headedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, diarrhea, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.

The nurse is caring for a client with chronic kidney disease. Arterial blood gas results indicate a pH of 7.30 (7.30), a Paco2 of 32 mm Hg (32 mm Hg), and a bicarbonate concentration of 20 mEq/L (20 mmol/L). Which laboratory value would the nurse expect to note?

Potassium level of 5.2 mEq/L (5.2 mmol/L) Rationale:Interpretation of the arterial blood gas (ABG) indicates metabolic acidosis with partial compensation by the respiratory system. Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul's respirations; headache; nausea, vomiting, and diarrhea; fruity-smelling breath resulting from improper fat metabolism; central nervous system depression, including mental dullness, drowsiness, stupor, and coma; twitching; and convulsions. Hyperkalemia will occur.

The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what would the nurse do with the 40 mL of gastric aspirate?

Pour the aspirate into the NG tube and reinstill through a syringe with the plunger removed. Rationale:After checking residual feeding contents, the gastric contents need to be reinstilled to maintain the client's electrolyte balance. The gastric contents would be poured into the NG tube through a syringe without a plunger and not injected by pushing on the plunger. Gastric contents are not mixed with formula or diluted with water and would not be discarded.

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse needs to call the surgeon to clarify that which medication would be given to the client and not withheld?

Prednisone Rationale:Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily and may be given parenterally rather than orally. Ferrous sulfate is an oral iron preparation used to treat iron-deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal individuals. These last three medications may be withheld before surgery without undue effects on the client.

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse would call the surgeon to clarify that which medication would be given to the client and not withheld?

Prednisone Rationale:Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily and may be given parenterally rather than orally. Ferrous sulfate is an oral iron preparation used to treat iron-deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. These last three medications may be withheld before surgery without undue effects on the client.

The nurse is preparing a plan of care for a client with cervical cancer who will be hospitalized for insertion of an internal cervical radiation implant. Which nursing intervention would the nurse implement in preparation for the arrival of the client?

Prepare a private room at the end of the hallway. Rationale:The client with an internal cervical radiation implant needs to be placed in a private room at the end of the hall because this location provides less chance of radiation exposure to others. Nurses assigned to this client need to be rotated so that one nurse is not consistently caring for the client and being exposed to excess amounts of radiation. The client's room needs to be marked with appropriate signs (per agency policy) that indicate the presence of radiation. Visitors would be limited to 30-minute visits. All linens need to be kept in the client's room until the implant is removed in case the implant has dislodged and needs to be located.

The nurse is collecting a 24-hour composite urine specimen for testing. What components will most likely be measured in this test? Select all that apply.

Protein Hormones Minerals Creatinine Electrolytes Catecholamines Rationale:A 24-hour urine collection helps diagnose kidney problems. It is often done to see how much creatinine clears through the kidneys. It's also done to measure protein, hormones, minerals, and other chemical compounds. Composite urine collection also measure electrolytes, glucose, 17-ketosteroids, catecholamines, and creatinine. Composite specimens are collected over a period ranging from 2 to 24 hours.

The nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who has undergone lumbar puncture. The nurse determines that which is an abnormal finding?

Protein 100 mg/dL (1 g/L) Rationale:Protein (15 to 45 mg/dL [0.15 to 0.45 g/L]) and glucose (50 to 75 mg/dL [2.8 to 4.2 mmol/L]) normally are present in CSF; however, the protein level for this client is above the expected range. The adult with normal CSF has no red blood cells in the CSF. The client may have small numbers of white blood cells (0 to 5 cells/mcL [0 to 5 × 106/L]).

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure?

Preventing and recognizing hyperglycemia Rationale:The normal reference range for the glycosylated hemoglobin A1c is less than 5.7%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Erythrocytes live for about 120 days, giving feedback about blood glucose for the past 120 days. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus, the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. The estimated average glucose for a glycosylated hemoglobin A1c of 8% is 183 mg/dL (10.1 mmol/L). Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes.

The primary health care provider (PHCP) has written a prescription to start progressive ambulation as tolerated in a hospitalized client who experiences periods of confusion because of bed rest and prolonged confinement to the hospital room. Which nursing intervention would be appropriate when planning to implement the PHCP's prescription and address the needs of the client?

Progressively ambulate the client in the hall 3 times daily. Rationale:The cause of the confusion in this situation is bed rest and decreased sensory stimulation resulting from prolonged confinement; therefore, it is best to ambulate the client in the hall. This will increase sensory stimulation and may decrease confusion. Ambulating in the room and to the bathroom in the client's room will not address the client's need for sensory stimulation. Range-of-motion exercises are an action that would have been performed in preparation for ambulation while the client was on bed rest.

The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L).Which patterns would the nurse watch for on the electrocardiogram? Select all that apply.

Prolonged QT interval Prolonged ST segment Rationale:A client with Crohn's disease is at risk for hypocalcemia. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. Peaked T waves occur with myocardial infarction. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply.

Prolonged QT interval Prolonged ST segment Rationale:The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level?

Prolonged bed rest Rationale:The normal serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A client with a serum calcium level of 6.0 mg/dL (1.66 mmol/L) is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia.

The nurse is reviewing the laboratory test results for a client who takes 325 mg of acetylsalicylic acid, or aspirin, daily and has been having frequent nosebleed episodes. What blood level would the nurse review?

Prothrombin time (PT) Rationale:PT is used to evaluate the adequacy of the extrinsic system and common pathway in the clotting mechanism. When clotting factors exist in deficient quantities, the PT is prolonged. Many diseases and medications such as salicylates are associated with decreased PTs. PT is also used to monitor the adequacy of warfarin therapy. The Hgb level is related to oxygen and carbon dioxide transport. Hgb concentration serves as the oxygen-carrying capacity of the blood and also acts as an important acid-base buffer system. The RBC level is helpful in identifying the cause of anemia and the presence of other diseases. The PTT is used to evaluate the intrinsic system and the common pathway of clot formation and is most commonly used to monitor heparin therapy.

An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse would take which action to help the client experiencing this acid-base disorder?

Provide emotional support and reassurance. Rationale:An anxious client benefits from emotional support and reassurance, which in turn reduces anxiety and may lower the respiratory rate. The client may benefit from the administration of a sedative or antianxiety medication if it is prescribed. The client would try to breathe more slowly. Lying supine provides no benefit to the client and may cause problems with breathing.

The nurse is administering ear drops to a 2-year-old child. To follow the correct administration procedure, the nurse would perform which action?

Pulls the pinna of the ear back and down. Rationale:Because of the internal anatomy of the ear, if the child is 3 years of age or younger, the pinna of the ear is pulled back and down. If the child is older than 3 years, the pinna of the ear is pulled back and up. The child needs to lie on the unaffected side with the ear to receive the drop facing upward.

The nurse is caring for a client with impaired mobility that occurred as the result of a stroke. The client has right-sided arm and leg weakness. Which assistive device would the nurse suggest that the client use to provide the best stability for ambulating?

Quad cane Rationale:Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A cane is better suited for the client with weakness of the arm and leg on one side, and a quad cane would provide the most stability because of the structure of the cane and because a quad cane has four legs.

The nurse is caring for a client following a craniotomy, in which a large tumor was removed from the left side. In which bed position can the nurse safely place the client? Click on the image to indicate your answer.

Rationale:Clients who have undergone crainotomy would have the head of the bed elevated 30 to 45 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion and the head is maintained in a midline neutral position. The client would not be positioned on the site that was operated on, especially if the bone flap was removed, because the brain has no bony covering on the affected site. A flat position (option 4) or Trendelenburg's position (option 2) would increase intracranial pressure. A reverse Trendelenburg's position (option 3) would not be helpful and may be uncomfortable for the client.

The nurse has called a client's primary health care provider (PHCP) to clarify a medication prescription. The PHCP gives a telephone prescription to the nurse for a new medication. What action by the nurse would best promote accuracy at this time?

Read the prescription back to the PHCP after writing it on the prescription sheet. Rationale:The Joint Commission (TJC) requires a verification process, such as reading back the prescription to the prescriber, when the nurse takes either telephone or verbal prescriptions. This verification acts to promote accuracy and reduce errors. Although options 1, 2, and 3 may be a part of the correct procedure, option 4 describes the best action.

The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse would implement which action next?

Reassess the client. Rationale:After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall would be treated as private information and shared on a "need to know" basis. Communication regarding the event would involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary.

The nurse is caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 81 beats/min; and respirations, 16 breaths/min. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/min; and respirations, 20 breaths/min. Which action would the nurse plan to take first?

Recheck the vital signs in 15 minutes. Rationale:A drop in blood pressure slightly below a client's preoperative baseline reading is common after surgery. The nurse would recheck the vital signs. Warm blankets are applied to maintain the client's body temperature. Level of consciousness can be assessed by the evaluation of the client's response to light touch and verbal stimuli. It is not necessary to contact the surgeon immediately.

An elderly client is being seen at the primary health care provider's (PHCP's) office. The client is thin and has multiple bruises on exposed skin, and the nurse suspects elder neglect and abuse. The client's caregiver does all the talking and updates the nurse about the client since last being seen. The nurse would take which best action?

Recognize that neglect and abuse are common in this population and try to follow up with the client privately. Rationale:Elder abuse and neglect is a concern. Health care professionals are mandated reporters. If there is a suspicion of elder abuse, it must be investigated and reported. The nurse would try to follow up with the client privately to confirm suspicions. Option 1 may produce fear in the client, especially if the caregiver is present and is the abuser. Options 2 and 3 are not client focused and place focus on the caregiver providing information and care to the elderly client.

The clinic nurse has obtained a throat culture specimen from a client in whom a throat infection is suspected. The nurse calls the laboratory to have the specimen picked up and is told that the laboratory is short staffed and the laboratory assistant will pick up the specimen in 2 hours. Which is the appropriate nursing action?

Refrigerate the specimen. Rationale:A specimen for a culture would not be allowed to sit unrefrigerated for longer than 1 hour because the unrefrigerated temperature can affect the results of the testing. It is not appropriate to request that the client return for a repeat culture, and it is inappropriate to demand that the laboratory pick up the specimen immediately. There is no reason to contact the PHCP.

A client with coronavirus-2019 (COVID-19) has a prescription for a set of arterial blood gas (ABG) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse would take which action?

Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. Rationale:The client would have oxygen supplementation removed for at least 15 minutes before ABGs are drawn if the client has a prescription for the ABGs to be drawn on room air. This allows time for the client's system to equilibrate so that the ABG results will accurately reflect ventilatory status without the supplemental oxygen. This prescription may be given when the primary health care provider is trying to decide whether to discontinue oxygen therapy, and it allows staff to observe how the client tolerates oxygen removal. Therefore, the remaining options are incorrect.

The nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction would the nurse plan to include in the client's teaching plan?

Remove throw rugs and clutter in the home. Rationale:The client with chronic vertigo needs to maintain the home without throw rugs and in a state that is free of clutter because the effort of trying to regain balance after slipping could trigger the onset of vertigo. To further prevent vertigo attacks, the client needs to change positions slowly and needs to turn the entire body, not just the head, when spoken to. If vertigo does occur, the client would immediately sit down or grasp the nearest piece of furniture. The client needs to avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack

The nurse is providing discharge instructions to the client with lung cancer who has had a pneumonectomy and prepares a list of postoperative instructions for the client. Which intervention would the nurse include in the list?

Report any signs of respiratory infection to the surgeon. Rationale:After a pneumonectomy, if any signs of respiratory infection occur, the surgeon needs to be notified. The client is instructed to perform breathing exercises for the first 3 weeks at home and to space activities to allow for frequent rest periods. The client also would be instructed to avoid heavy lifting of any objects more than 20 pounds until the muscles of the chest wall have healed completely, which takes about 3 to 6 months. The client needs to be told to expect feelings of weakness and fatigue for the first 3 weeks after surgery.

The nurse would plan to take which action next after assessing a homeless pediatric client who is a victim of abuse?

Report signs of abuse and document it. Rationale:Health care considerations for abused or neglected individuals are to treat them with compassion, respect, and dignity. Nurses are mandated reporters for domestic violence and abuse incidence, so a report needs to be done. Documentation of all injuries is also necessary for legal reasons. Asking the parents who abused the child and asking the child if they are scared of the parents or anyone else may cause fear and conflict. Finding out where the child sleeps at night may be helpful at some point of care but is not a next specific action.

The nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30% (0.30). Which action would the nurse take?

Report the abnormally low level. Rationale:The normal hematocrit level ranges from 37% to 52% (0.37 to 0.52), depending on age. A hematocrit level of 30% (0.30) is a low level and would be reported to the primary health care provider because it indicates blood loss.Therefore, the remaining options are incorrect.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation?

Requires nasogastric suction Rationale:The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia.

The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented?

Requires nasogastric suction Rationale:The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level ranges from 2.7 to 8.5 mg/dL (160 to 501 mcmol/L).

The nurse working in the hospital hears a client call out that there is a fire in the hospital room. What actions would the nurse take? Arrange the actions in the order that they would be performed. All options must be used.

Rescue the client from injury. Activate the fire alarm. Close the doors to the other clients' rooms. Pull the pin on the fire extinguisher. Extinguish the fire. Rationale:In the event of a fire, the first priority is to rescue the client and protect the client from injury. The next priority is to activate the fire alarm and report the exact location of the fire to emergency workers to aid in the rescue process. Next, the nurse would contain the fire by closing doors and placing towels under the doorways to prevent the spread of smoke. The nurse then obtains the fire extinguisher, pulls the pin, and extinguishes the fire.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply.

Respirations that are increased in rate Respirations that are abnormally deep Rationale:Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds.

The nurse is admitting to the hospital a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe, the client will be at risk for which acid-base imbalance?

Respiratory acidosis Rationale:Guillain-Barré is a neuromuscular disorder in which the client may experience weakening or paralysis of the muscles used for respiration. This could cause the client to retain carbon dioxide, leading to respiratory acidosis and ventilatory failure as the paralysis develops. Therefore, the remaining options are incorrect.

The nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31, Paco2 is 50 mm Hg, and the bicarbonate (HCO3) level is 26 mEq/L. The nurse concludes that which acid-base disturbance is present in this client?

Respiratory acidosis Rationale:In respiratory acidosis, the pH is decreased and the Paco2 level is increased. Options 1, 2, and 4 are incorrect. In respiratory alkalosis, the pH is elevated with a decrease in Paco2. In metabolic acidosis, both the pH and the HCO3 are decreased. In metabolic alkalosis, the pH and HCO3 are increased.

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance?

Respiratory acidosis Rationale:The normal pH is 7.35 to 7.45. Normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and Paco2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question.

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?

Respiratory acidosis from inadequate ventilation Rationale:Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis. The remaining options are incorrect. Respiratory alkalosis is associated with hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking analgesics containing base products.

A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg, and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition?

Respiratory acidosis without compensation Rationale:The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate HCO3- level is 21 to 28 mEq/L (21 to 28 mmol/L). Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg, and HCO3- is 22 mEq/L. The nurse interprets the results as indicating which condition?

Respiratory acidosis without compensation Rationale:The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm. In respiratory acidosis, the pH is decreased and the Paco2 is elevated. The normal bicarbonate (HCO3-) level is 21 to 28 mEq/L. Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.

The nurse reviews a client's arterial blood gas results and notes that the pH is 7.30 (7.30), the Paco2 is 52 mm Hg (50 mm Hg), and the HCO3 is 22 mEq/L (22 mmol/L). The nurse interprets these results as indicating which condition?

Respiratory acidosis, uncompensated Rationale:Normal pH is 7.35 to 7.45. In a respiratory condition, the pH and the Paco2 will exhibit opposite effects; in this case, the pH is low and the Paco2 is increased. In an acidotic condition, the pH is decreased. Therefore, the values identified in the question indicate a respiratory acidosis. Compensation occurs when the pH returns to a normal value. Because the pH is not within the normal range, the condition is uncompensated.

Arterial blood gas analysis yields the following results: pH 7.48 (7.48), Paco2 32 mm Hg (32 mm Hg), Pao2 94 mm Hg (94 mm Hg), HCO3 level 24 mEq/L (24 mmol/L) for a client seen in the health care clinic. The nurse interprets that the client has which acid-base disturbance?

Respiratory alkalosis Rationale:The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg, and the normal HCO3 concentration is 21 to 28 mEq/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In a metabolic condition, the pH and the bicarbonate move in the same direction.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg, and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?

Respiratory alkalosis, compensated Rationale:The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?

Respiratory alkalosis, compensated Rationale:The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In this situation, the pH is at the high end of the normal value, and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

The nurse reviews a client's arterial blood gas values and notes a pH of 7.50 (7.50), a Paco2 of 30 mm Hg (30 mm Hg), and an HCO3 of 25 mEq/L (25 mmol/L). The nurse would interpret these values as an indication of which condition?

Respiratory alkalosis, uncompensated Rationale:In respiratory alkalosis, the pH will be higher than normal, and the Paco2 will be low. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg. The correct option is the only one that reflects these conditions.

The nurse provides instructions to the parents of an infant regarding car travel and safety seats. Which is the appropriate information related to the safety of the infant?

Restrain in a car seat in the back seat in a semireclined rear-facing position. Rationale:Infants need to be restrained in a car seat (convertible seat) or infant-only seat in a semireclined rear-facing position in the back seat of the car. The infant is not placed in the front seat or in the forward-facing position; therefore, options 2, 3, and 4 are incorrect. Additionally, parents need to be instructed always to follow the guidelines from the manufacturer of the safety seat.

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action?

Resume full activity level. Rationale:Discharge instructions for the client hospitalized with hyperthermia include the prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting.

The nurse is caring for a client the day after a left total knee arthroplasty surgery. In reviewing the client's past medical history, the nurse notes that the client has a history of urinary incontinence and heart failure, which is managed with a potassium-sparing diuretic and a beta-adrenergic blocker. Which prescription, if not already prescribed, would the nurse contact the primary health care provider to obtain?

Resume the client's dose of metoprolol Rationale:According to core measures of The Joint Commission's Surgical Care Improvement Program, surgery clients on beta-blocker therapy prior to surgery would receive a beta blocker within 24 hours of surgery. Thus, option 3 is the correct option. Beta blockers have been found to decrease the risk for mortality associated with noncardiac surgery in high-risk clients. However, for treatment to be both safe and effective, dosing would begin before surgery and continue for at least 1 month after surgery. In this case, the client was already on the beta-blocker therapy prior to surgery, but it needs to be resumed postoperatively. Option 1 is incorrect, as the client is on a potassium-retaining diuretic, so hypokalemia is unlikely to occur. Option 2 is incorrect, as a 12-lead electrocardiogram would have been done prior to surgery, and there is no indication that another one is needed. Option 4 is incorrect, as there is nothing that indicates an indwelling urinary catheter is necessary (history of incontinence and diuretic therapy do not necessitate an indwelling urinary catheter), and it needs to be avoided to prevent the development of a catheter-associated urinary tract infection.

A client is experiencing chronic insomnia. The nurse interprets this to mean that which areas of the brain are involved?

Reticular activating system and cerebral hemispheres Rationale:The reticular activating system in conjunction with the cerebral hemispheres is responsible for arousal. The temporal lobe, hippocampus, and frontal lobe are responsible for memory. The limbic system is responsible for feelings and affect.

The nurse is preparing a plan of care for a postpartum client who is at risk for postpartum endometritis. Which intervention would the nurse include in the plan of care to minimize this risk?

Review hand-washing techniques and pericare procedures with the client. Rationale:Postpartum endometritis frequently is associated with the invasion of bacteria that may arise from the gastrointestinal tract or from the lower genital tract. Reviewing appropriate hand-washing techniques and pericare with clients during the postpartum period will reduce the risk of possible bacterial invasion. Options 1, 2, and 4 are unrelated to this postpartum complication.

A client with a diagnosis of rheumatoid arthritis (RA) is admitted to the unit. What blood tests would the nurse expect to be prescribed to confirm the diagnosis? Select all that apply.

Rheumatoid factor Rationale:Blood tests commonly used to confirm the diagnosis of RA include ANA, rheumatic factor, ESR, and anti-CCP. Cardiac enzymes and fasting blood glucose tests are not used to diagnose this condition. ANA is used to diagnose autoimmune diseases. An elevated ESR is used to detect inflammation of joints associated with RA. Rheumatoid factor is useful in the diagnosis of RA. Anti-CCP appears early in the course of RA and is present in the blood of most clients with the disease.

The nurse is providing mouth care to an unconscious client. The nurse would avoid which action during this procedure?

Rinsing with a large volume of fluid Rationale:The client who is unconscious is at great risk of aspiration. The nurse assesses the client for the presence of a gag reflex. The nurse turns the client's head to the side and places an emesis basin underneath the mouth. A bite stick or padded tongue blade is used to open the mouth; use of the nurse's gloved fingers is avoided to prevent injury to the nurse. Small volumes of fluid are used in rinsing the mouth, and oral suctioning is used to prevent aspiration.

The nurse is developing a plan of care for a client with late-stage Alzheimer's disease. The nurse identifies which client problem as having the highest priority?

Risk for injury Rationale:Clients who have Alzheimer's disease have significant cognitive impairment and are therefore at risk for injury. It is critical for the nurse to maintain a safe environment, particularly as the client's judgment becomes increasingly impaired. Options 2, 3, and 4 may be appropriate, but the highest priority is directed toward safety.

The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP?

Safely securing the safety device straps to the side rails Rationale:The safety device straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released. A half-bow or safety knot or device with a quick release buckle would be used to apply a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device would be secure, and one or two fingers need to slide easily between the safety device and the client's skin.

The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the AP?

Safely securing the safety device straps to the side rails Rationale:The safety device straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released. A half-bow or safety knot or device with a quick-release buckle would be used to apply a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device needs to be secure, and one or two fingers would slide easily between the safety device and the client's skin.

The nurse is admitting a client who has a cough, dyspnea, and an abnormal chest x-ray who is otherwise healthy. The client has an elevated serum angiotensin-converting enzyme (SACE) level. Based on this result, what condition is the client at risk for?

Sarcoidosis Rationale:SACE is found in pulmonary epithelial tissue and is used in the detection of sarcoidosis. It does not diagnose pulmonary fibrosis, bacterial pneumonia, or COPD. Normal SACE levels are 8 to 53 U/L. Elevated SACE levels are found in a high percentage of clients with sarcoidosis (an autoimmune granulomatous disease that affects many organs, especially the lungs). It is also used to monitor the clinical course of the disease.

The nurse is caring for a client who is experiencing metabolic alkalosis. Knowing the risks of this imbalance, the nurse plans to protect the client's safety by carefully implementing which prescribed precaution?

Seizure precautions Rationale:The client with metabolic alkalosis is at risk for tetany and seizures. The nurse would maintain client safety by using seizure precautions with this client. The remaining options are unnecessary in the care of the client experiencing metabolic alkalosis.

A client arrives at the surgical unit after undergoing rhinoplasty and has a nose splint and gauze drip (moustache dressing) in place. The nurse reviews the primary health care provider's prescriptions and anticipates that which client position will be prescribed?

Semi-Fowler's Rationale:The client who undergoes rhinoplasty experiences swelling in the affected area. To reduce swelling, the client would be placed in the semi-Fowler's position. The lateral side-lying position would not decrease swelling. The prone and supine positions would not decrease swelling because the client would be lying flat.

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

Serous drainage Rationale:Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.

The nurse has been giving a client furosemide intravenously for an exacerbation of heart failure. The nurse monitors which potentially abnormal blood levels that frequently occur when this medication is administered? Select all that apply.

Serum sodium Serum potassium Rationale:Serum sodium, potassium, and chloride levels can be affected with the administration of furosemide. Furosemide is a loop diuretic, and these medications block the Na-K-Cl2 (sodium, potassium, chloride cotransporter 2 [NKCC2]) in the nephron on the ascending limb of the loop of Henle, where most sodium is reabsorbed. Serum protein, albumin, and creatinine levels are not affected with the administration of this medication.

client with cirrhosis is being treated for hypernatremia. On reviewing the laboratory values for the client, the nurse determines that treatment is effective if which laboratory result is noted?

Serum sodium value of 145 mEq/L (145 mmol/L) Rationale:Laboratory data reflective of hypernatremia include a serum sodium value greater than 145 mEq/L (145 mmol/L), serum osmolality greater than 295 mOsm/kg (295 mmol/kg), and urine specific gravity greater than 1.030 when the kidneys are functioning normally. The increase in the urine specific gravity is a result of the compensatory attempt by the kidneys to conserve water. Normal serum sodium levels range from 135 to 145 mEq/L (135 to 145 mmol/L). The serum sodium level of 145 mEq/L (145 mmol/L) is the only normal value, indicating that treatment is effective

The nurse is reviewing the laboratory results of estimated glomerular filtration rate (eGFR). What are some conditions that can cause a decreased eGFR? Select all that apply.

Shock Dehydration Heart failure (HF) Cirrhosis with ascites Rationale:eGFR is an equation that uses the serum creatinine, age, and numbers that vary depending on sex and ethnicity to calculate the eGFR with very good accuracy. The value may be inaccurate in extremes of age; in clients with severe malnutrition or obesity, paraplegia, or quadriplegia; and in pregnant women. The eGFR can also be used to calculate medication dosage in clients with decreased renal function. Conditions causing decreased eGFR are shock, dehydration, HF, and cirrhosis with ascites. Decreased eGFR is not related to cystitis or fluid overload. Conditions that are associated with decreased blood flow to the kidney will decrease eGFR. Shock, dehydration, HF, and cirrhosis with ascites can lead to impaired kidney function related to renal artery atherosclerosis, glomerulonephritis, and acute tubular necrosis.

The nurse is reviewing the laboratory blood test results for a client and notes that the hemoglobin S (Hgb S) value is elevated. The nurse determines that this laboratory finding is associated with which condition?

Sickle cell anemia Rationale:Sickle cell anemia is a severe anemia that predominantly affects African Americans. It is characterized by the presence of Hgb S. The client must have two abnormal genes encoding Hgb S to have sickle cell disease. A client could have sickle cell trait by carrying one hemoglobin A gene and one Hgb S gene. Hgb S is not associated with aplastic anemia, infectious mononucleosis, or acute lymphocytic leukemia.

The nurse working in a community outreach program for foster children plans care, knowing that which health conditions are common in this population? Select all that apply.

Sleep problems Bipolar disorder Aggressive behavior Attention-deficit/hyperactivity disorder (ADHD) Rationale:Foster children are at risk for a variety of health conditions, including ADHD, aggressive behavior, anxiety disorder, bipolar disorder, depression, mood disorder, post-traumatic stress disorder, reactive detachment disorder, sleep problems, and personality disorder. Asthma and claustrophobia are not specifically associated with foster children.

The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse would select which solution to use for the nasogastric tube irrigation?

Sodium chloride Rationale:A potassium level of 4.5 mEq/L (4.5 mmol/L) is within normal range. A sodium level of 132 mEq/L (132 mmol/L) is low, indicating hyponatremia. In clients with hyponatremia, sodium chloride (normal saline) rather than water would be used for gastrointestinal irrigations because it is an isotonic solution.

The nurse has observed that an older client has episodes of extreme agitation. Which measure is most appropriate for the nurse to implement to avoid episodes of agitation?

Speak and move slowly toward the client while assessing the client's needs. Rationale:Speaking and moving slowly toward the client will prevent the client from becoming further agitated. Any sudden moves or speaking too quickly may cause the client to become agitated and could trigger a violent episode. Remaining at the entrance of the room may make the client feel alienated. If the client's agitation is not addressed, it will only increase. Therefore, waiting for the agitation to subside is not an appropriate option. Walking up behind the client may cause the client to become startled and react violently.

A registered nurse (RN) has instructed an assistive personnel (AP) to administer soap suds enemas until clear to a client. The AP reports that three enemas have been administered and the client is still passing brown, liquid stool. What would the RN instruct the AP to do?

Stop administering the enemas until the primary health care provider (PHCP) is notified. Rationale:Up to three enemas may be given when there is a prescription for enemas until clear. If more than three are necessary, the nurse would call the PHCP (or act according to agency policy). Excessive enemas could cause fluid and electrolyte depletion. Options 1 and 3 are incorrect for these reasons. An oil retention enema is an enema that is used to soften dry, hard stool and would have no use in this situation.

A child is receiving edetate calcium disodium (calcium ethylenediaminetetraacetic acid [EDTA]) by intravenous (IV) infusion for the treatment of lead poisoning. The primary health care provider (PHCP) prescribes a blood level lead concentration measurement. Which action would the nurse take to obtain the blood specimen?

Stop the IV infusion for 1 hour before obtaining the blood. Rationale:If the child is receiving an IV infusion of calcium EDTA, the infusion needs to be stopped for 1 hour before a blood level lead concentration is obtained. Otherwise, the blood level lead concentration will indicate a falsely elevated reading. Therefore, the actions in the remaining options are incorrect.

The nurse is caring for a client with respiratory failure related to Guillain-Barré syndrome. The nurse understands that what other extrapulmonary causes can lead to respiratory failure? Select all that apply.

Stroke Sleep apnea Opioid analgesics, sedatives, anesthetics Rationale:Extrapulmonary causes of respiratory failure include the following: stroke; sleep apnea; and opioid analgesics, sedatives, and anesthetics. Both obstructive lung disease and pneumonia are intrapulmonary causes of respiratory failure.

A client has had an invasive abdominal surgery to relieve an obstruction of the common bile duct. The client's surgery is completed, and the client has been transferred to the postanesthesia care unit (PACU). The PACU nurse observes that the client suddenly appears red in the face and appears to be coughing despite the presence of an endotracheal tube and ventilator support. What action would the PACU nurse take first?

Suction the client through the endotracheal tube. Rationale:The client is choking on secretions, which need to be removed by suctioning the endotracheal tube. The client is unable to use an incentive spirometer while an endotracheal tube is in place. The client's inability to breathe impairs ability to learn how to use a communication board. Turning the client assists in clearing the airway, but a supine position will worsen the airway problem. Suctioning the client is the best nursing intervention because it will have the most immediate effect.

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse would place the client in which position?

Supine, with the residual limb supported with pillows Rationale:The residual limb is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the residual limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check primary health care provider prescriptions regarding positioning following amputation.

An older client is seen in the clinic for a physical examination. Laboratory studies reveal that the hemoglobin and hematocrit levels are low, indicating possible anemia and the need for further diagnostic studies and a blood transfusion. The client refuses to have a blood transfusion due to cultural beliefs and practices. The nurse would take which most appropriate action?

Support the client's decision not to receive a blood transfusion. Rationale:A client's cultural beliefs and practices influence the response to health, illness, surgery, and death. Awareness of cultural differences enhances the nurse's knowledge of how a health care experience may be perceived by the client or family. In some cultures, the administration of blood and blood products is forbidden; therefore, the nurse would support the client's decision. Trying to convince the client of the need for the blood transfusion is inappropriate and does not respect the client's cultural beliefs. Speaking to the family is a violation of the client's right to confidentiality; in addition, it does not respect the client's cultural beliefs. Discussing the results of laboratory values is an indirect way of trying to convince the client of the need for a blood transfusion, which again is inappropriate and does not respect the client's cultural beliefs.

Which meal tray would the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet?

Sweet and sour chicken with rice and vegetables, mixed fruit, juice Rationale:Members of Orthodox Judaism adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable and the pork is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven hoofed, and ritually slaughtered.

The nurse is reviewing laboratory results for a client with chronic kidney disease before a hemodialysis treatment. The serum electrolyte levels are sodium 142 mEq/L (142 mmol/L), chloride 103 mEq/L (103 mmol/L), potassium 5.2 mEq/L (5.2 mmol/L), and bicarbonate 23 mEq/L (23 mmol/L). What action would the nurse plan to take?

Take no action. Rationale:No action is needed because all of the blood levels are normal for a hemodialysis client before a treatment. The normal adult ranges of serum electrolyte levels are sodium 135 to 145 mEq/L (135 to 145 mmol/L), chloride 98 to 106 mEq/L (98 to 106 mmol/L), bicarbonate (venous) 21 to 28 mEq/L (21 to 28 mmol/L), and potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Although the potassium level is elevated, the normal range for potassium for a client with chronic kidney disease receiving hemodialysis is 4 to 6.5 mEq/L (4 to 6.5 mmol/L).

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.

Tall peaked T waves Widened QRS complexes Rationale:The client with chronic kidney disease is at risk for hyperkalemia. The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occur in hypokalemia. A prolonged ST segment occurs in hypocalcemia.

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.

Tall peaked T waves Widened QRS complexes Rationale:The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occur in hypokalemia. A prolonged ST segment occurs in hypocalcemia.

The nurse would plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?

Teach the client and family about the need for hand hygiene. Rationale:In the neutropenic client, meticulous hand hygiene education is implemented for the client, family, visitors, and staff. Not all visitors are restricted, but the client is protected from persons with known infections. Fluids need to be encouraged. Invasive measures such as an indwelling urinary catheter need to be avoided to prevent infections.

Which teaching method is most effective when providing health care instructions to members of specific populations?

Teach-back Rationale:When providing health care instructions to members of specific populations, return explanation and demonstration (teach-back) are of particular importance to ensure safety and mutual understanding. This method is the most reliable in confirming client understanding of the instructions. Video instruction, written materials, and verbal explanation are helpful and may be incorporated with the teach-back method.

The nurse is providing preoperative teaching to a client scheduled for a laparoscopic cholecystectomy. Which intervention would be of highest priority in the preoperative teaching plan?

Teaching coughing and deep-breathing exercises Rationale:After cholecystectomy, respirations tend to be shallow because deep breathing is painful as a result of the location for the surgical procedure. Although all the options are correct, teaching coughing and deep-breathing exercises is the highest priority.

The nurse is teaching a client who had a stroke how to use a walker for ambulation. Which level of prevention is the nurse implementing?

Tertiary level Rationale:The tertiary level is focused on rehabilitation skills. Therefore, teaching a client who had a stroke how to use a walker is a tertiary level of prevention. The primary level is focused on prevention. The secondary level is a screening level that entails such procedures as vision screening, mammography, or similar screening tests. There is no basic level of prevention.

The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings would be anticipated in this client? Select all that apply.

Tetany Hypotension Prolonged QT interval Positive Chvostek's sign Rationale:The normal total serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L); thus, the client's results are reflective of hypocalcemia. The most common manifestations of hypocalcemia are caused by overstimulation of the nerves and muscles; therefore, tetany and the presence of Chvostek's sign would be expected. Calcium is needed by the heart for contraction. When the serum calcium level is decreased, cardiac contractility is decreased and the client will experience hypotension. A low serum calcium level could also lead to severe ventricular dysrhythmias and prolonged QT and ST intervals on the electrocardiogram.

The nurse is caring for a client whose arterial blood gas results reveal alkalosis. What client reactions would the nurse expect to see? Select all that apply.

Tetany Tingling Numbness Restlessness Rationale:A client's reaction to alkalosis causes tingling and numbness of the fingers, restlessness, and tetany caused by irritability of the central nervous system (CNS). If the severity of alkalosis increases, convulsions and coma may occur.

The nurse is preparing to initiate an intravenous (IV) puncture on a client and obtains the prescribed solution of 1000 mL of normal saline for the infusion. The nurse sets up the IV infusion and checks which before performing the venipuncture?

The IV solution for particles or contamination Rationale:All IV solutions need to be free of particles or precipitates and need to be assessed before initiation of an IV line. Although the client's vital signs and laboratory values may be assessed, these actions are unrelated to performing the venipuncture.

A client with trigeminal neuralgia who is receiving carbamazepine 400 mg orally daily has a white blood cell (WBC) count of 2800 mm3 (2.8 × 109/L), blood urea nitrogen (BUN) of 17 mg/dL (6.12 mmol/L), sodium of 141 mEq/L (141 mmol/L), and uric acid of 5 mg/dL (0.3 mmol/L). On the basis of these laboratory values, the nurse would make which interpretation?

The WBC count is low, indicating a blood dyscrasia. Rationale:Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia; cardiovascular disturbances; thrombophlebitis; dysrhythmias; and dermatological effects. The normal WBC count is 5000-10,000/mm3 (5-10 × 109/L). Normal sodium is 135-145 mEq/L (135-145 mmol/L), and normal BUN is 10-20 mg/dL (3.6-7.1 mmol/L), Normal uric acid for males is 4.0-8.5 mg/dL (240-501 mcmol/L) and for females is 2.7-7.3 mg/dL (160-430 mcmol/L). Therefore, options 2, 3, and 4 are incorrect.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse needs to include which piece of information in discussions with the client?

The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. Rationale:For optimal lung expansion with the incentive spirometer, the client would assume the semi-Fowler's or high-Fowler's position. The mouthpiece needs to be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath would be held for 5 seconds before exhaling slowly.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse would include which piece of information in discussions with the client?

The best results are achieved when sitting up or with the head of the bed elevated to 45 to 90 degrees. Rationale:For optimal lung expansion with the incentive spirometer, the client would assume the semi-Fowler's or high-Fowler's position. Clients who are obese need to be taught to use the reverse Trendelenburg or side-lying position because they are able to move their diaphragm better in these positions. The mouthpiece would be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath needs to be held for 5 seconds before exhaling slowly.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas (ABG) values are pH = 7.53, Pao2 = 72 mm Hg, Paco2 = 32 mm Hg, and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client would the nurse make?

The client is probably hyperventilating. Rationale:The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis, not acidosis, as a result of hyperventilating. Concluding that the client is overreacting is an inaccurate analysis. No conclusion can be made about a client's fluid volume status from the information provided.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?

The client who has sustained a traumatic burn Rationale:The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

Which clients are most likely to be at risk for the development of third spacing? Select all that apply.

The client with cirrhosis The client with liver failure The client with chronic kidney disease Rationale:Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors for third spacing include clients with liver or kidney disease, major trauma, severe burn injuries, sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?

The client with kidney disease that developed as a complication of diabetes mellitus Rationale:A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. Kidney disease is a complication of diabetes mellitus and as a result of the kidney disease, the elimination of fluid is affected and the client retains fluid. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

The nurse is caring for a hospitalized client with chronic obstructive pulmonary disease who is retaining carbon dioxide (CO2). The nurse anticipates which physical response will initially occur?

The client's arterial blood gas results will reflect acidosis. Rationale:When the client with respiratory disease retains CO2, a rise in CO2 will occur. This results in a corresponding fall in pH, thus respiratory acidosis. This concept forms the basis for key aspects of acid-base balance. The other options are incorrect and are not associated with this initial physical response.

A client is being seen at the primary health care provider (PHCP) office. The client has a history of schizophrenia and has been taking a new psychotropic medication for 3 weeks. Which finding(s) indicate a need for follow-up? Select all that apply.

The client's cholesterol level is elevated. The client gained 8 pounds since the last visit. The client's blood pressure is increased from baseline. Rationale:Clients with schizoaffective disorders are at higher incidence for metabolic syndrome and diabetes mellitus due to the side effects experienced while taking psychotropic medications, such as increase in appetite, weight gain, increased cholesterol levels, and increased blood pressure. Psychotropic medications cause sedation; therefore option 1 is incorrect.

The home care nurse visits a client at home who has been experiencing increased weakness. The client tells the nurse that he is using a cane that was purchased at a local pharmacy. The home care nurse assesses the client's use of the cane and determines that the cane is sized correctly if which observation is made?

The client's elbow is flexed at a 15- to 30-degree angle when ambulating with the cane. Rationale:The height of a cane would be even with the greater trochanter. This allows the elbow to be held at approximately 15 to 30 degrees of flexion. The flexion is necessary to allow the client to push off without bending over when ambulating. Options 1, 2, and 4 are incorrect and present an unsafe situation.

A client is being transferred from the intensive care unit to a step-down unit. The nurse is performing a final assessment of the client before moving the client to the new unit. The priority components of this final assessment would include which parameters? Select all that apply.

The client's vital signs The client's level of consciousness The patency of intravenous lines Rationale:The client's vital signs, the client's level of consciousness, and patency of intravenous (IV) lines are priority parameters when assessing a client for transfer to another unit or area. Assessing these can help reduce the risk of complications during the transfer. The client's weight and dietary orders, although important in the client's care, are not an immediate priority.

The nurse is working in a very busy outpatient clinic that cares primarily for uninsured clients. The nurse plans care, knowing that the most likely reason for this clinic being so busy is which factor?

The clients lack access to preventive health care. Rationale:The underinsured or uninsured client is at increased risk for health disorders due to a lack of access to care. Additionally, preventive care or treatment for chronic diseases is decreased among this population as well. A client can be employed and still be uninsured. There are no data to indicate that the clinic has payment options or that the clinic can qualify clients for Medicaid. Qualifying for Medicaid needs to be done through the state or federal social services department.

The nurse is caring for a client in the emergency department who states they are homeless. Which statement, if made by the nurse, requires the need for further teaching?

The homeless population is comprised primarily of physically and mentally disabled persons. Rationale:Individuals affected by homelessness are at increased risk for death related to chronic illness, environmental exposures, communicable diseases, mental illnesses, and many other conditions. Homeless individuals can also experience violence, and physical and emotional trauma. There are many reasons leading to homelessness, and disability is one factor but not necessarily the primary factor.

The prenatal clinic nurse is performing an assessment on a culturally diverse client. Besides conversational style, what are some of the most important cultural and communication considerations the nurse must be aware of? Select all that apply.

Touch Eye contact Personal space Time orientation Rationale:The most important cultural and communication considerations the nurse must be aware of are touch, eye contact, personal space, and time orientation. Family presence and facial expression are not important concepts.

The nurse is preparing to provide preoperative teaching to a non-English-speaking client and the client's family. Which nursing action would be most effective for teaching the client?

The nurse secures the assistance of a professional interpreter to communicate with the client. Rationale:Using the services of a professional interpreter is the most effective way to provide preoperative instructions. Asking a family member to interpret is not acceptable because that client may interpret different or erroneous meanings from the nurse's instructions. Nurses who speak only English should never attempt to do the teaching themselves with only the help of a dictionary. A brochure with pictures may be given to the client as an adjunct to interpreted verbal instructions but would not be adequate by itself.

The nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse plans interventions, knowing that as the client's CO2 level rises, what will occur with the blood pH?

The pH will fall Rationale:CO2 acts as an acid in the body. A rise in blood CO2 will result in a fall in pH. The other options are incorrect.

The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?

The passage of flatus Rationale:Following abdominal perineal resection, the nurse would expect the colostomy to begin to function within 72 hours after surgery, although it may take up to 5 days. The nurse would assess for a return of peristalsis, listen for bowel sounds, and check for the passage of flatus. Absent bowel sounds would not indicate the return of peristalsis. The client would remain NPO (nothing by mouth) until bowel sounds return and the colostomy is functioning. Bloody drainage is not expected from a colostomy.

A primary health care provider has written a prescription for wrist restraints to be applied on a client from 10:00 p.m. to 7:00 a.m. because the client becomes disoriented during the night and is at risk for pulling out the nasogastric tube and the intravenous catheter. At 11:00 p.m., the charge nurse makes rounds on all of the clients in the unit. When assessing the client with the restraints, which observation by the charge nurse indicates that the nurse who applied the restraints performed an unsafe action?

The restraints were applied tightly. Rationale:Restraints would never be applied tightly because that could impair circulation. The restraints would be applied securely (not tightly) to prevent the client from being endangered by slipping through the restraints. A safety knot needs to be used because it can be released easily in an emergency. The call light must always be within the client's reach in case the client needs assistance. Restraints, especially limb restraints, must be released every 2 hours (or per agency policy) to inspect the skin for abnormalities.

A home care nurse performs a home safety assessment and discovers that a client is using a space heater in the apartment. Which instruction would the nurse provide to the client regarding the use of the space heater?

The space heater needs to be placed at least 3 feet from anything that can burn. Rationale:Space heaters need to be used appropriately because they present a great risk of fire. A space heater needs to be placed at least 3 feet from anything that can burn. A space heater can be used in an apartment if there is ample space and safety precautions are followed. Placing a heater in a hallway does not guarantee that it will be 3 feet from anything that can burn. A low setting does not reduce the risk of fire.

The home health nurse performs an assessment on a client who had cardiac surgery 10 days ago. The client states, "I get dizzy in the shower." On the basis of the client's statement, which would the nurse assess first?

The temperature of the water of the client's shower Rationale:The client may be taking hot showers, which can cause vasodilation with a consequent decrease in venous return to the heart. Decreased venous return decreases cerebral blood flow, leading to symptoms of dizziness. By assessing the temperature of the shower first, the nurse may identify the problem and instruct the client to decrease the water temperature or defer hot showers or baths until the healing process has occurred. The client's complaint is dizziness. Factors that increase dizziness would be the first assessment. Options 1, 3, and 4 do not directly relate to the client's complaint.

A client is donating blood for a family member who is having surgery. The nurse tells the client that an indirect Coombs' test will be performed on the blood. The client asks the nurse about the purpose of the test. Which response would the nurse provide to the client?

The test detects circulating antibodies against red blood cells (RBCs)." Rationale:The indirect Coombs' test detects circulating antibodies against RBCs. This test is used in addition to the ABO typing that normally is done to determine blood type. The indirect Coombs' test does not detect the presence of hepatitis B virus, the amount of hemoglobin in the blood, or the presence of HIV.

The nurse is reviewing the white blood cell (WBC) count and differential on a client and notes that the results indicate a left shift. What are the possible indications for these laboratory results? Select all that apply.

The total number of WBCs An increased number of bands The presence of an acute infectious process An increased number of immature neutrophils Rationale:The differential count reflects the percentage of the total number of WBCs. A left shift indicates an increased number of immature neutrophils or an increased number of bands. This signals the presence of an acute infectious process. A right shift represents an increased number of mature neutrophils.

The community health nurse is performing a safety assessment in the home of a parent with two children, ages 1 and 3 years. Which, if noted during the assessment, presents the greatest hazard to the children?

Toys with small loose parts in the playroom Rationale:Toys with small loose parts would be the priority concern. Children at this age are likely to place the small toy parts in their mouths, which could lead to aspiration and choking. A small dog as a house pet is not necessarily a hazard. The water temperature of the hot water heater is a concern but is not the greatest hazard. The mother needs to be aware of and taught safety measures related to safe water temperatures for bathing the children. A gate placed at the stairs of the second floor is a safety measure.

The community health nurse is conducting an educational session for community members regarding measures to prevent skin cancer and is providing instructions for the use of sunscreen. The nurse determines that teaching was effective if a community member states that chemical sunscreens are most effective when applied at what time?

Twenty to 30 minutes before exposure to the sun Rationale:Sunscreens are most effective when applied about 20 to 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens need to be reapplied after swimming or sweating and should be applied even on cloudy days.

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

Twitching Rationale:A client with lactose intolerance is at risk for developing hypocalcemia, because food products that contain calcium also contain lactose. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns would the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.

U waves Inverted T waves Depressed ST segment Rationale:The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.

The home care nurse is performing an environmental assessment in the home of an older client. Which observation by the nurse requires intervention?

Unsecured scatter rugs Rationale:Trauma to the older client in the home may be caused by a variety of factors. These include an unsteady gait, the presence of unsecured scatter rugs, cluttered passageways, inoperable smoke detectors, and a history of previous falls. Any assessment findings that could lead to injury or trauma in the home would be addressed immediately.

The nurse is caring for an older client with dysphagia who is at risk for aspiration. When preparing the client for eating, the nurse would place the client in which position to minimize the risk for aspiration?

Upright in a chair Rationale:It is best to assist the client who is at risk for aspiration and is dysphagic to sit upright in a chair for meals. This position facilitates chewing and swallowing and prevents reflux of stomach contents. Options 1, 2, and 4 are not the best positions to prevent aspiration of food and fluids.

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

Urinary output of 20 mL/hr Rationale:Urine output would be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 mL for 2 consecutive hours needs to be reported to the surgeon. A temperature higher than 37.7° C (100° F) or lower than 36.1° C (97° F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

A client has received atropine sulfate intravenously during a surgical procedure. The nurse would monitor the client for which side effect of the medication in the immediate postoperative period?

Urinary retention Rationale:Atropine sulfate is an anticholinergic medication that causes tachycardia, drowsiness, blurred vision, dry mouth, constipation, and urinary retention. The nurse monitors the client for any of these effects in the immediate postoperative period.

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment?

Urine specific gravity of 1.032 Rationale:The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.005 to 1.030. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.6 to 8.0 normal), and this value is not used in monitoring hydration status.

The nurse is caring for an older client who had a hip pinned after being fractured. Which would the nurse do to prevent further injury?

Use a night-light in the hospital room and the bathroom. Rationale:Use of a night-light may help with orientation as well as fall prevention. Option 1 is not appropriate because 10 minutes is a long time for someone to have to wait after pressing the call light. Responding promptly to the client's use of the call light minimizes the chance that the client will try to get up alone, which could result in a fall. A sleeping pill may increase the fall risk of a client who tries to get up during the night. Having full side rails (or four side rails) could increase the level of injury when a client tries to get out of bed in spite of the side rails. In addition, agency policy is always followed with regard to the use of side rails.

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?

Use of an incentive spirometer will help prevent pneumonia." Rationale:Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help detect hypoxemia, monitoring is not directly related to coughing and deep-breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to one or more lobes of the lung; this is usually due to clot formation. Early ambulation and administration of blood thinners help prevent this complication; however, it is not related to coughing and deep-breathing techniques.

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client relating to these techniques?

Use of an incentive spirometer will help prevent pneumonia." Rationale:Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help to detect hypoxemia, monitoring is not directly related to coughing and deep-breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to one or more lobes of the lung; this is usually due to clot formation. Early ambulation and the administration of blood thinners help to prevent this complication; however, they are not related to coughing and deep-breathing techniques.

The nurse is supervising an assistive personnel (AP) performing mouth care on an unconscious client. The nurse would intervene if the AP is observed taking which action?

Using a gloved finger to open the client's mouth Rationale:The client who is unconscious is at great risk for aspiration. The AP turns the client's head to the side and places an emesis basin underneath the mouth. A bite stick or a padded tongue blade, not a gloved finger, is used to open the mouth to prevent injury to the caregiver. Small volumes of fluids are used to rinse the mouth.

Which is most appropriate when communicating with a transgender person?

Using identified pronouns Rationale:The nurse needs to address the client with the name and pronouns that the client identifies with, and the first name may not necessarily be what they use. For the transgender person, it is likely that they would expect to be addressed using pronouns associated with the sex they identify with now, which typically is not their birth sex. Anticipating the client's needs and making suggestions may be seen as judgmental, so the nurse needs to refrain from doing this.

An unconscious client has an impaired corneal reflex on one side. The nurse would demonstrate the best understanding of how to protect the client's eye by performing which action?

Using sterile saline drops every few hours to keep the eye moist Rationale:With loss of the corneal (blink) reflex, the client is at risk for eye dryness and also for corneal abrasions if foreign matter comes in contact with the eye. Use of sterile saline drops is indicated to keep the eyes lubricated. An eye patch would have to be used carefully because corneal abrasion could result if the cornea comes in contact with the patch. Taping the eye shut is inappropriate and could impair the conscious client's vision, putting the client at risk for other injury, such as from falls. Introduction of a cotton-tipped applicator (foreign object) inside the lower eyelid also risks corneal abrasion.

A client has a fiberglass cast applied to the lower leg. The client asks the nurse when the client will be able to walk using the casted leg. The nurse replies that the client will be able to bear weight on the casted leg in which time period?

Within 20 to 30 minutes of application Rationale:A fiberglass cast is made of water-activated polyurethane materials that are dry to the touch within minutes and reach full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30 minutes. Therefore, the remaining options are incorrect

he nurse is reviewing an adult's serum creatinine level and notes that it is 4.0 mg/dL (353 mcmol/L). What does this level indicate?

Very high, indicating severe renal failure Rationale:The normal serum creatinine level for an adult ranges from 0.5 to 1.2 mg/dL (44 to 106 mcmol/L). A creatinine level of 4.0 mg/dL (353 mcmol/L) is a critical value and indicates serious impairment in renal function. This value is not low, normal, or slightly elevated.

A client has a cerebellar lesion. The nurse would plan to obtain which item for use by the client?

Walker Rationale:The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board would be used in transferring a client with weak or paralyzed legs from a bed to a stretcher or wheelchair. A raised toilet seat would be useful if the client did not have sufficient mobility or ability to flex the hips. Adaptive eating utensils would be beneficial if the client had partial paralysis of the hand.

The nurse prepares a client for ear irrigation as prescribed by the primary health care provider. Which action would the nurse take when performing the procedure?

Warm the irrigating solution to 98.6° F (37.0° C). Rationale:Before ear irrigation, the nurse would inspect the tympanic membrane to ensure that it is intact. The irrigating solution needs to be warmed to 98.6° F (37.0° C), because a solution temperature that is not close to the client's body temperature will cause ear injury, nausea, and vertigo. The nurse would check the temperature of the solution on the inner forearm. The affected side needs to be down following the irrigation to assist in drainage of the fluid. When irrigating, a direct and slow steady stream of irrigation solution is directed toward the wall of the canal, not toward the eardrum. The client is positioned sitting, facing forward with the head in a natural position; if the ear is faced upward, the nurse would not be able to visualize the canal.

The nurse caring for a client with heart failure who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?

Weight loss and poor skin turgor Rationale:A fluid volume deficit occurs when the fluid intake is insufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.

The nurse is monitoring for agranulocytosis in a client who is taking clozapine. The nurse would check which serum laboratory result to determine the presence of agranulocytosis?

White blood cell (WBC) count lower than normal Rationale:In agranulocytosis, the WBC count decreases as a result of bone marrow suppression, and the deficiency causes the affected client to become susceptible to infection. Because some antipsychotic medications, such as clozapine, can produce this adverse effect, a baseline WBC count is obtained and is evaluated periodically during therapy with this medication. Although a basophil count is a component of the WBC differential count, it does not provide adequate data to determine the presence of agranulocytosis. Levels of BUN and creatinine that are higher than normal may indicate renal disease.

The nurse is providing instructions to an assistive personnel (AP) who is assigned to care for a client who had a brain attack (stroke) and is experiencing hemiparesis of the right arm and leg. Where would the nurse instruct the AP to place personal articles for morning care?

Within the client's reach on the left side Rationale:Hemiparesis is weakness of the face, arm, and leg on one side. The nurse would instruct the assistive personnel to place objects on the unaffected side and within reach of the client. Options 2, 3, and 4 are incorrect and would not be helpful or safe for the client.

A client with heart failure who has a serum potassium (K+) level of 2.9 mEq/L (2.9 mmol/L) tells the nurse that he does not feel like eating lunch. The nurse checks his serum digoxin level from that morning and notes that it is 1.0 ng/mL (1.2 nmol/L). What would the nurse determine about this digoxin level?

Within the therapeutic range Rationale:Digoxin is a cardiac glycoside that is used to treat dysrhythmias such as atrial fibrillation in clients with heart failure. Digoxin blood levels need to be checked while the client is taking this medication to monitor for toxicity. The therapeutic range for digoxin is 0.5 to 2.0 ng/mL (0.6 to 2.4 nmol/L). Therefore, a blood level of 1.0 ng/mL (1.2 nmol/L) is within the therapeutic range. It is important to be aware that a low K+ level has an additive effect in increasing the risk of digoxin toxicity. The normal K+ level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).

The nurse is developing a list of home care instructions for a client being discharged after a laparoscopic cholecystectomy. Which instructions would the nurse include in the postoperative discharge plan of care? Select all that apply.

Wound care Follow-up care Activity restrictions Dietary instructions Rationale:The type of planning and instructions required vary with the individual client and the type of surgery. Specific instructions that this client needs to receive before discharge would include wound care, activity restrictions, dietary instructions, postoperative medication instructions, personal hygiene, and follow-up appointments. Deep-breathing exercises are taught in the preoperative period.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?

pH 7.25, Paco2 50 mm Hg Rationale:Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is decreased and the Paco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 identifies respiratory alkalosis.

The nurse has instructed a client diagnosed with tuberculosis about how to prevent the spread of infection after discharge from the hospital. The nurse determines that the client needs further teaching if the client makes which statement?

"I need to use disposable plates, forks, and knives." Rationale:Because tuberculosis is transmitted by droplet, it cannot be carried on clothing, eating utensils, or other possessions. It is not necessary to discard any of these. The client needs to cover the mouth with a tissue when laughing, coughing, or sneezing and would dispose of tissues carefully. The client also may need to wear a mask as advised by the primary health care provider. It is important to perform proper handwashing after contact with body substances, tissues, or face masks.

The home care nurse visits a child recently discharged from the hospital with a diagnosis of hepatitis A virus (HAV) infection. The parent asks the nurse when the child can return to school. The nurse would make which response to the mother?

"One week after the onset of jaundice." Rationale:Because HAV is not infectious 1 week after the onset of jaundice, a return to school at that time is permitted if the child feels well enough. Options 1, 2, and 4 are incorrect.

A nursing student is assigned to administer an intramuscular iron injection to a client. The coassigned nurse asks the student about the technique for administration of this medication. The student indicates understanding of the administration procedure by identifying what as the correct injection site and method?

Ventrogluteal muscle using Z-track technique Rationale:The correct technique for administering intramuscular iron is deep in the ventrogluteal muscle using Z-track technique. This method minimizes the possibility that the injection will stain the skin a dark color. The medication is not given in the thighs, arms, or abdomen or by the subcutaneous route.

The nurse places a hospitalized client with active tuberculosis in a private, well-ventilated isolation room. In addition, which action would the nurse take before entering the client's room?

Wash hands and place a high-efficiency particulate air (HEPA) respirator mask over the nose and mouth. Rationale:The nurse wears a HEPA respirator mask when caring for a client with active tuberculosis. Hands are always thoroughly washed before and after caring for the client. Options 1, 2, and 4 offer inadequate protection. In addition, a surgical mask will not protect against Mycobacterium tuberculosis.

The nurse is giving a bed bath to a client and discovers that an additional washcloth and towel are needed. Which is the most appropriate action to take to obtain the needed items?

Wash hands, leave the client's room, and obtain the needed items. Rationale:To avoid spreading the client's germs, the nurse's hands must be washed before leaving. By going to the linen room without washing the hands first, the nurse will spread those germs into the clean linen. It is inappropriate to ask the unit secretary or a family member to obtain the supplies. It is never appropriate to borrow other clients' supplies because this action may spread germs.

The home health nurse visits a client with suspected scabies. Which precaution would the nurse institute during the assessment of the client?

Wear a gown and gloves. Rationale:The Centers for Disease Control and Prevention recommends wearing gowns and gloves for close contact with a client infested with scabies. Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon. Scabies usually is transmitted from client to client by direct skin contact. All contacts that the client has had need to be treated at the same time.

The nurse is working in an illness prevention clinic. An important component of the nurse's practice is to advise high-risk clients to receive an influenza vaccination. Which clients are at high risk for influenza and would benefit from vaccination? Select all that apply.

A 47-year-old parent of a child with cystic fibrosis A 54-year-old client scheduled for a routine diabetes check A 35-year-old registered nurse scheduled for an annual pelvic exam An 87-year-old client from a nursing home scheduled for a surgical follow-up Rationale:Influenza vaccinations are recommended yearly and developed according to predicted strain for clients at high risk. Influenza immunization is recommended for high-risk clients. Anyone in close contact with clients with a chronic respiratory or other chronic disorder need to receive the vaccine. Adults with chronic metabolic disease such as diabetes mellitus are in the high-risk population. Residents of chronic care facilities are at risk for influenza. Health care workers are in the high-risk population. The influenza vaccine does not treat an active infection with the virus.

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 50,000 mm3 (50 × 109/L) Rationale:Bleeding precautions need to be initiated when the platelet count decreases. The normal platelet count is 150,000 to 450,000 mm3 (150 to 400 × 109/L). When the platelet count decreases, the client is at risk for bleeding. The normal white blood cell count is 5000 to 10,000 mm3 (5.0 to 10.0 × 109/L). When the white blood cell count drops, neutropenic precautions need to be implemented. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 10 to 80 mcg/dL (6 to 47 mcmol/L).

The nurse is preparing to administer 1 mg of hydromorphone, a Schedule II opioid. The medication is available in a premeasured syringe of 2 mg/mL. Which action by the nurse is correct?

Ask a second nurse to witness disposal of the unused portion. Rationale:The Controlled Substances Act requires the nurse to have a second nurse witness disposal of unused scheduled medications. Both nurses will document on the required form. Unused portions are not saved or reused.

Precautions are used when caring for a client with Clostridium difficile. The nurse is planning on providing morning care for the client and needs to obtain which specific protective equipment for this infection?

Gloves and a gown Rationale:Clostridium difficile (C. diff) is an infection that destroys normal bowel flora and leads to increased diarrhea. Contact precautions are used for clients with Clostridium difficile because the infection is in the stool. With contact precautions, the nurse needs to wear gloves and a gown to provide protection from the infection. A mask is not necessary unless another condition that is transmitted via the droplet or airborne routes is present, or if agency policy and procedure mandates the use of a mask.

The nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action would the nurse take next?

Isolate the client in a private room. Rationale:The nurse would suspect the potential for Ebola virus disease (EVD) because of the client's recent travel to Nigeria. The nurse needs to consider the symptoms that the client is reporting, and clients who meet the exposure criteria need to be isolated in a private room before other treatment measures are taken. Exposure criteria include a fever reported at home or in the ED of 38.0°C (100.4°F) or headache, fatigue, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or signs of bleeding. This client is reporting a fever and is showing other signs of EVD, and therefore needs to be isolated. After isolating the client, it would be acceptable to then collect further data and notify the primary health care provider and other state and local authorities of the client's signs and symptoms.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action?

Removing the client from any immediate danger Rationale:Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusive situation. Options 1, 2, and 4 may be appropriate interventions but are not the priority.

The nurse is admitting a homeless person who was brought to the emergency department by paramedics. The client was found unresponsive next to the back door of a restaurant, was unkempt in appearance, and had various scratches on the body. The nurse develops a plan of care for the client. Which priority client problems apply? Select all that apply.

Risk for unsafe conditions because of homelessness Anxiety when consciousness is regained because of the unfamiliar surroundings Risk for infection because of his unkempt condition, various scratches, and homelessness Rationale:Infection is a priority because of the client's poor hygiene, altered skin integrity, and homelessness. Injury is also a concern because of the client's situation (homelessness). Waking up in an unfamiliar place can lead to anxiety. No data in the question indicate that the client has confusion or lacks knowledge.

The school nurse prepares a list of home care instructions for the parents of school children diagnosed with pediculosis capitis. Which instruction would the nurse include in the list?

Vacuum floors, play areas, and furniture to remove any hairs that might carry live nits. Rationale:Pediculosis capitis is an infestation of the hair and scalp with lice. Thorough home cleaning is necessary to remove any lice or nits that may fall from the host. Combs and brushes need to be soaked in hot water for 10 minutes or a pediculicide for 1 hour. Anti-lice sprays are unnecessary and may be harmful. In addition, they would never be used on a child or on bedding or linens. Bedding and linens need to be washed with hot water and dried on a hot setting. Items that cannot be washed need to be dry cleaned or sealed in plastic bags in a warm place for 2 weeks.

The nurse is admitting a client who is suspected of having tuberculosis (TB) to the nursing unit. The nurse would plan to admit the client to a room that has which properties?

Venting to the outside, six air exchanges per hour, and ultraviolet light Rationale:A client suspected of having TB is admitted to a private room that has at least six air exchanges per hour and negative pressure in relation to surrounding areas. The room would be vented to the outside and needs to have ultraviolet lights installed.

A client with lung cancer has been receiving a series of medications as part of intravenous antineoplastic therapy. The nurse would implement neutropenic precautions after noting which laboratory result for this client?

White blood cell (WBC) count of 2000 mm3 (2 × 109/L) Rationale:The normal WBC count is 5000 to 10,000 mm3 (5 to 10 × 109/L). When the WBC count drops, neutropenic precautions need to be implemented to protect the client from infection. Bleeding precautions need to be initiated when the platelet count drops; bleeding precautions include avoiding trauma such as from rectal temperatures or injections. The normal ammonia value is 10 to 80 mcg/dL (6 to 47 mcmol/L). The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L). The normal INR is 0.81 to 1.2 for someone who is not on anticoagulant therapy.

The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take?

Hold the feeding and reinstill the residual amount. Rationale:Unless specifically indicated, residual amounts greater than 100 mL require holding the feeding, but this is individualized and each agency's policy needs to be checked. The residual amount needs to be reinstilled unless it is greater than 250 mL or per agency policy. In addition, the feeding is not discarded unless its contents are abnormal in color or characteristics.

The nurse is caring for a client with a wound infected with methicillin-resistant Staphylococcus aureus (MRSA). The most appropriate infection control precautions for MRSA include which intervention?

Private room, gown, gloves, and face shield Rationale:Isolation guidelines from the Centers for Disease Control and Prevention (CDC) place MRSA at the tier 2 transmission category. Contact precautions are required and include a private room, gloves, gowns, and face shields in case a splash from the wound drainage occurs, such as with wound irrigation. A room with negative-pressure airflow is required for airborne precautions from small droplet infections such as measles, chicken pox, or tuberculosis. A respiratory protection device is recommended for larger droplet infections such as pneumonia. A room with positive-pressure airflow is recommended for protective environments such as those required for clients with stem cell transplants.

A client has been admitted to the surgical unit after hernia repair surgery. The medical record reports that the client is human immunodeficiency virus (HIV) positive. The nurse would implement which precautions for this client?

Standard precautions Rationale:Having an HIV-positive status does not warrant a special type of precaution; instead, the nurse will implement standard precautions. Contact, droplet, and airborne precautions are implemented with specific types of infections or diseases but are not necessary for clients who are HIV positive unless some additional specific infection is present.

A client who is admitted for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The assistive personnel (AP) assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. What would the nurse tell the AP?

Standard precautions are sufficient because the disease is transmitted sexually.

The nurse is assigned to care for an infant following a cleft lip repair. The nurse is asked to observe the parent in the procedure for cleaning the lip repair site. The nurse determines that the parent is performing the procedure correctly if the parent uses which solution to clean the site?

Sterile water Rationale:The lip repair site is cleansed with sterile water using a cotton swab; it is cleansed after feeding and as prescribed. The parent needs to be instructed to use a rolling motion from the suture line outward. Some surgeons may prescribe diluted hydrogen peroxide but full-strength would be harmful. Options 1, 3, and 4 are incorrect solutions and can affect tissue integrity.

A client is seen in the health care clinic, and a diagnosis of acute sinusitis is made. The nurse provides home care instructions to the client regarding measures that will promote sinus drainage and comfort. Which statement by the client indicates a need for further instruction?

"I need to use a cold mist vaporizer to liquefy secretions." Rationale:The nurse provides instructions to the client regarding measures to promote sinus drainage, comfort, and resolution of the infection. The client needs to be instructed to take hot showers, use a steam inhaler, and use a bedside humidifier to help liquefy secretions and promote drainage. Consumption of large amounts of fluids is important to help liquefy secretions. Sleeping with the head of the bed elevated to a 45-degree angle will assist in promoting drainage. The nurse instructs the client to apply heat in the form of wet packs over the affected sinuses to promote comfort and help resolve the infection.

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS). In planning infection control for this client, the nurse would implement which form of isolation to prevent the spread of the AIDS virus to others?

Blood and body fluid precautions Rationale:The AIDS virus is transmitted through contact with oral secretions, sexual contact with infected semen or vaginal secretions, through contact with infected blood or blood products, from parent to fetus during childbirth, or during breast/chest-feeding. Blood and body fluid precautions will prevent contact with infectious matter from the AIDS virus. Strict isolation is not needed and may contribute to feelings of isolation in the client. Enteric or contact precautions alone are insufficient to prevent transmission of the AIDS virus.

An assistive personnel (AP) is caring for a client who has an indwelling urinary catheter. Which action by the AP would indicate the need for further instruction in the care of the client?

Allowed the drainage tubing to rest under the leg Rationale:Proper care of an indwelling urinary catheter is especially important to prevent infection in the client. The drainage tubing is not placed under the client's leg; for the same reason, the drainage bag is kept below the level of the bladder to prevent urine from being trapped in the bladder. The tubing must drain freely at all times. The perineal area is cleansed thoroughly, using mild soap and water at least twice a day and following a bowel movement. The nurse and all caregivers must use strict aseptic technique when emptying the drainage bag or obtaining urine specimens.

The nurse is assisting the assistive personnel (AP) in cleaning a room that was infected with Clostridium difficile. To ensure that all surfaces are evenly disinfected, which cleaning solution would the nurse plan to use?

Bleach solution Rationale:Clostridium difficile is a bacterium that disrupts healthy normal bowel flora. Clostridium difficile is difficult to destroy. A 10% bleach solution or a disinfectant that is sporicidal needs to be used to ensure that all equipment is properly disinfected. Soap and water, alcohol-based solutions, and ammonia-based disinfectant are not effective in eliminating this infection.

A parent calls a neighbor who is a nurse and tells the nurse that their 3-year-old child has just ingested liquid furniture polish. The nurse would direct the parent to take which immediate action?

Call the Poison Control Center. Rationale:If a poisoning occurs, the Poison Control Center needs to be contacted immediately. Vomiting would not be induced if the victim is unconscious or if the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would not be the initial action because this would delay treatment. The Poison Control Center may advise the parent to bring the child to the emergency department; if this is the case, the parent needs to call an ambulance.

The nurse is caring for a client with newly diagnosed human immunodeficiency virus (HIV). Besides preventing the transmission of the disease, what are the goals of medication therapy? Select all that apply.

Decreasing the viral load Delaying disease progression Maintaining or increasing CD4+ T cell counts Preventing HIV-related symptoms and opportunistic diseases Rationale:Besides preventing HIV transmission, the goals of medication therapy include decreasing the viral load, delaying disease progression, maintaining or increasing CD4+ T cell counts, and preventing HIV-related symptoms and opportunistic diseases. Administering the HIV vaccine and eliminating the use of illegal drugs are not included in the goals of medication therapy. Antiretroviral therapy (ART) can delay disease progression, and when taken consistently and correctly, ART can reduce viral loads by 90% to 99%. This makes adherence to treatment regimens extremely important. Although it is usually not possible to eradicate opportunistic diseases once they occur, prophylactic medications can significantly decrease morbidity and mortality rates.

The nurse is preparing an intravenous (IV) set before starting the infusion. After removing the cap from the IV tubing port on the IV bag, the nurse removes the cover from the tubing insertion spike but then touches the spike with a finger. What would the nurse do next?

Discard the IV tubing and use a new set for the infusion. Rationale:The IV tubing's insertion spike must remain sterile. If it is touched during the preparation of the infusion, the tubing must be discarded and replaced with a sterile set. Otherwise, the infusion set is contaminated, which could cause infection in the client. Therefore, the remaining actions are incorrect.

A client is to undergo weekly intravesical chemotherapy for bladder cancer for the next 8 weeks. What instruction would the nurse provide to the client regarding management of the urine as a biohazard?

Disinfect the toilet with bleach after voiding for 6 hours after a treatment. Rationale:After intravesical chemotherapy, the client treats the urine as a biohazard. This involves disinfecting the urine and the toilet with household bleach for 6 hours after the treatment. Using a bedpan for voiding is of no value in this situation. Scented disinfectants are of no particular use. The client does not need to have a separate bathroom for personal use.

The nurse is caring for a client who is on strict bed rest. The nurse develops a plan of care and develops goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is appropriate to prevent these disorders from developing?

Encouraging active range-of-motion exercises Rationale:Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat would not be applied without a primary health care provider's prescription.

A cold, moist compress is prescribed to be applied to the client's right knee. Which would the nurse plan for?

Ensure that the temperature of the compress is 15° C (59° F). Rationale:The procedure for applying cold, moist compresses is the same as that for warm compresses. The cold compress is applied for 20 minutes at a temperature of 15° C (59° F) to relieve inflammation and swelling. Clean or sterile compresses can be used, although sterile may be prescribed for open wounds. When using cold compresses, the nurse needs to observe for adverse reactions such as burning or numbness, mottling of the skin, redness, extreme paleness, and a bluish skin discoloration. If these adverse reactions occur, the compress is immediately removed.

An adolescent is admitted to the hospital after an accidental self-inflicted gunshot wound to the foot. The nurse would plan to take which action as a first step for the prevention of future injury?

Explore the client's knowledge of gun safety. Rationale:A leading cause of accidental death in the adolescent population is improper use of firearms. Before implementing firearm safety goals, the nurse needs to obtain baseline data through a firearm safety history, which is described in the correct option. Option 2 may be indicated because of the relationships among accidents, impulsivity, and risk-taking behaviors, but assessing past risk-taking behaviors would not be the first step directed at prevention. Option 3 may be effective, but referral to a firearm safety course would not come before assessing the client's knowledge of gun safety. Option 4 may or may not be effective, at some point, for this client.

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and would obtain which protective items to perform this procedure?

Gloves, gown, goggles, and a mask or face shield Rationale:Splashes of body secretions can occur when providing colostomy care. Goggles and a mask or face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown needs to be worn if direct client contact is anticipated. Shoe protectors are not necessary.

The nurse is preparing to nasotracheally suction a client with acquired immunodeficiency syndrome (AIDS) who has had blood-tinged sputum with previous suctioning. The nurse plans to use which items as part of standard precautions for this client?

Gloves, gown, mask, and protective eyewear Rationale:Standard precautions include the use of gloves whenever there is actual or potential contact with blood or body fluids. During procedures that aerosolize blood, the nurse wears a mask and protective eyewear or a face shield. Impervious gowns are worn in those instances when it is anticipated that there will be contact with splashes of secretions or blood.

The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn infant. Which statement would the nurse make to the client?

Hands needs to be washed thoroughly before holding the infant. Rationale:Transmission of infectious diseases can occur through contaminated items such as the hands and bed linens of clients with endometritis. An important method of preventing infection is to break the chain of infection. Hand washing is one of the most effective methods of preventing the transmission of infectious diseases. The newborn infant is allowed in the parent's room and visitors are allowed to hold the newborn infant as long as hand washing and other protective measures are instituted.

The ambulatory care nurse is seeing a client for a follow-up visit after treatment for toxic shock syndrome (TSS). To assess the client's recovery from TSS, the nurse would ask whether which signs and symptoms have resolved?

High fever, abdominal pain, vomiting, and diarrhea Rationale:The classic symptoms of TSS are high fever (temperature of 101° F [38.3° C] or higher), vomiting, and severe diarrhea. Other typical symptoms include headache, myalgia, chills, abdominal pain, dizziness, lethargy, possible confusion, and agitation. Vaginal bleeding or discharge is not part of the clinical picture. TSS typically is caused by Staphylococcus aureus infection associated with tampon use during menses.

The nurse in the health care clinic is preparing to obtain a throat swab for culture in a client suspected of having a beta-hemolytic streptococcal infection. Which actions are appropriate in collecting this specimen? Select all that apply.

Instruct the client to tilt the head back. Swab the tonsillar pillars and the posterior pharynx wall. Tell the client that the test will help to identify microorganisms. Place a tongue depressor on the client's tongue before swabbing the throat. Rationale:When collecting a throat culture, the client is told that the test is performed to help identify microorganisms causing the symptoms. The client is instructed to tilt the head back, and both the tonsillar pillars and the posterior pharynx wall are swabbed. A tongue depressor is used in the collection so that the swab is less likely to contact the normal flora of the mouth. The swab is immediately placed in a labeled culture tube and transported to the laboratory. Agency procedures are always followed; to ensure accuracy of the results, some laboratories prefer a two-swab collection.

The nurse working in the emergency department (ED) is assessing a client who recently returned from Liberia and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action would the nurse take next?

Isolate the client in a private room. Rationale:The nurse would suspect the potential for Ebola virus disease (EVD) because of the client's recent travel to Liberia. The nurse needs to consider the symptoms that the client is reporting, and clients who meet the exposure criteria need to be isolated in a private room before other treatment measures are taken. Exposure criteria include a fever reported at home or in the ED of 38.0° C (100.4° F) or headache, fatigue, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or signs of bleeding. This client is reporting a fever and is showing other signs of EVD, and therefore needs to be isolated. After isolating the client, it would be acceptable to then collect further data and notify the primary health care provider and other state and local authorities of the client's signs and symptoms.

When caring for a client with an internal radiation implant, the nurse would observe which principles? Select all that apply.

Keeping pregnant people out of the client's room Placing the client in a private room with a private bath Wearing a lead shield when providing direct client care Rationale:The time that the nurse spends in the room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The client must be placed in a private room with a private bath. Lead shielding can be used to reduce the transmission of radiation. The dosimeter film badge must be worn when in the client's room. Children younger than 16 years of age and pregnant people are not allowed in the client's room.

Treatment for a client with bleeding esophageal varices has been unsuccessful, and the primary health care provider decides to insert a Sengstaken-Blakemore tube. What is the priority nursing action?

Place a pair of scissors at the client's bedside. Rationale:When the client has a Sengstaken-Blakemore tube inserted, a pair of scissors must be kept at the client's bedside at all times. The client must be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures, moving the esophageal balloon upward and occluding the airway. If this occurs, all balloon lumens are cut and the tube is removed. An obturator and Kelly clamp would be kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside but is not the priority item.

The nurse is preparing a plan of care for a client with a diagnosis of agranulocytosis who is being admitted to the hospital. The nurse determines that which is the priority when formulating the client's plan of care?

Potential for infection Rationale:Agranulocytosis is characterized by a reduced number of leukocytes (leukopenia) and neutrophils (neutropenia) in the blood. The client is at high risk for infection because of the decreased body defenses against microorganisms. Insufficient knowledge related to the nature of the disorder and the prevention of complications may be appropriate, but it is not the priority. Similarly, fatigue and constipation may be a concern for the client with agranulocytosis, but the priority problem relates specifically to infection.

Which interventions are essential to perform when a central venous site is suspected of being infected? Select all that apply.

Prepare to administer antibiotics. Notify the primary health care provider (PHCP). Inform the client that blood cultures will need to be obtained. Document the occurrence, the actions taken, and the client's response. Rationale:Signs of infection at the catheter site include redness or drainage. The client will also exhibit chills, fever, and an elevated white blood cell count. If the nurse suspects infection, the PHCP is notified because of the risk for sepsis. The catheter is removed, and the client is prepared for a possible restart at a different location as prescribed. A central line may be removed by a nurse who has been trained in approved protocol to remove a central line. If requested, the catheter tip may be sent to the laboratory for culture to identify the bacteria present so that the effective antibiotic is prescribed. Intravenous (IV) antibiotics may be prescribed, and an IV site will be needed for administration. Blood cultures are also performed to determine the presence of bacteria in the blood. Antibiotics are not started until blood cultures are obtained; otherwise, the results of the cultures may be inaccurate. Finally, the nurse documents the occurrence, actions taken, and the client's response. Additionally, per agency protocol, pictures of the infected catheter site may be taken and added to the documentation.

The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client?

Private room or cohort client Rationale:Meningitis is transmitted by droplet infection. Precautions for this disease include a private room or cohort client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis. When appropriate, a mask must be worn by the client and not the staff when the client leaves the room.

What action would the nurse take as a priority after administering an opioid analgesic to a client experiencing pain?

Provide safety measures per agency protocol. Rationale:The nurse would ensure client safety after administering an opioid analgesic to prevent injury once the medication has taken effect. The nurse needs to provide safety measures per agency protocol, such as raising side rails, ensuring that the client understands the use of the call bell, and ensuring that the nurse would be called before the client gets out of bed. Dimming the light in the room is the next most helpful action. The client would have been asked about the need to urinate before the medication was administered. It is unnecessary to do range-of-motion exercises to the injection site.

A hospitalized client who has been placed on contact precautions has been prescribed to have a chest radiograph in the radiology department. The nurse would take which action on receipt of this prescription?

Question the primary health care provider about whether a portable chest radiograph may be obtained. Rationale:The client who is placed on contact precautions has a high microorganism count in some type of body secretion (e.g., feces or wound drainage). This client is placed in a private room whenever possible and is removed from the room only when absolutely necessary. Client transport would be done only for essential purposes. Notification of departmental personnel and disinfection of any environmental surfaces with which the client has contact are imperative.

The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider (PHCP) have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse would implement which action next?

Reassess the client. Rationale:After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall needs to be treated as private information and shared on a "need to know" basis. Communication regarding the event would involve only the individuals participating in the client's care. An occurrence report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the occurrence, the supervisor will contact the nurse if status update is necessary.

The community health nurse is providing a session on childhood poisoning and has instructed a group of parents of preschoolers about home safety measures. Which statement by one of the parents would the nurse identify as something that requires the need for reinforcement of the instructions?

Refers to medication as "candy for when you are sick" Rationale:Medicine would not be referred to as candy. Home safety measures are simple but important. Medications need to be stored in child-proof containers. The number of tablets in a container needs to be limited. The poison control center telephone number needs to be visible near all telephones. Toxic substances need to be labeled with poison stickers and placed in a locked area out of reach of children.

A client with an infection develops a fever and while receiving therapy with a hypothermia blanket starts to shiver. The nurse raises the blanket temperature and monitors the client. After 15 minutes the client's temperature has not increased, and the client is still shivering. What would the nurse do next?

Remove the hypothermia blanket and notify the client's primary health care provider. Rationale:Shivering is not a desired outcome of therapy with a hypothermia blanket. Even though shivering increases the body's metabolic rate and heat production, oxygen consumption is also increased. Another adverse effect is that shivering can cause vasoconstriction, which may injure areas in distal parts of the body. If shivering cannot be stopped, then the therapy with the hypothermia blanket must be stopped and the client's primary health care provider notified. Waiting and rechecking the client's temperature delays necessary treatment. Applying a heating pad to the axillae and neck also delays necessary treatment. Additionally, it could cause a burn.

The nurse is conducting a community surveillance study for the purpose of communicable disease control. The nurse knows that performing an active surveillance method of assessment is best for what reason?

Results in detection of a more accurate number of cases Rationale:The best outcome of any type of surveillance is accuracy. An active surveillance method focuses on assessment rather than interventions and is best because it results in detection of a more accurate number of cases. Relying on the initiative of PHCPs to report cases is a passive method that results in an upward swing of cases reported based on the latest disease trend.

A man is admitted to the hospital with the diagnosis of urethritis secondary to chlamydial infection. What precaution would the nurse implement for this client?

Standard Rationale:Chlamydial infection is a sexually transmitted infection and frequently is called nongonococcal urethritis. It requires no special precautions other than standard precautions. Caregivers cannot acquire the disease during administration of care, and using standard precautions is the only necessary measure.

A hospitalized client has a diagnosis of pelvic inflammatory disease (PID). The nurse would encourage the client to assume which therapeutic position when in bed?

Supine in semi-Fowler's Rationale:Placing the client in a semi-Fowler's position allows gravity to aid in drainage of the abdominal cavity. This helps to prevent the formation of abscesses high in the abdomen. Abscesses in this location could rupture, potentially causing peritonitis. The color, odor, and amount of vaginal secretions also are noted and recorded. Options 1, 2, and 3 will not aid in gravity drainage.

The nurse is providing home care instructions to the parent of a child who has bacterial conjunctivitis. The nurse would provide the parent with which information?

The child's towels and washcloths would not be used by other members of the household. Rationale:Bacterial conjunctivitis is highly contagious, and infection control measures need to be taught. These include good handwashing and not sharing towels or washcloths with others. The child would be kept home from school until 24 hours after antibiotics are started. Bottles of eye medication would never be shared with others. Crusted material may be wiped from the eye with a cotton ball soaked in warm water, starting at the inner aspect of the eye and moving toward the outer aspect.

A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting family members and others. How would the nurse respond to provide reassurance?

The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. Rationale:Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client usually is not contagious after taking the medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or medication-resistant tuberculosis.

A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor would the nurse include when responding to the client?

Three sputum cultures are negative. Rationale:The client with tuberculosis must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative, because the client is considered noninfectious at that point. Options 1, 3, and 4 are not reliable determinants of a noninfectious status.

The nurse is preparing to insert an intravenous (IV) angiocatheter into a client's inner forearm. Before cannulating the vein, what motion will the nurse implement to cleanse the site?

Using a circular motion from the center outward Rationale:The nurse cleans the skin by using a circular motion from inward to outward. This is the standard, accepted aseptic technique to carry microorganisms away from the insertion site. The same technique is used to cleanse any area requiring surgical asepsis. Options 1, 2, and 4 are incorrect procedures and do not represent aseptic technique.